Loading...
HomeMy WebLinkAboutCOM 0094.001 2016-2018 Harry Kim •oo-tv-.o`"'-yam Collins Tomei Mayor .' ., Director _„ Deanna S. Sako _- Deputy Director ef'+ w•r`'Akli••` •*�'oF -- COUNTY CLERK COUNTY OF RAWAIFI •4• RECEIVED County of Hawaii Time $:S awt " Finance Department Date r Eai 1 0 Nt 25 Aupuni Street,Suite 2103 • Hilo,Hawaii 96720 (808)961-8234 • Fax(808)961-8569 February 10, 2017 Valerie Poindexter, Council Chair and Members of the Hawai`i County Council Hawai`i County Council 25 Aupuni Street Hilo, Hawai`i 96720 Re: Nonprofit Grant Applications In compliance with Chapter 2, Article 25 of the Hawai`i County Code, I am submitting the applications from eligible nonprofit organizations for your review and appropriation of funds for the FY 2017 - 18 nonprofit grant program. The applications are submitted as received from the applicants and may contain blank or extra pages. Also enclosed is a list of these eligible organizations with the name of their program and the amount they are requesting from the County. Should you have any questions, please feel free to call Ted Schrey at 961-8489. Collins Tomei Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants (Note: Due to the size of the content, the applications are not made a part of the duplicate copies of this document, but are avaialable for viewing in the Office of the County Clerk and on the pages of the Legislative Branch s website at http://hawaiicounty.gov.) Comm.No, q 4 • Ref.To: 4-Ref.Dots1.407.0 11 Hawai'i County is an Equal Opportunity Employer and Provider FISCAL YEAR 2017-2018 APPLICATIONS FROM NON-PROFIT ORGANIZATIONS HAWAII COUNTY COUNCIL HUMAN SERVICES AND SOCIAL SERVICES COMMITTEE * N-44,4f: ifA 4° « F FEBRUARY 2017 NONPROFIT GRANT APPLICANTS FOR FY2017-18 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants retain their sort number resulting in those numbers being skipped in the main table. Numerical Sort Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 1 5 Aloha Independent Living Hawaii Independent Living Services 10,000 2 6 Aloha Performing Arts Company Theatre Education Program 19,000 3 7 ALS Ohana of Hawai'i Excellence in ALS Care 50,000 4 8 American National Red Cross Disaster Preparedness&Response in Hawai'i County 50,000 5 9 Arc of Hilo,The Cold Kitchen Development Project 50,000 6 10 Arc of Kona Basic Life Skills for Independent Living 22,000 7 11 Art &Sciences Center ASC Community Education Program 91,800 8 12 Bay Clinic,Inc Breast Cancer Prevention Program 40,000 9 13 Bay Clinic,Inc Diabetes Awareness&Self-Management Program 26,500 10 14 Bay Clinic,Inc Information Technology Integration to Improve Patient Health 28,942 11 15 Bayada Home Care Autism Center 50,000 12 16 Big Brothers Big Sisters Hawai'i One-to-One Mentoring 10,000 13 17 Big Island Mediation,Inc.dba West Hawai'i Mediation Center Community&Foreclosure Mediation Services 12,500 14 18 Big Island Mediation,Inc.dba West Hawaii Mediation Center Peer Mediation&Conflict Resolution Education 12,500 15 19 Big Island Resource Conservation&Development(BIRCD) Junior Forest TEAM(JRFT)/Ho'oulu Lehua(HL) 27,500 16 20 Big Island Substance Abuse Council East Hawai'i Substance Abuse Treatment Services 76,093 17 21 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo 46,500 18 22 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Kea'au 35,000 19 23 Big Island Substance Abuse Council Kea'au Health and Wellness Garden 25,000 20 24 Big Island Substance Abuse Council Po'okela Vocational Program 25,000 21 25 Big Island Substance Abuse Council Therapeutic Living Programs and Clean and Sober Living Program 61,775 22 26 Big Island Substance Abuse Council West Hawai'i Substance Abuse Program 45,600 23 27 Boys&Girls Club of the Big Island,Fiilo Club Daily Nutritional Security to Support Income Challenged Youth 45,000 24 28 Boys&Girls Club of the Big Island,Hilo Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 25 29 Boys&Girls Club of the Big Island,Kea'au Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 26 30 Boys&Girls Club of the Big Island,Kealakehe Club Kealakehe After School Support for Income Challenged Youth 90,000 27 31 Boys&Girls Club of the Big Island,Ocean View Club Ocean View Club Daily Services for Income Challenged Youth 45,000 28 32 Boys&Girls Club of the Big Island,Pahala Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 29 33 Boys&Girls Club of the Big Island,Pahoa Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 30 34 Brantley Center,Inc. Job Skills Development Program 50,000 31 35 Bridge House Mala'Ai,food garden project 7,650 32 36 Bridge House Vocational Skills Building 27,500 33 37 Child&Family Services Alternatives to Violence 60,000 34 38 Child&Family Services East Hawaii Domestic Abuse Shelter 60,000 35 39 Child&Family Services Hale Kahua Pa'a Transitional Housing Program 45,000 36 40 Child&Family Services West Hawai'i Domestic Abuse Shelter 60,000 37 41 East Hawaii Cultural Council Emerging Artist Sustainability and Education Program(EASE) 34,000 38 42 Family Support Hawaii Hamakua Fatherhood Initiative 10,000 39 43 Family Support Hawaii Healthy Keiki 36,750 40 44 Family Support Hawai'i North Kona Fatherhood Initiative 20,000 41 45 Family Support Hawaii South Kona Fatherhood Initiative 20,000 42 46 Food Basket,Inc.,The Hawaii Island Emergency Distribution Program 84,460 NONPROFIT GRANT APPLICANTS FOR FY2017-18 Numerical Sort Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 43 47 Friends of the Children of West Hawaii Basic Needs and Enhancement Activities 10,000 44 48 Friends of the Children's Justice Center of East Hawaii Special Needs,Enhancement,Support,Education and Training 20,000 45 49 Friends of the Palace Theater Hawaiian Cultural Legacy Program 58,450 46 50 Friends of the Palace Theater Palace Theater Fall Musical 21,630 47 51 Friends of the Palace Theater Spotlight on Youth 21,300 48 52 Full Life Individualized Career Planning and Employment Services 56,000 49 53 Going Home Hawai'i Hawaii Island Going Home Consortium 25,120 50 54 Going Home Hawaii In-Reach and Reintegration 115,139 51 55 Going Home Hawai'i SOAR(SSI/SSDI,Outreach,Access and Recovery) 53,968 52 56 Goodwill Industries of Fiawai'i,Inc. Job Connections 30,000 53 57 Goodwill Industries of Hawaii,Inc. Work Experience Program 45,000 54 58 Grassroots Community Development Group Hawaii Youth Business Center 10,000 55 59 Green Will Conservancy Inc.,The The Green Will Conservancy Inc. 20,000 56 60 Habitat for Humanity West Hawai'i Blitz Build 2017 150,000 57 61 Hale Aikane The Kona Paradise Club 11,000 58 62 Hamakua Youth Foundation Hamakua Youth Center 60,000 59 63 Hawaii County Economic Opportunity Council Drop Out Prevention Program 188,954 60 64 Hawaii County Economic Opportunity Council Language Arts Multicultural Program 340,085 61 65 I iawai'i County Economic Opportunity Council Transportation Program 530,000 62 66 Hawaii Institute of Pacific Agriculture Ha Ike Pono Youth Education in North Kohala 30,000 63 67 Hawaii Island Adult Care,Inc. Adult Day Care 30,000 64 68 Hawai'i Island HIV/AIDS Foundation Sexually Transmitted Disease Education&Testing 25,000 65 69 Hawaii Island HIV/AIDS Foundation SISTA and BRADDA programs 25,000 66 70 Hawai'i Island Home for Recovery,Inc. HIHR Food Pantry 10,000 67 71 Hawaii Island Home for Recovery,Inc. FIIHR Supportive Housing Program#1 49,000 68 72 Hawai'i Island Home for Recovery,Inc. HIHR Supportive Housing Program#2 12,000 69 73 Hawaii Island Home for Recovery,Inc. 111118 Supportive l lousing Program#3 12,000 70 74 Hawaii Island Home for Recovery,Inc. HIHR Transitional Housing Program 49,000 71 75 Hawai'i Montessori Schools Financial Aid Program 10,000 72 76 Hawai'i Oil Seed Producers(FIOSPRO)LLC Training Oil Palm Mill Operators for Vegetable Oil Production 14,936 73 77 Hawaii Tropical Fruit Growers Rainwater Catchment Video Project 44,000 74 78 Hawaiian Habitats Foundation,Inc. County of Hawaii Nonprofit Grants Program 627,395 75 79 Heart Ranch Heart Ranch 15,000 76 80 Help the Poor FEADS 182,000 77 81 Hilo Community Players Theatre to Inspire Our Community 17,000 78 82 Honoka'a Hongwanji Mission Katsu Goto Memorial Committee 32,000 79 83 Hope Services Hawaii,Inc. Continuum of Care Programs(CoC) 50,000 80 84 Hope Services Hawai'i,Inc. Friendly Place Resource Center 50,000 81 85 Hope Services Hawai'i,Inc. Hale Kikaha 25,000 82 86 Hope Services Hawaii,Inc. HOPE Resource Center 50,000 83 87 Hope Services Hawaii,Inc. Representative Payee Services 17,500 84 88 Hope Services Hawai'i,Inc. West Hawaii Emergency Housing Program 30,000 85 89 Hospice of Flilo Technology for Improved Health Care Access 50,000 86 90 Hui Malama Ola Na Oiwi Cancer Program-Malama Ka Pili Pa'a Expansion 20,000 NONPROFIT GRANT APPLICANTS FOR FY2017-18 Numerical Sort Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 87 91 Hui Malama Ola Na Oiwi Community Relations Program-Ladies Night Out 2017 6,000 88 92 Hui Malama Ola Na Oiwi Diabetes Program-Lets Talk Story with Aunty 18,000 89 93 Hui Malama Ola Na Oiwi Nutrition Program-Hele Mai'Ai,Eat dis not dat,Eat a rainbow 18,000 90 94 Hui Malama Ola Na Oiwi Traditional Healing Program-La'au Project 32,000 91 95 Hui Malama Ola Na Oiwi Transportation Program-KOkua Hall Specialty Transportation 60,000 92 96 Hui Pono Holoholona Rehomed Lava Cats Continued Care 5,000 93 97 Hui Pono Holoholona Subsidized Low Cost Spay/Neuter Clinics 40,000 94 99 Island of Hawaii YMCA,The Family Visitation Center 76,000 95 100 Ka'u Rural Health Community Association,Inc Ka'u Pilot Telehealth Outreach Project 69,750 96 101 Keaukaha One Youth Development H0kualaka'i Restoration Project 20,000 97 102 Keaukaha One Youth Development RISE 21st Century After School Program 20,000 98 103 Keaukaha One Youth Development Youth Paddling Program 20,000 99 104 Kailapa Community Association Ka Wai Ola-Water is Life 100,000 100 105 Kamuela Philharmonic Orchestra Society Kamuela Philharmonic Strategic Realignment 18,300 101 106 Kohala Animal Relocation and Education Service(KARES) Canine Spay and Neuter Program 48,250 102 107 Kohala Institute GRACE Leadership Journey 25,000 103 108 Kona Adult Day Care Center,Inc Adult Day Care 15,000 104 109 Kona Historical Society New Living History Activities&Community Education Programs 20,000 105 110 Ku'ikahi Mediation Center Community Conflict Prevention&Resolution Services 15,000 106 111 Ku'ikahi Mediation Center Youth Peer Mediation Program 10,000 107 112 Legal Aid Society of Ilawai'i Expanding Civil Legal Access to Rural Communities 25,000 108 113 Lokahi Treatment Centers Adolescent Substance Abuse Treatment Programs 20,000 109 114 Lokahi Treatment Centers Adult Substance Abuse Treatment Programs 25,000 110 115 Lokahi Treatment Centers Domestic Violence Intervention Treatment Programs 15,000 111 116 Malamalama Waldorf School Hui'Ano'Ano Parent/Child Development 10,000 112 117 Malamalama Waldorf School Puna Arts in the Park 10,500 113 118 Malamalama Waldorf School Puna Off the Streets Aftercare 7,500 114 119 Mental Health Kokua Residental Rehabilitation Services 10,000 115 120 Na Kalai Wa'a Hoea Moku Canoe Garden 51,780 116 121 Neighborhood Place of Puna Emergency Food Pantry 25,000 117 122 Neighborhood Place of F'una Family Strengthening Home Visiting 25,000 118 123 North Kohala Community Resource Center Kohala Coqui Coalition 20,000 119 124 North Kohala Community Resource Center North Kohala Eat Locally Grown 7,500 120 125 0 Ka'u Kakou Family Fun Fest 5,000 121 126 0 Ka'u Kakou Ka'O Coffee Trail Run 7,500 122 127 0 Ka'0 Kakou Ka'u Sanitation Program 9,000 123 128 0 Ka'u Kakou Punalu'u Fishing Tournament 5,000 124 129 Pacific Tsunami Museum Tsunami Education: School Outreach;4th Grade 11,494 125 130 Parents and Children Together Head Start 144,806 126 131 PFLAG Kona/Big Island One'Ohana Youth and Family Services 25,000 127 132 Project Vision Hawai'i Health and Vision Services on Hawaii Island 25,000 128 133 Salvation Army Family Intervention Services,The Independent Living Skills Program-West Hawai'i 35,000 129 134 Salvation Army Family Intervention Services,The Life Skills Program-Kea'au 35,000 130 135 Salvation Army Family Intervention Services,The Project TLP Hilo 35,000 NONPROFIT GRANT APPLICANTS FOR FY2017-18 Numerical Sort Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 131 136 Salvation Army Family Intervention Services, The Substance Abuse Prevention Program-Pahoa 35,000 132 137 Self Discovery Through Art Recovery,Resiliance,ReCreation 30,000 133 138 Society for Kona's Education&Art Art Camps for Children&Teens 15,750 134 139 Society for Kona's Education&Art South Kona Workshops&Events 5,500 135 140 Special Olympics Hawai'i Special Olympics East Hawai'i 60,000 136 141 Special Olympics Hawai'I-West Hawaii General Fund 102,963 137 142 Three Ring Ranch Internships,Externships and Mentoring 15,000 138 143 Volunteer Legal Services Hawai'i I iawai'i County Pop-Up Legal Clinics 15,000 139 144 West Hawaii Community Health Center Inc. WI ICHC Community Outreach to Vulnerable Populations 9,000 140 145 West Hawai'i Community Health Center Inc. WHCHC Honaunau School Based Health Center 20,000 141 146 West Hawaii County Band Friends Music and Equipment Fund 5,000 142 147 West Hawai'i County Band Friends Volunteer Musicians Fund 5,000 143 148 YWCA of Hawai'i Island SANE 4,053 144 149 YWCA of Hawai'i Island Sexual Assault Support Services-Prevention Education 30,000 145 150 YWCA of I lawai'i Island YWCA Developmental Preschool 15,000 Total 6,528,193 Note: The following applicants did not meet one or more application requirements(disqualified) 1 1 AAA Academy Academic Program 40,000 2 2 AAA Academy Arts Program 40,000 3 3 AAA Academy Athletic Program 40,000 4 4 AAA Academy Vocational/Technical Program 40,000 5 98 Innovations Public Charter School Na Ka Ola-Life Navigators-Wellness Program 10,000 Total 170,000 Aloha Independent Living Hawaii Independent Living Services 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services Agency Director: Roxanna U. Bolden Phone No.: (808) 688 — 4817 Contact Person: Roxanna U. Bolden Phone No.: (808) 688 — 4817 Mailing Address: Address: P.O. Box 283 Address: City,ST,Zip Pearl City, Hawaii 96782 Facility Address: Address: 94-909 Kau'olu Street Address: City,ST,Zip Waipahu, HI 96797 Email Address: Fax No.: (800 ) 385 — 2454 Accountant/CPA: Darrell Lim Phone No.: (808 ) 522 — 8833 Firm (if applicable): Darrell Lim and Company, Inc. Mailing Address: Address: 81 South Hotel Street#300 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) fl Puna n Hamakua ❑✓ North Kona n South Hilo ri North Kohala ❑✓ South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth n Victims of Crimes n Culture and the arts ri Aged ❑Victims of Health or Social Crises n Needs of the poor ✓❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 $5,000 $3,875 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. 4.Total Budget& Position Count: Total Program Budget: $609,000 Total Program Position Count: 10 Total Agency Budget: $725,000 Total Agency Position Count: 13 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Title VII Part B Independent Living Services Funded by DHS under DVR $237,000 Title VII Part C Independent Living Services Funded by DHS under ACL $377,892 Supplemental Funding for Title VII Part C Independent Living Services Funded by DHS by AC $42,814 Count of Hawaii $10,000 Donations and Trusts $57,294 TOTAL: $725,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: AILH will continue to apply for grants to help support both operational and programmatic costs. This is in addition to continually working on developing new,creative resource opportunities, including: • Federally funded grants and contracts •State-funded grants and contracts •Local government grants and contracts •Center on Disability Studies •Adding a fee-for-service component •Hawaii Community Foundation 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 5. Provide assistance in locating affordable and accessible housing 6. Provide assistance in learning daily life skills to further independence EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Training in landlord/tenant rights 30 How to complete housing application 30 How to locate and maintain housing 30 Training in independent living skills 25 Training in legal rights and self-advocacy 25 Provide information and referral 75 Provide attendant referrals to acquire personal assistance services 10 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $3,875 $10,000 $10,000 Professional Fees Operations Supplies Equipment Other Other: Other: Other: Other TOTAL $3,875 $10,000 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. /4 J a i 7- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding regnect nnri may recult in nrtinnc taken to rernvar theca funric, By signing below, you are acknowledging that you have read and understood these requirements. 1/111/1417 7Jii(t? Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 Projected Result 30 30 30 25 25 75 10 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $10,000 Professional Fees Operations . Supplies Equipment Other: Other: Other: Other: Other: TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Aloha Performing Arts Company Theatre Education Program 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program Agency Director: Melissa Geiger Phone No.: (808) 322 — 9924 Contact Person: Melissa Geiger Phone No.: (808) 322 — 9924 Mailing Address: Address: PO Box 794 Address: City,ST,Zip Kealakekua, HI 96750 Facility Address: Address: 79-7384 Hawaii Belt Road Address: City,ST,Zip Kealakekua, HI 96750 Email Address: admin@apachawaii.org Fax No.: ( ) — Accountant/CPA: Patricia Schumacher Phone No.: (480 ) 584 — 4344 Firm (if applicable): Schumacher Tax&Accounting Mailing Address: Address: 530 E Hunt Highway,Suite 103,PMB 488 Address: City,ST,Zip San Tan Valley,AZ 85143-6582 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $18,000 Geographical Areas To Be Served: (One or more can be checked) ❑ 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 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 $5500 2.Agency Mission Statement: Aloha Performing Arts Company's("APAC")mission is to enrich the lives of Hawaii residents and visitors by presenting quality theatre and providing theatre education. APAC shall also maintain and operate a venue which provides opportunities for APAC and other organizations to present performing arts. 3. Program Description: APAC has long provided theatre arts education in West Hawaii,and takes great pride in the quality of instruction and positive impact on both individuals and the community.The company has offered a consistent slate of classes to students of all ages in recent years,which has resulted in youth now pursuing careers in theatre and film,as well as long-time participation by adults. Classes in basic theatre skills are available for keiki ages 4 to 7,and continued skill development for ages 8 to 12. The Aloha Teen Theatre program provides skill development,leadership training and performance opportunities for teens 13 to 18,and is free to all participants. The Intergenerational Acting Class meets year-round and reaches actors of all ages. APAC also holds vacation workshops for youth and occasional workshops for adults. Building on research conducted during 2015-2016,APAC would like to continue enhancing its offerings and increasing program stability.To achieve its goal of expanding its education program,APAC has set an objective of hiring an Education Coordinator. Existing staff are presently managing classes,but expansion of the education program and ensuring long term viability requires an individual to focus solely on this education effort.A dedicated Coordinator would organize existing classes and seek additional students,focusing particularly on sectors of the community with no access to training. The Coordinator will also design and staff additional courses according to community interest,and write grants to fund program needs. Until the Coordinator can expand workshop offerings for youth and classes for adults,APAC will be offering additional courses for youth during 2017. Investment in APAC's education program will result in increased opportunity for residents of West Hawaii for many years to come. 4.Total Budget& Position Count: Total Program Budget: $41,650 Total Program Position Count: 0.75 Total Agency Budget: $436,832 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii $19,000 Tuition $11,000 Revenues from Other Programs $4,200 John M Ross Foundation $3,000 • Other Grants $2,500 Donations $1,500 • Hawaii State Foundation on Culture and the Arts $1,200 TOTAL: $42,400 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Presently efforts to increase non-program revenue for APAC's education program are managed with APAC's other funding needs. Investment in a dedicated Education Coordinator will mean that education-specific funding opportunities will be pursued in a more strategic manner. Additionally,thoughtful planning and leadership from the Coordinator will produce higher enrollment and thereby drive increased tuition. Finally,APAC is embarking on a redesign of its fund development strategy,and will utilize the Coordinator in the creation of an education-centered element in the resulting plan. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective One:Hire an Education Coordinator to manage the APAC education program Objective Two: Increase enrollment in existing coursework Objective Three: Hold 3 youth workshops Objective Four: Design and implement 2 new courses for adults Objective Five: Research and design a program for seniors Objective Six:Submit 5 additional education-focused grants EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 6 Session Class for Ages 4 to 7 4 Terms,minimum 5 students 6 Session Class for Ages 8 to 12 4 Terms,minimum 8 students Year-Round Weekly Free Class for Teens 48 Classes per Year Youth Vacation Workshops 3 5-session workshops 6 Session Class for Adults, Primarily Senior 6 Terms,minimum 10 students Adult Workshops on Acting, Music,and Dancing 4 Workshops Adult Classes on Technical Theatre,Acting, Improvization, Music and Dance 4 Terms of 4 Classes,8 students per class Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $2,700 $2,700 $0 Professional Fees $12,500 $27,500 $14,500 Operations $10,100 $10,850 $3,800 Supplies $450 $600 $250 Equipment Other: Performance Rights (for Aloha Teen Theatre shows) $725 $750 $450 Other: Other: ALL 16-17 FIGURES ARE Other: PROJECTIONS, FISCAL YEAR IS Other: STILL UNDERWAY TOTAL $26,475 $42,400 $19,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program ,,. IIIAA WO ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n M- ember or members of the Council n S- taff appointed by a member of the Council n The Mayor ❑ The Managing Director E The Director of Finance n T- he Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. 1 /41/Ink1%1btvt.' elJanuary 30, 2017 Signature of th�rized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program i1. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's fiiturp funding rPqiuPct and mny racult in nrtinnc tnkan to rernvpr thPcp fiindc. By signing below, you are acknowledging that you have read and understood these requirements. Qqait) (ONIiY1 bOttc17){ January 30, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Aloha Performing Arts Company Program Name: Theatre Education Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 6 Session Class for Ages 4 to 7 4 Terms,minimum 5 students 6 Session Class for Ages 8 to 12 4 Terms,minimum 8 students Year-Round Weekly Free Class for Teens 48 Classes per Year Youth Vacation Workshops 3 5-session workshops 6 Session Class for Adults, Primarily Senior 6 Terms,minimum 10 students Adult Workshops on Acting,Music,and Dancing 4 workshops Adult Classes on Technical Theatre,Actin Im rovization,Music and Dance 4 Terms oClasses,8 g' p students peerr class TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0 Professional Fees $14,500 Operations $3,800 Supplies $250 Equipment Other: Performance Rights (for Aloha Teen Theatre shows) $450 Other: Other: ALL 16-17 FIGURES ARE Other: PROJECTIONS, FISCAL YEAR IS Other: STILL UNDERWAY TOTAL $19,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 ALS Ohana of Hawaii Excellence in ALS Care 7 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care Agency Director: n/a Phone No.: (808) 531 - 2765 Contact Person: Natalie Jones Phone No.: (808) 258 - 9388 Mailing Address: Address: 800 Bethel Street,Suite 404 Address: City,ST,Zip Honolulu, Hawaii 96813 Facility Address: Address: n/a Address: City,ST,Zip Email Address: nataliejones@alsohana.org Fax No.: ( ) — Accountant/CPA: n/a Phone No.: ( ) — Firm (if applicable): n/a Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo H North Kohala H South Kona ❑✓ North Hilo I✓I 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 I✓]Victims of Health or Social Crises ❑✓ Needs of the poor U Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0.00 0.00 0.00 2. Agency Mission Statement: The mission of ALS Ohana of Hawaii is to enhance the quality of life for those individuals in Hawaii who are affected by ALS by providing compassionate,practical support.This includes the person with ALS as well as family and friends. ALS Ohana of Hawaii is a community-based,volunteer-led organization and we partner with program providers to fulfill our mission, including The ALS Association Golden West Chapter. The mission of the Golden West Chapter is to lead the fight to treat and cure ALS through global research and nationwide advocacy while also empowering people with Lou Gehrig's Disease and their families to live fuller lives by providing them with compassionate care and support. 3. Program Description: The Excellence in ALS Care Initiative is a program designed to: 1)ensure that no one is alone with ALS;2)provide people with ALS and their loved ones with access to the best possible proactive care and support;and 3)engage the ALS community in the search for a cure for this devastating disease.Currently,the Golden West Chapter has established a highly valued model of care management and community outreach in Hawaii supported annually by philanthropic donations to the Chapter. In 2016, ALS Ohana of Hawaii was awarded a Grant in Aid(funding is yet to be received)to support the two full time Golden West Chapter staff(via a subcontract)who are currently serving the entire state of Hawaii. In order to better serve the state of Hawaii,ALS Ohana of Hawaii is seeking funds to support a subcontracted part time Care Manager to serve the County of Hawai'i and Oahu's neighbor islands.This Care Manager will provide access to comprehensive care services to help people with ALS,their family members and professional care givers find solutions as the disease progresses and the person with ALS loses the ability to move,swallow,speak and eventually,to breathe. The Care Manager will connect individuals and families to essential information, local community resources,educational opportunities,other people with ALS and their families,and access to free loans of durable medical equipment(power wheelchairs,etc.)and technology (augmentative communication devices, adaptive switches,etc.) necessary to make living with ALS easier. The Care Manager will be a member of multidisciplinary ALS clinic teams that are developed on the neighbor islands,serving as a bridge from the home and community to the health care professionals who make up the clinic team, including neurologists,pulmonologists, speech language pathologists, physical and occupational therapists, nutritionists and others,all of whom are essential to the proactive treatment of ALS. 4.Total Budget& Position Count: Total Program Budget: 50,000 _ Total Program Position Count: 1 Total Agency Budget: 6,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Special Events and Philanthropy $8,000 TOTAL: $8,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: ALS Ohana of Hawaii will partner with the Golden West Chapter to increase revenues to support this program. Potential sources of increased revenue include: government grants;community outreach events, including new local Walks to Defeat ALS; philanthropic gifts from individuals,families and foundations;estate gifts;and local corporate support. All of these opportunities will be explored throughout the year for viability and implementation if appropriate. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program objectives related to this request are to: • Maximize access to care support and community resources in Hawaii to help people live longer and better with ALS • Increase the number of people with ALS served in Hawaii • Reach people living with ALS in the earliest stages of the disease EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) The number of people with ALS served 30 The number of ALS caregivers served 50 The number of support groups offered 6 The number of people attending support groups 90 The number of public programs produced The number of public program attendees 30 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees 50,000 50,000 Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 50,000 50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council The Mayor n The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. TeEA-surzI- a at - I -4-- Signature I -4-- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-errant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future fiinding requpct rind mny reciilt in nrtinnc tnkpn tri rernvPr the SP flinch. By signing below, you are acknowledging that you have read and understood these requirements. ' .____,Q. 1� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ALS Ohana of Hawaii Program Name: Excellence In ALS Care 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result The number of people with ALS served 30 The number of ALS caregivers served 50 The number of support groups offered 6 The number of people attending support groups 90 The number of public programs produced1 The number of public program attendees 30 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 50,000 Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 ALS Ohana of Hawaii 800 Bethel Street, Suite 404 Honolulu, Hawaii 96813 iufo@alsohana.org (808) 258-9388 www.alsohana.org BOARD RESOLUTION TO APPOINT SIGNING AUTHORITY January 29, 2017 Be it resolved that the Board of Directors of ALS Ohana of Hawaii authorizes Jan R. Medusky, (Vice President and Secretary) and Natalie Jones (Treasurer) to sign contracts and documents relating to State and/or County Grants,both jointly or individually on behalf of the organization. 7o, R ja,e-rJ-A/1 et t Jan R. Medusky Date Vice President & Secretary 4‘-jcL q/i t-2 c't - t Natalie Jones Date Treasurer American National Red Cross Disaster Preparedness & Response in Hawaii County 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County Agency Director: Coralie Matayoshi Phone No.: (808) 739 — 8103 Contact Person: Kerrey Gomes Phone No.: (808) 739 — 8140 Mailing Address: Address: 4155 Diamond Head Road Address: City,ST,Zip Honolulu, HI 96816 Facility Address: Address: 55 Ululani Street Address: City,ST,Zip Hilo, HI 96720 Email Address: Kerrey.Gomes@redcross.org Fax No.: (808 ) 735 — 8626 Accountant/CPA: KPMG LLP Phone No.: (703 ) 286 — 8000 Firm (if applicable): KPMG LLP Mailing Address: Address: 1676 International Drive Address: City,ST,Zip McLean,VA 22012 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona C 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 n 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 14-15 FY 15-16 FY 16-17 • $12,500 $15,000 $10,500 2. Agency Mission Statement: Since its founding,the Red Cross has been the nation's premier emergency response organization,and the Red Cross is committed to helping people through the entire disaster cycle—preparedness,response and recovery. Each year,the American Red Cross of Hawaii delivers help, hope and healing to people affected by disasters by transforming donors' generous funding into shelter,food and emotional support. Twenty-four hours a day, seven days a week,the Red Cross assists victims of house and apartment fires,floods and other natural or man-made disasters. The mission of the Red Cross is to prevent and alleviate human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors. Founded in 1917,the Hawaii Red Cross has assisted victims of every major disaster in the island's history,including the: bombing of Pearl Harbor, Hilo tsunami,volcanic eruptions, Big Isle earthquake, Hurricanes Iwa, Iniki and Iselle, New Year's&Manoa floods, Kaloko Dam burst, Sacred Falls landslide,Xerox shooting, air transportation crashes,and hostage situations. The Red Cross fulfills its humanitarian mission by coming to the aid of disaster victims, teaching people how to save lives, and providing emergency communication between deployed military service members and their families in times of crisis. 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 and anywhere throughout the state;2)to provide individuals,families,schools, businesses and communities with the knowledge and skills to better prepare themselves and others before emergencies occur. The Red Cross responds every four days to disasters in Hawaii,and the immediate and compassionate services reduce the harsh physical and emotional distress that prevents people from meeting their own basic needs following a disaster. The following goals and objectives have been defined for the Disaster Preparedness and Response Program: •Meet the immediate emergency needs of victims(food, clothing, shelter,crisis counseling)following disasters by recruiting, training and coordinating volunteers to be on call 24/7, 365 days a year to provide disaster relief assistance to victims of disasters. •Create informed communities that know how to protect their own lives and property following a disaster by reaching individuals with lifesaving information through disaster preparedness presentations, including schools and participation at community fairs. • Establish integrated community networks to ensure that response to any type of disaster is coordinated and effective in protecting people and property by working closely with government and private partners to ensure inclusive and robust mass care plans:clear evacuation routes, private and government facilities that can serve as shelters in most communities,shelter supplies in different areas of various counties,trained partners that can assist with mass evacuation and other partners that can enhance mass care services. •Target economically and socially disadvantaged populations with disaster preparedness information. 4.Total Budget & Position Count: Total Program Budget: 143,972 Total Program Position Count: 1 Total Agency Budget: 3,729,173 Total Agency Position Count: 20 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii $25,000 Hawaii Island United Way $30,000 Other contributions (direct mail and grants) $75,000 Subsidy by American Red Cross to meet deficit $13,972 TOTAL: $143,972 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: During the past decade, Hawaii has been impacted by real, large-scale disasters:the Big Island earthquake and Kauai Kaloko Dam burst in 2006, Hurricane Flossie in 2007, a federally declared flooding disaster following severe winter storms in 2008, Hurricane Felicia in 2009,a tsunami warning following the Chile earthquake in 2010,the Japan earthquake and tsunami that caused$30 million in damage in Hawaii in 2011, another tsunami warning following the Canada earthquake in 2012,Tropical Storm Flossie in 2013,Tropical Storms Iselle and Ana and the Puna lava flow in 2014,Tropical Storms Guillermo and Kilo in 2015,and Tropical Storm Darby in 2016. Since disasters impact entire communities,effective disaster preparedness requires the involvement of everyone in the area. The geographic remoteness of the Hawaiian Islands makes community preparedness and resiliency not only relevant, but crucial. Following a major disaster,our logistics bridge could become compromised and critical resupply of items such as food, medical supplies and fuel could be delayed for weeks. Being prepared—having the resources and plans in place to withstand disaster—is a key component to mitigating disaster risk and is essential to a community's ability to recover. Although the Red Cross is not a government agency, it is mandated by Congress to provide disaster relief assistance. This is an unfunded responsibility that stipulates the American Red Cross must provide emergency mass care and assistance for individuals with urgent and verified disaster-caused needs. The Red Cross is not a government agency and does not receive federal funding for disaster operations. All disaster response and training are provided to the public free of charge. The Red Cross continually seeks funding from foundations,corporations,and individuals to support the critical services provided and sustain their ability to help people through the entire disaster cycle. Each of their voting Board of Directors contributes financial support to the organization and efforts to help the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Disaster Preparedness and Response Program address both the Red Cross humanitarian mission and its federal mandate. The mission is to ensure that victims of disasters have a safe place to stay,food to eat, assistance or referrals to help replace essential items and support from trained professionals to aid in recovery planning. In a major disaster,crisis counseling, sheltering,feeding,disaster welfare information,emergency first aid and other support services are also provided to victims and those affected. In preparation for a major disaster,the following are ongoing Red Cross efforts: • Identifying necessary supplies,equipment, staff and volunteers to better serve vulnerable populations. • Developing preparedness strategies for diverse communities, including multi-lingual education materials. • Signing shelter agreements with large capacity facilities. • Forging agreements with large-scale food distributors and developing plans for both mobile and bulk distribution of food. • Strategically pre-positioning disaster relief supplies across the state. • Participating in disaster preparedness drills with community partners to assess readiness. It takes preparation, resources and infrastructure to be able to respond everyday throughout the year. The Red Cross accomplishes this with a small staff and volunteers. Volunteers need to be recruited beforehand and trained, put on call, and deployed at a moment's notice whenever there is a disaster. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of disaster responses 15 Number of individuals assisted after a disaster 40 Number of individuals reached with disaster preparedness information 800 Number of smoke alarms installed 150 Number of children reached with preparedness info via the Pillowcase Project 200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $53,885 $55,000 $50,000 Professional Fees $0 $0 Operations $68,760 $71,500 Supplies $1,153 $1,000 Equipment $4,640 $3,183 Other: Disaster Relief Assistance (unpredictable) $20,000 $10,000 Other: Travel, Postage, Gas, Program-Related Expenses $5,406 $3,289 Other: Other: Other: TOTAL $153,844 $143,972 $50,000 if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance (l The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. ‘IzoIll Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation ofyour agency's future funding rPquPct and mny rPcult in nrtinnc tnkPn to rPrnvPr these fundc. By signing below, you are acknowledging that you have read and understood these requirements. 'I74 111 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of disaster responses 15 Number of individuals assisted after a disaster 40 Number of individuals reached with disaster preparedness information 800 Number of smoke alarms installed 150 Number of children reached with preparedness info via the Pillowcase Project 200 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $50,000 Professional Fees Operations Supplies Equipment Other: Disaster Relief Assistance (unpredictable) Other: Travel, Postage, Gas, Program-Related Expenses Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 YEARS 01 ALOHA The American National Red Cross— Disaster Preparedness and Response in Hawaii County Additional Page for#3 Program Description American Red Cross Hao-...i Disasters strip people of their essentials, like shelter and food, and larger events, such as hurricanes, can ravage entire islands. Every day,the American Red Cross assists people who face disasters, offering care and comfort in their darkest hours. The Red Cross maintains its steadfast commitment to provide assistance to those affected by disasters. 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. County of Hawaii funding would help to support the basic infrastructure of our disaster response and preparedness program so the Big Island Red Cross is able to respond and prepare the community beforehand to mitigate the loss of life and property. Specifically, 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 conduct 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. 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. Just 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. Without support of these fixed costs, we couldn't operate and wouldn't be able to respond when needed. The fact that we don't have to pay our volunteers to do the work demonstrates the Red Cross is a wise investment. 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. 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 of this program 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 delayed. Educating families and businesses to take responsibility for their own Y E ARS 01 AEU 11 1 The American National Red Cross— Disaster Preparedness and Response in Hawaii County Additional Page for#3 Program Description American Red Cross 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. Today, emergency management experts emphasize the importance of resilience, which is the ability for a community to not just survive, but to adapt and bounce back. During FY16 (7/1/15—6/30/16), we responded to 9 disasters on the Big Island and assisted 26 individuals with their immediate emergency needs. Through community disaster education outreach, we shared critical disaster preparedness information with 2,383 individuals on the Big Island on how to prepare for emergencies. We issued 59 disaster training certificates and maintained a base of 216 active and trained disaster volunteers. Throughout the year, we will continue to train more volunteers, conduct disaster preparedness education outreach in the community and provide disaster relief assistance. According to the Census Bureau, from 2010 to 2014, 18.1% of the County of Hawaii's population lived below the poverty level, and in FY15, at least 44% of the disaster families served on the Big Island were below the poverty guidelines set by the U.S. Department of Housing& Urban Development. No one can predict when or where the next disaster will strike. For the past 100 years,the Hawaii Red Cross has kept a simple promise—to be there to alleviate suffering. As the Red Cross continues to honor this pledge,the financial burden also increases with the growing scale and frequency of each passing disaster. When a major disaster threatens whole communities or the entire state,the Red Cross is even more critical to saving lives and giving hope. An investment in community education and capacity building now will help reduce the impact of a catastrophic disaster and will help save lives. While we cannot control the timing, we can work to make sure Hawaii is as prepared as possible. Arc of Hilo, The Cold Kitchen Development Project 9 z cF'/ County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project Agency Director: Debbie Perkins, CEO Phone No.: (808 ) 935 — 8535 Contact Person: Marta Birchard, Fund Development Phone No.: (808 ) 935 — 8535 Mailing Address: Address: 1099 Waianuenue Ave. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1099 Waianuenue Ave. Address: City,ST,Zip Hilo, HI 96720 Email Address: mbirchard@hiloarc.org Fax No.: (808 ) 934 — 7714 Accountant/CPA: Rozanne Connell Phone No.: (808 ) 930 — 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: 136 Kinoole St. Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) ✓ Puna Hamakua ❑ North Kona H South Hilo North Kohala ❑South Kona O North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ✓]Youth Victims of Crimes n Culture and the arts ❑✓ Aged ❑ Victims of Health or Social Crises O Needs of the poor I✓I Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $20,000 0.00 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 skills training as well as employment and residential opportunities. 3. Program Description: Many of The Arc's disabled participants are interested in finding meaningful employment in the food industry. Currently, in Hawaii,food prep is one of the highest areas of projected growth and the restaurant industry is by far the largest employer of disabled people. Unfortunately,we do not have a kitchen facility that would enable us to create a teaching/learning space for transferable skills in the food prep and restaurant service arenas.With a cold kitchen site,clients could gain firsthand experience by initially supplementing the pre-packaged items in the client-run snack shop,and in time,offering a catering service for our Conference Center at the Job Creation&Training Center slated to open in 2017.The availability of a cold kitchen site would also allow The Arc to develop new opportunities for catering/delivery options in our community. Additionally,the lack of a cold kitchen forces us to purchase daily lunches for The Arc's 50+ participants from a local grocery store deli or diner.The content of the meals are high in calories,fat, sodium and cholesterol and offer little in the way of vitamins,fiber and other nutrients important to health.This contradicts our focus of teaching health and wellness practices to our people. By incorporating locally grown fruits&vegetable choices, smoothies&wraps to our daily client lunches,it would cut our food budget by 1/3, allowing for more program funding. Clients could have an opportunity to expand their knowledge of how food choices directly relate to their health issues and become life-long learners.As the national agenda becomes increasingly rooted in supporting individuals with intellectual and developmental disabilities to live completely self-determined lives in the community,we too are engaging in incentives to help individuals by providing vocational training opportunities and the ability to join the workforce in an environment of their choosing. 4. Total Budget & Position Count: Total Program Budget: $91,500 Total Program Position Count: 73 Total Agency Budget: 3.2 M Total Agency Position Count: 94 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Safeway Charitable Foundation (Received) $1500 Cooke Foundation (Received) $5,000 The Arc of Hilo (Allocated) $2,500 Mclnerny Foundation (Pending) 32,500 County of Hawaii (Pending) $50,000 TOTAL: $91,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The bulk of the funds are for the professional (architectural)design, infrastructure(equipment), permitting and labor costs (demo, plumbing,electrical,flooring, painting, installation). The Arc of Hilo will increase revenues to support this program through: *Marketing the expansion of new menu items sold in the snack shop(through flyers,web page,social media) *Creating new revenue streams with our micro-businesses,such as lunch delivery and catering for the Conference Center and local businesses * Fund raising activities dedicated to our cold kitchen program(through car washes, garage sales, craft fair) 7. Program Objectives Using County Nonprofit Grant Program Funds: The Arc of Hilo would utilize these funds for the renovation and development of the cold kitchen area, purchase appliances and related equipment in order to meet County/State regulations.The items needed for the build-out of a cold kitchen as regulated by the Hawaii State Department of Health include the following:commercial grade equipment: refrigerator,freezer,dishwasher, stainless steel 3 compartment sink, hand washing sink&fixtures,stainless steel counter top/tables,garbage disposal, miscellaneous kitchen cookware, utensils, storage containers,etc. Program Objectives: 1. For clients of the Adult Day Program are:Create/promote nutritional options for daily lunches. •To provide a on-site kitchen space to teach kitchen safety,food prep and cooking,while adding new items to the snack shop •To provide a reality based hands-on learning experience which will include budgeting, menu planning,grocery shopping, calorie intake,sodium/sugar and expiration awareness, portion control 2.As a job training site: •To provide learning opportunities and transferable skills for employment in food prep, and restaurant service •Cultivate and grow future micro enterprises, such as catering and delivery service 3. For our Commercial Services Program: •Provides additional opportunities for employment and foster inclusion of Hawaii's disabled population •Provides the ability to increase catering opportunities with local businesses EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) The number of people this project will directly impact are 70+participants&staff Serve nutritionally sound lunches The number of people being trained for restaurant prep/service 15-20 per year Create full time or p/t client employment The number of people impacted by better choices in the snack shop are 50+ Promote better food choices The number of people impacted by conference catering opportunities are 10-12 per year Development of micro-businesses Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees 20,000 $15,000 Operations Supplies Equipment 38,500 $20,000 Other: Subcontractors-plumbing, electrical,flooring 20,000 $15,000 Other: Shipping/Handling 5,500 Other: Tax 1,500 Other: Contingency Fee $6,000 Other: TOTAL 91,500 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council Staff appointed by a member of the Council I I The Mayor The Managing Director The Director of Finance I I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. pC4 C. ( 15 111 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai`i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aciencv's future funding rergiPct rind mny recult in nrtinncinkPn to rernwPr thece fundc, By signing below, you are acknowledging that you have read and understood these requirements. VS/V701Q.A.K, e_...- ---(:),L-1----1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Arc of Hilo Program Name: Cold Kitchen Development Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Serve nutritionally sound lunches Create full time or p/t client employment Promote better food choices Development of micro-businesses TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $15,000 Operations Supplies Equipment $20,000 Other: Subcontractors-plumbing, electrical, flooring $15,000 Other: Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Arc of Kona Basic Life Skills for Independent Living 10 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living Agency Director: Michele Ku, President/CEO Phone No.: (808) 323 — 2626 Contact Person: Michele Ku, President/CEO Phone No.: (808) 323 — 2626 Mailing Address: Address: PO Box 127 Address: City,ST,Zip Kealakekua, HI 96750 Facility Address: Address: 81-1065 Konawaena School Road Address: City,ST,Zip Kealakekua, HI 96750 Email Address: michele@arcofkona.org Fax No.: (808 ) 323 — 9444 Accountant/CPA: Ann N. Fukuhara, CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: PO Box 6691 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $22,000 Geographical Areas To Be Served: (One or more can be checked) n Puna ✓❑ Hamakua ❑✓ North Kona 0 South Hilo ✓❑ North Kohala n South Kona ❑✓ North Hilo ✓ South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) I✓I Educational concerns l✓l Youth ❑Victims of Crimes ❑✓ Culture and the arts n 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $24,500 $20,000.00 $ 8,750.00 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".We have served the Intellectually, Developmentally, and Physically disabled population for over 55 years and now have five physical office locations to better outreach and serve the more isolated rural areas of Hawaii County. Our vision is to support persons limited by disability to work with their own strengths,talents, and skills to contribute to their own communities and in turn have those communities accept, honor and utilize those talents and abilities. Our motto expresses these concepts by"Believing in Potential...Expanding the Possibilities"(Ho'o Nui Ka Hiki). The Arc of Kona's Core Values of Integrity, Vision, Dedication, Inclusiveness, Sensitivity, and Excellence describe our culture and the infrastructure that has allows us sto successfully carry forth our mi8ssion. 3. Program Description: Intellectually and Developmentally Disabled individuals are one of the most vulnerable populations on the island. Easy targets for a variety of types of abuse and challenged with making good judgments due to cognitive delays, they need a strong mix of supports to insure their safety and assist with activities of daily living. The Arc of Kona's Basic Life Skills for Independent Living Program provides protective factors for our participants including social development, appropriate sexual behavior, protection from abuse by family members, employers and strangers, nutrition, hygiene, and communication skills so each person can live as independently as possible with or without assistance. Along with these supports is the opportunity to prepare for work in an inclusive and competitive environment. The Basic Life Skills Program for Independent Living uses the"community as a classroom" approach to learning where participants can practice individualized and measurable skills sets in the community where they reside. Participants receive services 365 days per year including transports into the community. These Basic Life Skills are essential to strengthening the protective factors around each individual according to their needs. When provided community integration for learning new skills, participants have opportunities to share their own gifts and talents with the community and transfer new life skills to multiple settings. 4.Total Budget& Position Count: Total Program Budget: 365,202 Total Program Position Count: 20 Total Agency Budget: 3,539,152 Total Agency Position Count: 128 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Medicaid Home and Community Based Services $ 319,202.00 Hawaii Island United Way $ 24,000.00 County of Hawaii $ 22,000.00 TOTAL: $ 365,202.00 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 always been proactive seeking funding for program support and has a strategic funding plan. Our current funding strategy for this program includes: 1. Continuously upgrading our website to receive on-line donations. 2. Increasing our donor base which this year was very generous as we continue to educate the community about our services. 3.Actively seeking government and non government proposal opportunities to supplement the program budget. 4. Holding yearly signature events(The Arc of Kona held is 20th Annual Bazaar December 2016.A portion of the proceeds is utilized to support the Basic Life Skills program). 5.Working continuously with other philanthropic organizations such as West Hawaii Rotary clubs and West Hawaii Association of Realtors to receive larger donations. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide a safe, healthy and supportive environment for training both in a classroom and community setting 365 days a year from July 1, 2017-June 30, 2018 for 120 participants referred from the Department of Health Developmental Disabilities Division with a special focus on individuals living in the most rural under-served areas of the island. 2. Provide individualized independent living skills through the Basic Life Skills training program 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 Basic Life Skills training in the community as a learning laboratory. 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. 5. Provide support services for seeking, attaining and maintaining employment for individuals who desire to work. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) See Attachment Table 1: Question#8 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $299,785 $18,400 Professional Fees $5,147 $300 Operations $50,395 $3,000 Supplies $9,875 $300 Equipment Other: Other: Other: Other: Other: TOTAL $365,202 $22,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council I I The Mayor I I The Managing Director The Director of Finance I I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I✓1 If no conflicts exist, check here. 7,7/(i 116 pi,eside„/./ co January 30, 2017 Signature of Authorize• .-rson. s ecif title Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaency's fl(ture funding rPgiiPct rind mny result in nrtinnc taken to rernver thece funds, By signing below,you are acknowledging that you have read and understood these requirements. 7' nff < January 30, 2017 f _ >�sldee =) Signature of Authorized P-rsor (specify title) / Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arc of Kona Program Name: Basic Life Skills for Independent Living 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $18,400 Professional Fees $300 Operations $3,000 Supplies $300 Equipment Other: Other: Other: Other: Other: TOTAL $22,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Arc of Kona 2017-2018 County Grant Application ATTACHMENT 1 Question 8 Table l BASIC LIFE SKILLS FOR INDEPENDENT LIVING Performance Measures: Applicant Projected Results: Basic Life Skills For Independent Living Basic Life Skills For Independent Living 1. a) Provide a safe, secure 1. a) 260 days of standard classroom activities environment with sufficient staff for 27 individuals. supervision, 5 days a week, 52 weeks a year, for 27 I/DD participants. b) Deliver ongoing independence b) 240 days of one on one and group through life skills training in the service for approximately 93 participants in the classroom and the rural areas as community. per each individual's plan which is developed by the Department of Health, the family and the Arc of Kona. 2. Provide access to the community 2. a) 144 classroom/group transports into the for hands-on independent living community per year to achieve individual goals through life skills training for independent living through life skills. experiences leading to independent living including budgeting for food b) 356 transports in rural areas to achieve and clothing, shopping, fire safety, individual independent living through life skills ordering and eating in public, plans in the community setting. handling money, making and keeping appointments, nutrition and exercise, and appropriate behaviors in public (including sexual behavior). 3. Provide on-going Independent 3. 365 days of instruction provided with Living Life Skills assessments and assessment, base line, and data collection for data collection and evaluation for results reporting. Tools used are the Brigance each individual. Life Skills Assessment, and Individualized Service Plans (ISPs) developed by the This includes areas such as fine Participant, the family, and the Department of and gross motor skills, receptive Health Case Managers. and expressive language, volunteering, recognizing and This results in extensive progress reports reporting abuse, health, hygiene, written quarterly for the Department of Health safety, socialization, basic cooking and the family to determine success and any skills, behaviors, consumerism, changes needed for the current year to better basic literacy and pre vocational achieve the individual goals. 80% of the total skills training. enrolled will meet at least one Life Skills goal during the year. Art & Sciences Center ASC Community Education Program 11 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Program Agency Director: Gail Clarke Phone No.: (808) 938 — 2933 Contact Person: same Phone No.: (808) 965 — 3730 Mailing Address: Address: PO Box 2091 Address: City,ST,Zip Pahoa, HI 96778 Facility Address: Address: 15-1397 Homestead Rd Address: City,ST,Zip Pahoa, HI 96778 Email Address: ascpuna@gmail.com Fax No.: (808 ) 965 — 3733 Accountant/CPA: Rozanne Connell Phone No.: (808) 968 — 1002 Firm (if applicable): Carbonaro CPA and Associates Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $91,800 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 n Culture and the arts ✓❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 7200 9000 7250 2.Agency Mission Statement: ASC formed as a 501 c3 in 2003,to provide outstanding support and infrastructure for community based learning rooted in Puna.ASC envisions learning and sharing opportunities to empower participants to thrive,cooperate,innovate and serve.ASC works to provide(1)access to education,(2)stewardship of diversity and cultural infusion,(3)stewardship of our environments, and(4)partnerships for positive economic impacts. 3. Program Description: a.ASC continues to develop partnerships and provide services for local groups to hold meetings,classes and network via Community Learning Festivals, launched in 2016. Learning festival participants are educators,vendors,entertainers and guests.The spring Tropical Living Festival is focused on culture,community,environment and energy,and the fall Art Is Life Festival is to create,share,celebrate and support local art. Both were attended by hundreds and surveys indicated all want to see them repeated and expanded. ASC is working to again offer HCC classes in Puna,for community members.The Hawaii Island school Garden Network (HISGN)will be holding workshops at ASC in March and June 2017,the island-wide Spelling Bee was hosted for the second year and community groups book regularly.Management of facility use and an activity calendar require staff,currently limited to 5 hours per week, backed-up by volunteers.Community groups apply for use of facilities and fees are based on a sliding scale. b.ASC's primary tenant, HAASPCS,with 678 grade k-12 students,seeks expanded afterschool activities focused on STEAM learning that ASC strives to facilitate with staff support(2 x 0.4FTE positions); •Science(garden and food,weather,observation and inquiry), •Technology(including ethical use to address cyber-bullying), •Engineering(project development from crafts to small buildings), •Arts(fine,fitness and performing)and •Math(with economic and entrepreneurial endeavors). ASC is exploring shared-workspace models that would allow students,interns, mentors and entrepreneurs to work and learn together. An accessible kitchen to process value-added food,and shops and studios for woodworking,art,music and access to technology are needed.Staff is needed to coordinate offerings. 4.Total Budget& Position Count: Total Program Budget: 93,000 Total Program Position Count: 1.8 FTE Total Agency Budget: 256,900 Total Agency Position Count: 1.925 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate ASC General Funds (rent,fees, contributions) 1200 County of Hawaii Grant 91800 TOTAL: 93,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: .To the extent funding allows for staffing and marketing,ASC will develop partnerships,events and activities to increase use of facilities and educational services in our community.A current example of success in this area is the networking of Paradise Ponies(wood carvers working on a Carousel of Aloha)and the HAASPCS community service project students who will be learning woodcarving from experienced mentors.This project amplifies the need for a shared,student and community accessible woodshop that could be rented by local entities and individuals. .To meet an often vocalized need for commercial kitchen spaces to clean and process produce and create value-added products for market, plans for a kitchen and workspace are gaining momentum.With funding,ASC can accelerate strategic planning and implementation.ASC has applied for two state 2017 grants-in-aid for an alarm system($28k)and a TIAR of the Hwy. 130 by-pass and Post Office Road in Pahoa($66k)and plans to re-apply for USDA Rural Development and other foundation funds for planning and facility development($3-5 million). Expanded facilities will result in rental revenue. .To date,ASC has worked with HAASPCS including their community service projects and Workplace Readiness Program for special students to learn important job skills, Hawaii Community College,the American Red Cross, Puna Pono Alliance, Hawaii Farmers Union Unified—East Hawaii Chapter, HCEOC, Hawaii Youth Business Center,Big Island Invasive Species Council, Aha Kuka Wao Kele'I Puna,Oral Traditions intersession camp, Paradise Ponies,local halau,the Men of Pa'a,the Kohala Center and Hawaii Island School Garden Network. Funds for staff are the limiting factor that will allow expanded service and revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: a.Provide a safe and accessible place for community education,events,meetings and programs including two—four Community Learning Festivals and weekly community meetings serving up to 3000 residents. b.Support a network of partners,community and possibly virtual mentors and students who collaborate and produce together, ideally via safe,afterschool and intersession programs,to strengthen our community and economy. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Host 2-4 Community Learning Festivals—400-600/ea 800—2400 participants Host 20-50 community meetings w sliding scale fees 200—500 participants Host afterschool and intersession STEAM and student:mentor learning 80-300 participants Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 2000 40000 40000 Professional Fees 2000 2000 Operations 2500 1300 Supplies 950 500 500 Equipment Other: Festival (4x ads,tents, entertain, security)2016-17=2 festivals 4300 16000 16000 Other: Afterschool program facilitator(0.4 FTE x 2) 32000 32000 Other: Other: Other TOTAL 7250 93000 91,800 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education 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 I Staff appointed by a member of the Council n The Mayor The Managing Director n The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. r 1 _ .a, 45c 1 /30/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 ,Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's faturPlanriing rPgiiPst anti may result in nrtinnc tnkPn to rpr tier thpcP fl/nrJc, By signing below, you are acknowledging that you have read and understood these requirements. j_ ( — 1/30/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Host 2-4 Community Learning Festivals—400-600/ea 800—2400 participants Host 20-50 community meetings w sliding scale fees 200—500 participants Host afterschool STEAM and student:mentor learning 80-300 participants TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 40000 Professional Fees 2000 Operations 1300 Supplies 500 Equipment Other: Festival (4x ads,tents,entertain, security)2016-17=2 festivals 16000 Other: Afterschool program facilitator(0.4 FTE x 2) 32000 Other: Other: Other: TOTAL 91,800 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Bay Clinic, Inc Breast Cancer Prevention Program 12 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program Agency Director: Harold Wallace Phone No.: (808) 930 — 0499 Contact Person: Youlsau Bells Phone No.: (808) 961 — 4078 Mailing Address: Address: 450 Kilauea Avenue Address: Suite 105 City,ST,Zip Hilo, HI 96720 Facility Address: Address: 450 Kilauea Avenue Address: Suite 105 City,ST,Zip Hilo, HI 96720 Email Address: ybells@bayclinic.org Fax No.: (808 ) 961 — 5678 Accountant/CPA: Rozanne Connell Phone No.: (808) 930 — 6850 Firm (if applicable): Cabonaro CPAs&Management Group Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑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 2017-2018 Page 1 of 8 County of flawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $35,000 $0 2. Agency Mission Statement: Mission:Bay Clinic is a community-directed healthcare organization that provides quality primary and preventive care services to the people of East Hawai'i. Bay Clinic will ensure that patient-centered,culturally responsive,and affordable healthcare services are locally accessible in our communities. Founded in 1983, Bay Clinic, Inc. (BCI)is a 501(c)(3)non-profit Federally Qualified Health Center network of eight health center sites serving over 22,000 patients annually. Bay Clinic serves the health care needs of the medically underserved districts of North and South Hilo, Puna,and Ka'u. Bay Clinic's health centers are located in the towns of Hilo, Kea'au, Pahoa,and Na'alehu;as well as a Mobile Health Unit,offering primary medical and dental care,rotating between Ocean View,Volcano Village, Mountain View,including school-based clinic services to the DOE KKP District Complex schools. Bay Clinic 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's Breast Cancer Prevention Program(PCPP)helps address the breast cancer disparity in our East Hawai'i community through outreach and education to increase the number of women who receive regularly scheduled screenings,to improve the early malignancy detection,and ultimately reduce breast cancer morbidity and mortality in our community. Women interested in accessing screening services through our outreach efforts are referred to one of our six primary medical care sites. Each woman who seeks care meet with one of our patient service representatives(PSR.) The PSR then works one-on-one with the patient as they check them in and assess their insurance status. The patient is then linked with one of our care coordinators who works alongside the patient's health care team that is headed by the patient's BCI primary care provider. Screening services are affordable through a Sliding Fee Scale and accessible for all,including clinical breast exam, individualized counseling,and mammograms. When clinically indicated further diagnostic services will be prescribed. The PCPP provides outreach and education,screening,and diagnostic services to reduce barriers to care,and health care navigation assistance for those diagnosed with breast cancer and requiring more specialized care. Our Breast Cancer Prevention Program is vital to the long-term health of all at-risk women in East Hawai'i. We are making a difference. Last year,BCI provided women's health services to 2,962 unduplicated patients;of those 1,144 were referred for a mammogram and of those 223 were found to have abnormal breast findings.80%of those who were found to have abnormal breast findings,were detected very early and all referrals and care coordination was immediate and on-going. 4.Total Budget& Position Count: Total Program Budget: $219,223 Total Program Position Count: 10 Total Agency Budget: $16,858,836 Total Agency Position Count: 178 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Safeway Foundation $10,000 Hawai'i Department of Health- Breast and Cervical Cancer Control Program $30,000 Susan G Komen $10,000 TOTAL: $50,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BCI provides affordable and quality care for all,based on a Sliding Fee Schedule applied to all patients based on family size and income level. However, patients who are low-income and do not meet the eligibility criteria for assistance under the state's Breast and Cervical Cancer Control Program(BCCCP)are flagged for support assistance from partners such as the County of Hawaii,as well as the Safeway Foundation and others. Bay Clinic requests$40,000 from the County of Hawai'i will be applied directly towards the costs associated with providing breast cancer education,care coordination,screening and follow-up(as needed)for those women who fall through the gap in care provided by the BCCCP. To augment the costs of this program,funds totaling$30,000 from BCCCP is confirmed as well as$10,000 from the Safeway Foundation,and Bay Clinic will provide the remaining$75,313 in in-kind support. A detailed budget outlining the income and expenses for our Breast Cancer Prevention Program is attached. BCI's Breast Cancer Prevention Program is highly successful with a proven track record of providing breast cancer screening and care coordination to all at-risk women in our East Hawai'i service region for over twelve years. This program is sustained through insurance billing,as 63%of our patients qualify for Medicaid/QUEST insurance. 7. Program Objectives Using County Nonprofit Grant Program Funds: BCI provides clinical breast exams and refer women to Hawai'i Radiologic for mammograms. The County of Hawai'i support will cover the cost of mammograms for those women who are financially vulnerable and do not meet the state's Breast and Cervical Cancer Control Program age eligibility criteria for financial assistance. This support will ensure that women who would put off care until their condition becomes critical will receive the health care services needed to have a positive health outcome and help save their lives. As a result,the support will also enhance BCI's patient care coordination to ensure that patient's who have abnormal findings get the continuum of care they need to address their condition. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of BCI's Women Health patients who receive breast cancer screenings. 3,014 Number of women who receive mammograms in the program period. 1,259 Number of women who receive care coordination for abnormal findings. 144 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $126,458 $133,840 $20,000 Professional Fees $1,500 $1,500 $0 Operations $16,021 $16,822 $0 Supplies $2,250 $2,363 $0 Equipment $0 $0 $0 Other: Diagnostics(mammograms) $62,814 $64,698 $20,000 Other: Other: Other: Other: TOTAL $193,038 $219,223 $40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: 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): n Member or members of the Council F7 S- taff appointed by a member of the Council n The Mayor n The Managing Director n T- he Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 2 If no conflicts xi , c c <. M1- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding regIJPct and mny recult in nrtinnc token to rernvPr thece funds. By signing below,you are acknowledging that you have read and understood these requirements. January 23, 2017 i Signature of ize Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Breast Cancer Prevention Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of BCI's Women Health patients who receive breast cancer screenings. 3,014 Number of women who receive mammograms in the program period. 1,259 Number of women who receive care coordination for abnormal findings. 144 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $20,000 Professional Fees $0 Operations $0 Supplies $0 Equipment $0 Other: Diagnostics(mammograms) $20,000 Other: Other: Other: Other: TOTAL $40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Bay Clinic, Inc Diabetes Awareness & Self-Management Program 13 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program Agency Director: Harold Wallace Phone No.: (808) 930 — 0499 Contact Person: Youlsau Bells Phone No.: (808) 961 — 4078 Mailing Address: Address: 450 Kilauea Avenue Address: Suite 105 City,ST,Zip Hilo,HI 06720 Facility Address: Address: Same as above. Address: City,ST,Zip Email Address: ydbells@bayclinic.org Fax No.: (808 ) 961 — 5678 Accountant/CPA: Rozanne Connell Phone No.: (808) 930 — 6850 Firm (if applicable): Cabonaro CPAs&Management Group Mailing Address: Address: P.O.Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES • Amount of Request for County Nonprofit Grant Program Funds: $26,500 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑./ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $35,000 $0 2.Agency Mission Statement: Founded in 1983, Bay Clinic, Inc. (BCI)is a 501(c)(3)nonprofit Federally Qualified Health Center(FQHC)network of eight community health centers serving the Hawaii County districts of North and South Hilo, Puna,and Ka'u. Bay Clinic health centers are located in the towns of Hilo,Kea'au, Pahoa,and Na'alehu;with a Mobile Health Unit providing primary medical and dental care to the towns of Ocean View and Volcano,as well as school-based clinic services to the DOE Kea'au-Ka'u-Pahoa District Complex schools. 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. BCI works to ensure that affordable,comprehensive,and patient-centered health care is available to all in East Hawaii. As a Federally Qualified Health Center, Bay Clinic provides primary medical,dental,and behavioral health care on a sliding fee schedule that is applied to all patients depending on income level and family size. 3. Program Description: BCI is the only organization on the entire island that provides Medicaid/QUEST supported Diabetes Self Management and Education(DSME)program;making it absolutely critical that we continue to expand access, provide outreach and prevention, and culturally appropriate care management and self-empowerment support for all in need. Included in BCI's DSME program are 9-week DSME classes that are led by BCI's registered dietitian(RD)and follows the American Association of Diabetes Educators(AADE)DSME class requirements. The DSME team is comprised of highly trained professionals including BCI's Director of Operations,who is an RN and oversees the RD,the RD,a Physician's Assistant,a Clinical Psychologist,and a number of support staff including nurses,health information systems technologists,quality improvement specialists,and clerical support personnel. Hawai'i County had the highest diabetes(underlying or non-underlying)mortality rate in the entire state. For those dealing with diabetes, its complications and the high cost of care,an estimated 20-45%of sufferers also experience anxiety,depressive or distress symptoms,complicating their ability to manage the lifelong behavior modification aspects of diabetes treatment. In addition to DSME classes,the RD partners with: 1)other BCI providers and behavioral health specialists to ensure patients that are at-risk are provided nutrition counseling,mental health support as needed,and other support options with social service organizations,transportation,and other help to ensure they succeed in their efforts to live healthy and control their diabetes; and 2)local organizations and events to outreach and educate community members on the importance of living healthy,as well as provide healthy cooking demonstrations. 4.Total Budget&Position Count: Total Program Budget: $100,743 Total Program Position Count: 12 Total Agency Budget: $16,858,836 Total Agency Position Count: 178 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Bay Clinic, Inc. $74,243 TOTAL: $74,243 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program is sustainable as BCI is an FQHC and receive federal support for comprehensive health and preventive care to the underserved and low-income in East Hawaii. However, Bay Clinic plans to increase outreach and education,and thereby increase the number of people aware of the risk factors for diabetes,the importance of regularly scheduled screenings and chronic disease management. Through increase outreach efforts, BCI expects to increase diabetes screening by fifteen(85) new patients and forty(40)people completing the DSME module in the program year. Bay Clinic's DSME courses are completely self-sustained through Medicaid(QUEST)and insurance billing. BCI's approved 2017 Medicaid Federally Qualified Health Clinic PPS rate for primary medical services is$202.79. New patient diabetes screenings in the program year is expected to be 85 at$202.79 per encounter,which is$17,237.15. In addition to screenings, BCI expects to help at least 40 patients diagnosed with diabetes successfully complete the DSME classes and managing their diabetes. The DSME classes take place once a week for nine(9)weeks,which equates to 40 patients x 9 weeks x$202.79 (PPS rate)for a total of$73,004.04. Combined total of increased revenue for this program period is$90,241.55($17,237.15+ $73,004.04.) 7. Program Objectives Using County Nonprofit Grant Program Funds: Bay Clinic respectfully requests$26,500 from the County of Hawai'i to be used to cover a portion of the cost of salaries, equipment,and supplies. The equipment support will be used to purchase portable burner stoves,cooking pans,cooking utensils,and storage containers that will be used to conduct cooking demonstrations at health fairs and community events. Funds for supplies will include office supplies,fresh produce from the farmers markets and other food stuffs for the cooking demonstrations,and diabetes education supplies for the DSME classes. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1. Complete 3 cooking demonstration classes at community events in the program year. 150 residents learn healthy cooking options. 2.Complete 4 DSME modules(9 week duration each)in the program year. 40 people finish&managing their diabetes. 3. Participate at a minimum of 7 health fairs/educational events-outreach&education. 850 receive info.on diabetes risks&options. 4. Increase number of people being screened for and receiving treatment,if diagnosed. 85 people screened for diabetes. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $77,919 $80,329 $20,000 Professional Fees $165 $165 $0 Operations $6,597 $7,166 $0 Supplies $8,208 $10,083 $5,000 Equipment $0 $3,000 $1,500 Other: n/a Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $92,889 $100,743 $26,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bay Clinic, Inc. POSITION: N/A May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts .st he January 23, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPrluPct and mny rperiit in (retinae tnkcn to rPrnvpr thPCP parte. By signing below,you are acknowledging that you have read and understood these requirements. January 23, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Diabetes Awareness & Self-Management Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 1.Complete 3 cooking demonstration classes at community events in the program year. c01500 kriensgideoptnatsnsleamhealthy 2.Complete 4 DSME modules(9 week duration each)in the programyear. 40 people finish&managing p P 9 their diabetes. 3. Participate at a minimum of 7 health fairs/education events-outreach&education. 550 receive into.on diabetes 4. Increase number of people being screened for and receiving treatment,if diagnosed. as pe screened for TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $20,000 Professional Fees $0 Operations $0 Supplies $5,000 Equipment $1,500 Other: n/a Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $26,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Bay Clinic, Inc Information Technology Integration to Improve Patient Health 14 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technolo• Integration to Im•rove Patient Health Agency Director: Harold Wallace Phone No.: (808) 930 — 0499 Contact Person: Youlsau Bells Phone No.: (808) 961 — 4078 Mailing Address: Address: 450 Kilauea Avenue Address: Suite 105 City,ST,Zip Hilo, HI 96720 Facility Address: Address: Same as above. Address: City,ST,Zip Email Address: ybells@bayclinic.org Fax No.: (808 ) 961 — 5678 Accountant/CPA: Rozanne Connell Phone No.: (808) 930 — 6850 Firm (if applicable): Cabonaro CPAs&Management Group Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $28,942 Geographical Areas To Be Served: (One or more can be checked) Q✓ Puna ❑Hamakua ❑North Kona 2 South Hilo ❑ North Kohala ❑South Kona ✓�North Hilo ❑South Kohala 0✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑Educational concerns Q✓ Youth LI Victims of Crimes ❑Culture and the arts Q✓ Aged El Victims of Health or Social Crises 0✓ Needs of the poor ❑ Physical/Emotional Disabilities Q✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of I-lawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technolo.y Inte•ration to Im•rove Patient Health 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $35,000 $0 2.Agency Mission Statement: Mission: Bay Clinic is a community-directed healthcare organization that provides quality primary and preventive care services to the people of East Hawaii. Bay Clinic will ensure that patient-centered,culturally responsive,and affordable healthcare services are locally accessible in our communities. Founded in 1983,Bay Clinic, Inc.is a 501(c)(3)Federally Qualified Health Center(FQHC)network of eight community health centers serving the Hawaii County districts of North and South Hilo, Puna,and Ka'u, East Hawai'i. Bay Clinic's health centers are located in the towns of Hilo, Kea'au, Pahoa,and Na'alehu. For over 34 years, BCI has provided comprehensive primary medical,dental,and behavioral health care for all regardless of income level or insurance status. Clinic fees are based on a federally approved Sliding Fee Schedule and applied to all patients depending on their income level,family size,and insurance status. 3. Program Description: BCI is a recognized Level 3 Patient Centered Medical Home(PCMH)by the National Committee on Quality Assurance,the highest level attainable by a medical practice. As a Level 3 PCMH, BCI is a fully electronic practice that uses systematic processes and information technology to enhance the quality of care our patients receive. However,BCI has experienced a growth in its patient population at an average of 5%over the past four years. As a result BCI's current Storage Area Network (SAN)is overburdened and inefficient. The SAN experiences regular'freezes,'making the certified Electronic Health Record (EHR)system slow. Because of this,providers are forced to endure delays in updating patient charts,thereby reducing the quality of care,as well as limiting the number of patients that a provider can see daily by a minimum of 1.5 per day. In addition,BCI's Electronic Dental Records(EDR)system is not integrated into its network-wide Centers for Medicare& Medicaid Services(CMS)certified EHR system. Currently, BCI's EDR is separate from its EHR system and must be interfaced to move patient data over to the EHR where all BCI patient records are kept. This process is time consuming and inefficient as it slows the EHR system and creates greater potential for error in data collection. This project will enable BCI to: 1)upgrade its SAN to accommodate patient growth over the past several years and eliminate 'freezes'of the EHR network;and 2)fully integrate BCI's EDR with its EHR system thereby eliminating the need for a separate host,which will enable real-time updating patient records and reduces errors in data accuracy. This project will also allow BCI's dental program to be fully aligned with the federal program'Meaningful Use'(MU)that rewards clinicians for using health information technology(HIT)to improve quality of care;such as electronic health records,electronic prescribing,e-labs,and a web-based patient portal. 4. Total Budget&Position Count: Total Program Budget: $101,900.48 Total Program Position Count: 26 Total Agency Budget: $16,858,836 Total Agency Position Count: 178 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technology Integration to Improve Patient Health 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate HRSA FY16 Delivery System Health Information Investment(SAN upgrade) $66,682.00 TOTAL: $66,682.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: By updating the SAN, BCI will be able to more efficiently schedule patient appointments, update patient records,and allow for quicker turnaround in billing and collections. This project will also allow BCI's dental program to be fully aligned with the federal program'Meaningful Use'(MU)that financially rewards clinicians for using health information technology(HIT)to improve quality of care;such as electronic health records,electronic prescribing,e-labs,and a web-based patient portal. As a result, BCI expects to receive between$25,000 to$40,000 in annual incentive payments for meeting or exceeding MU standards. In addition to the MU financial incentives, BCI expects to increase revenue through enhanced efficiency of its SAN that will facilitate each BCI primary medical provider to see 6 additional patients per week. Currently,BCI employs a total of fifteen(15) primary care providers. BCPs approved Medicaid Federally Qualified Health Clinic PPS rate for primary medical services is $202.79. With the new upgrades to its HIT systems, BCI expects to generate 4,320 new encounters, 1.5 patients per day x 15 providers at four days per week for a total of$876,052.80. The dental interface will also increase turnaround time and allow our eight(8)dentists to see one additional patient per day, generating 1,536 new dental encounters. BCI's approved dental PPS rate is$162.83 per encounter x 1,536 encounters for a total of$250,106.88. All expected additional revenue generated by both primary medical and dental encounters is $1,126,159.68 in the program year. 7. Program Objectives Using County Nonprofit Grant Program Funds: BCI respecfully requests$28,942 from the County of Hawai'i that will be used to purchase the necessary equipment to integrate BCI's EDR with its EHR network-wide system,thereby eliminating the need for a separate hosting system and provides for real-time updating of patient records. In addition,this project will allow for CMS certification of BCI's EDR since it will be incorporated into BCI's already CMS certified EHR. This project will also allow BCI's dental program to be fully aligned with MU. Lastly,this integration will provide for enhanced patient satisfaction and more efficient billing and collections. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technolo. Inte.ration to Im•rove Patient Health 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Expected number of new appointments generated by the HIT upgrades. 4,320 Expected number of dental patients with enhanced patient experience. 6,408 Expected increase in clinical operations efficiency. 16% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $0 $6,276.84 $0 Professional Fees $0 $38,746.64 $22,867.00 Operations $0 $0 $0 Supplies $0 $0 $0 Equipment $0 $52,422.00 $1,620.00 Other: EDR Remote Installation&Testing $0 $2,430.00 $2,430.00 Other: BCI Staff Training for new EDR $0 $2,025.00 $2,025.00 Other: Other: Other: TOTAL $0 $101,900.48 $28,942.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of FIawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technology Integration to Improve Patient Health 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: 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): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. January 23, 2017 Signature ofor' e• •erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technology Integration to Improve Patient Health 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technology Integration to Improve Patient Health 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future fimrling rPrluPct nnrl mny racult in nrtinnc tnkPn to rPrnvPr thPCP funrit. By signing below,you are acknowledging that you have read and understood these requirements. January 23, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bay Clinic, Inc. Program Name: Information Technology Integration to Improve Patient Health 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Expected number of new appointments generated by the HIT upgrades. 4,320 Expected number of dental patients with enhanced patient experience. 6,408 Expected increase in clinic operations efficiency. t6% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $0 Professional Fees $22,867.00 Operations $0 Supplies $0 Equipment $1,620.00 Other: EDR Remote Installation&Testing $2,430.00 Other: BCI Staff Training for new EDR $2,025.00 Other: Other: Other: TOTAL $28,942.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Bayada Home Care Autism Center 15 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism Center Agency Director: Carl Pierce Phone No.: (808) 591 — 6050 Contact Person: Jennie Immanuel Phone No.: (808) 969 — 9622 Mailing Address: Address: 1221 Kilauea Avenue Address: Suite 60 City,ST,Zip Hilo HI, 96720 Facility Address: Address: 1221 Kilauea Avenue Address: Suite 60 City,ST,Zip Hilo HI, 96720 Email Address: jimmanuel@bayada.com Fax No.: (808 ) 969 — 9894 Accountant/CPA: Phone No.: (609 ) 883 — 9000 Firm (if applicable): Hill Barth& King Mailing Address: Address: 2564 Brunswick Pike Address: City,ST,Zip Lawrenceville, NJ 08648 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth n Victims of Crimes n Culture and the arts n Aged Victims of Health or Social Crises n Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2. Agency Mission Statement: BAYADA Home Care BHC)has a special purpose—to help people have a safe home life with comfort, independence, and dignity. BHC has the three areas of specialty that include home care, behavioral and habilitation for children and adults. Our goal at BAYADA is to provide the highest quality care services available. BHC's Behavioral Health services provide quality, compassionate services for individuals diagnosed with an Autism Spectrum Disorder. Our services enable individuals with autism or intellectual or developmental disabilities to learn, maintain, and improve skills related to communication, socialization, and behavior. Our behavioral health professionals provide individualized positive behavioral supports to those with autism in the comfort of their own home, community, or school. These services are available 24 hours a day, 7 days a week. Our goals are to help individuals with autism live safely at home and to participate in their communities with confidence, independence, and success. Our mission is to build a path to the future for our clients and their families.We believe our clients and their families deserve care delivered with compassion, excellence, and reliability, our BAYADA core values. 3. Program Description: For 25 years, BHC has provided clinical services for children with autism and their families in Hawaii. In 2015,BHC began providing autism services in Hawaii County. Currently these services are provided in the home and school setting by BHC Behavioral.With many years of success behind them,the staff at BHC is preparing to expand the organization's reach and increase access to autism services for Hawaii County through the opening of an Autism Center in Hilo. Their is a drastic need for evidence based autism services in Hawaii County. One in 68 children have autism which means that there are 628 children in the county who have autism (nearly 200 of which are under the age of 5). Center-based care will allow BHC to improve the quality of life for clients with autism by providing ease of access to applied behavior analysis(ABA)therapy.ABA is an evidence-based intervention in the reduction of challenging behaviors and the increase of functional skills for individuals.ABA is provided 1:1 in the home by a Registered Behavior Technician(RBT)and overseen and supervised by Board Certified Behavior Analysts(BCBAs). BHC has the most developed ABA program,the only BCBA and the most RBTs in Hawaii County, yet this is not sufficient to meet the County's need for services. Our clients and referral sources continue to request services in center-based settings and BHC will begin piloting Hawaii's first ABA center based site on Maui in February 2017.An Autism Center on Hawaii Island would provide numerous benefits that include: reduction in travel time for families and staff;the ability to learn in group setting that promote social and communication skills;the ability to have more intensive sessions outside the home and; reduction in caregiver burnout. BHC is requesting seed money to fund the start up costs of Hilo's first Autism Center. 4.Total Budget& Position Count: Total Program Budget: 292,558 Total Program Position Count: 6.8 Total Agency Budget: 1,317,638 _ Total Agency Position Count: 8.8 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Private and government insurers 1,317,638 TOTAL: 1,317,638 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Centers provide the means of optimizing large amounts of authorized billable hours. Currently clients being served by the standard ABA in home 1:1 model do not fully utilize all their authorized services. For example, if a child is authorized for 20 hours of service a week,they may actually only receive 8 hours. Reasons for this are due to transportation factors(the RBT driving to rural and remote locations)and, more significantly, family level factors. For example, having the RBT or BCBA in the home for numerous hours a week can be highly disruptive to a family(particularly families where there multiple children or others in need of care taking). The current utilization rate of services for clients in Hawaii County is 32.9%. For 2016 a total of 7792 hours were authorized by insurers for ABA services but only 2562.5 hours were actually delivered. It is expected that the billable revenue that BHC would be able to collect if this utilization was even increased by 50%would be sufficient to sustain the Center. It is further expected that a Center would allow BHC to serve more clients through its expanded capacity which also would generate revenue to support ongoing Center services. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Secure additional office space(899 sq feet)at Hilo Shopping Center within one month of release of grant funds. 2. Renovate the office space to meet the unique needs of ABA services within two months of release of grant funds. 3. Hire an addtional 1.5 BCBAs and receptionist to augment additional staff within two months of release of grant funds. 4. Have center operational within 3 months of release of grant funds. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism Center 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase utlization rate of clients with autism by 50% Improved access for clients Increase number of new clients with autism served by 20 Improved access for clients Reduce disparity in the Behavioral Health Workforce by the addtion on 1.5 BCBAs Improved workforce development Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 1,058,418 10,000 Professional Fees 130,700 Operations 37,800 Supplies 6000 1,000 Equipment 5000 3,000 Other: Rent 42720 6,000 Other: Renovations new office space 30000 Other: Travel 18,000 Other: Recuiting 19,000 Other: TOTAL 1,317,638 50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council I I Staff appointed by a member of the Council n The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no confli exist, check here. 1 /30/1 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism 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 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.hawaiicountvgov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funning requast nnri mny result in nrtinnc tnkan to rerrnier theca fiinrlc, By signing below, you are acknowledging that you have read and understood these requirements. rt) / 1 /30/17 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bayada Home Care Program Name: Autism Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result ncrease utlization rate of clients wiuth autism by 50% Improved access for clients Increase number of new clients with autism served by 20 Improved access for clients Reduce disparity in the Behavioral Health Workforce by the addtion on 1.5 BCBAs Improved workforce developme TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 10,000 Professional Fees Operations Supplies 1,000 Equipment 3,000 Other: Rent 6,000 Other: Renovations new office space 30000 Other: Travel Other: Recuiting Other: TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Brothers Big Sisters Hawaii One-to-One Mentoring 16 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (Hawaii Island) Program Name: One-to-One Mentoring Agency Director: Dennis Brown Phone No.: (808) 695 — 4570 Contact Person: Holly Brown Phone No.: (808) 695 — 4571 Mailing Address: Address: 418 Kuwili Street, Suite 106 Address: City,ST,Zip Honolulu, HI 96817 Facility Address: Address: Address: City,ST,Zip Email Address: hbrown@bbbshawaii.org Fax No.: ( ) — Accountant/CPA: Jan Byrer Phone No.: (808 ) 695 — 4561 Firm (if applicable): Mailing Address: Address: 418 Kuwili Street, Suite 106 Address: City,ST,Zip Honolulu, HI 96817 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑ North Kohala ❑✓ South Kona ✓❑ North Hilo 0 South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑Aged n Victims of Health or Social Crises ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (Hawaii Island) Program Name: One-to-One Mentoring 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $10,000 $7,000 $7,250 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. Our goal is to provide mentoring services that result in proven, positive short-term and long-term outcomes for youth in three overarching areas: educational success, avoidance of risky behaviors, and increased social and emotional well-being. 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 academic success by supporting and motivating their goals to graduate high school, be prepared for college, and accomplish higher education goals;and developing higher aspirations and preparedness for career and life skills through the exposure of a variety of new experiences and opportunities.This has a positive impact on the community at-large as the children in our mentoring programs 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: Big Brothers Big Sisters Hawaii serves at-risk youth on Hawaii Island through two types of one-to-one mentoring programs: community and afterschool mentoring. In the community mentoring program, Case Managers match at-risk children with trained,volunteer mentors based on interests, hobbies, geographic locations, gender, and personal preferences. Matches spend time together doing activities they both enjoy in the community two to four times a month. Mentors take the time to listen, encourage and model positive behavior in addition to providing new opportunities and activities that children may not otherwise be able to experience.We facilitate this program on both East and West Hawaii. In the afterschool mentoring program, Big Brothers Big Sisters Hawaii pairs at-risk children in one-to-one friendships with mentors from nearby high schools.The child and mentor interact weekly in hour-long sessions under the supervision of a Case Manager for the duration of the school year. Mentors assist with homework and then participate in carefully-planned activities designed to deepen trust and friendship between pairs. In East and West Hawaii we currently work with the Hawaii Department of Education to host mentoring programs for children at four schools: Konawaena Elementary School (students are paired with mentors from Konawaena High School, Hilo Union Elementary School (students are paired with mentors from Hilo High School), Waiakea Elementary School(students are paired with mentors from Waiakea High School)and Keaau Elementary School (students are paired with mentors from Keaau High School). 4. Total Budget & Position Count: Total Program Budget: $147,880 Total Program Position Count: 3 Total Agency Budget: $1,995,353 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (Hawaii Island) Program Name: One-to-One Mentoring 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Fundraising Events $25,000 Big Brothers Big Sisters Hawaii Foundation, Inc. $13,000 FLEX Grants through Hawaii Community Foundation $13,000 Hawaii Island United Way $7,200 State of Hawaii - TANF $4,000 Unrestricted Donations $23,000 TOTAL: $85,200 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2016 we worked to build a four-person team on Hawaii Island. This is the largest number of staff the Hawaii Island agency has ever had, and our goal is to serve more children than ever before and raise more revenue than ever before. In particular, in October 2016 we hired a new Regional Director.Vanessa Carlson holds a Bachelor of Arts in Communication from the University of Hawaii at Hilo and an Academic Certificate in Women's Studies. She completed her Master of Science in Nonprofit Management and Leadership at Walden University this year. She has worked with youth on the island in various capacities for the past fifteen years. Her role as Regional Director will be to ensure community support functions, such as fund development, marketing, and volunteer recruitment. Vanessa will also work with regional board members and case managers to ensure the needs of the organization are met. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of our one-to-one mentoring programs is to serve youth and families who need to be connected to healthy, supportive relationships. This includes,for example,those in poverty, homeless, single-parent, foster-parent, or incarcerated-parent households, or those struggling with social and relational issues. Many of the children we work with are of Hawaiian ancestry or have been abused, neglected, or involved with the juvenile justice courts.We seek out communities and families that are stretched for resources,whether it is time, money or support systems,to provide individual attention and friendship to children in need of academic, social-emotional, or behavioral support. Big Brothers Big Sisters Hawaii will serve these children and youth through community and afterschool mentoring programs, which are facilitated by Case Managers. Our staff are professional coaches responsible for recruiting, enrolling, matching, training, and supporting at-risk children and volunteer mentors. It is this professional support that sets our program apart from other mentoring programs and produces so many lifelong friendships. The main objective of our mentoring programs is to change children's lives for the better,forever, and for mentored youth to show statistically significant improvements in educational success, avoidance of risky behaviors, and increased social and emotional well-being. We respectfully request support from the County of Hawaii to help us achieve these goals. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (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 Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of children and mentors served 160 Length of one-to-one mentoring friendships 70%remain matched for+6 months Youth Outcomes Survey results 90%show improvement in at least one area Number of weekly afterschool mentoring sessions facilitated by Case Managers 18-20 sessions per program from Oct-May Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $110,241 $129,521 $10,000 Professional Fees Operations 3,264 2,222 Supplies 1,873 1,449 Equipment Other: Program Supplies 5,031 3,650 Other: Travel/Mileage 14152 7,173 Other: Service Fees 2858 3,143 Other: Training 722 Other: TOTAL $137,419 $147,880 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (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 Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council The Mayor The Managing Director n The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 2 If no conflicts exist, check here. a'1 I �I Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (Hawaii Island) Program Name: One-to-One Mentoring ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (Hawaii Island) Program Name: One-to-One Mentoring 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 reriuPst and may recult in artinnc taken to rernver thecP funds, By signing below, you are acknowledging that you have read and understood these requirements. '`-'4"`;`-r\ESck-'8 k e‘e-71ctikvt CES XA-,‘A-ka all act 1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Brothers Big Sisters Hawaii (Hawaii Island) Program Name: One-to-One Mentoring 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of children and mentors served 160 Length of one-to-one mentoring friendships 70%remain matched for+6 months Youth Outcomes Survey results 90%show improvement in at le Number of weeklyafterschool mentoringsessions facilitated byCase Managers 18-20 sessions per program g from Oct-May TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $10,000 Professional Fees Operations Supplies Equipment Other: Program Supplies Other: Travel/Mileage Other: Service Fees Other: Training Other: TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Mediation, Inc. dba West Hawaii Mediation Center Community & Foreclosure Mediation Services 17 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services Agency Director: Zaheva S. Knowles Phone No.: (808) 885 — 5525 Contact Person: Zaheva S. Knowles Phone No.: (808) 885 — 5525 Mailing Address: Address: PO Box 7020 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: 65-1291 Kawaihae Road Address: Suite 202 City,ST,Zip Kamuela, HI 96743 Email Address: zknowles@whmediation.org Fax No.: (808 ) 887 — 5025 Accountant/CPA: John Carbonaro Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: 136 Kinoole Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,500 Geographical Areas To Be Served: (One or more can be checked) [DPuna ✓❑ Hamakua n North Kona n South Hilo ✓❑ North Kohala n South Kona n North Hilo ✓]South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ri Youth n Victims of Crimes n Culture and the arts n Aged [Victims of Health or Social Crises ✓❑ Needs of the poor IT Physical/Emotional Disabilities Z✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $10,000 $7,500 2.Agency Mission Statement: Since its founding in 1988,West Hawaii Mediation Center("WHMC"or the"Center")has provided dispute resolution and education services to empower individuals and build communities that view conflict resolution as a catalyst for positive change. Through our mediation and education programs,WHMC provides tools and opportunities for people to resolve their differences in a safe and neutral environment. Recognizing that we all inevitably face conflict at some point in our lives,WHMC provides our clients with the resources necessary for creating lasting, holistic solutions that build bridges and community, not barriers and discord. 3. Program Description: WHMC is requesting funding from the County of Hawaii to help sustain and expand its community and foreclosure mediation programs.WHMC's community mediation services are at the core of the work we do. In FY 2015-16,WHMC provided mediation services for 408 cases,serving approximately 835 individual clients.Of those cases,256 were court-referred—Circuit Court(58 cases), District Court(151 cases)and Family Court(47 cases)—and 152 were self-referred or referred by other sources. More than 40%of our clients had household incomes of$20,652 or less.Of those surveyed, more than 90%were satisfied with the process and more than 70%of those that we serves.The quantifiable results show that WHMC's programs help reduce court congestion and provide critical pathways to justice for those who otherwise might lack access;the intangible impact is fostering meaningful opportunities for participants to develop important life-skills that help to reduce stress and anxiety,and build stronger relationships. No one is denied service due to an inability to pay. In 2012, in response to the record number of foreclosures sweeping the state,WHMC began its foreclosure mediation pilot program in partnership with the Hawai'i Department of the Attorney General("AG"),the Hawai'i State Judiciary and Ku'ikahi Mediation Center.To date,the foreclosure mediation pilot program has mediated 535 court-referred foreclosure cases in Hawaii County.Of these cases, 74%closed with a mediated agreement and 95%were satisfied with the process.The four-year pilot program has helped more than 200 Hawaii Island families. After four years of the pilot,we have a proven model and a well-trained foreclosure specialist in place; however,the AG's funding for the foreclosure program lapsed on September 30,2016.This funding represented one-third of our organizational budget,so the loss of these funds is significant and may jeopardize continuation of services. 4.Total Budget& Position Count: Total Program Budget: 164,383 Total Program Position Count: 2.5 Total Agency Budget: 326,728 Total Agency Position Count: 3.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Grants-Foundations and Government(State and Local) 75,000 Donations- Individuals and Businesses 30,000 Contracts 39,138 Annual Fundraising- Events, Drives and Annual Appeal 20,245 TOTAL: 164,383 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: WHMC is looking to increase revenue for its community and foreclosure mediation programs from a variety of sources, including but not limited to, increasing our annual fundraising efforts with a specific emphasis on peer mediation, individual donor development initiatives,grant writing,and program sponsorship opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: (1)continue to provide affordable, accessible mediation and conflict resolution services to the West Hawaii Community;(2) expand community training and outreach efforts by continuing to develop our partnerships with the Hawaii County Office of Aging, Hawaii Island United Way, Hilo's Ku'kahi Mediation Center, Legal Aid Society of Hawaii,and others; (3)recruit and train new volunteer mediators; (4)continue to raise awareness about the important services that WHMC provides and the critical role we play in providing access to justice to all West Hawaii residents.. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Case Management Hours 2,000 Cases Mediated(Court&Self-Referred) 500 Individual Clients Served (Unduplicated) 850 Active Volunteer Mediators 50 Low Income Residents Served by Mediation 350 Workshops and Trainings Offered 15 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wags 68,365 114,900 8,000 Professional Fees 3,470 3,500 Operations 9,205 13,500 1,500 Supplies 1,126 4,000 500 Equipment 0 0 Other: Benefits and Payroll Taxes 11,989 14,983 Other: Training Costs (incl. mileage and meals) 1,303 8,500 2,000 Other: Advertising and Promotion 130 5,000 500 Other: Other: TOTAL 95,588 164,383 12,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Zaheva S. Knowles 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 Li Staff appointed by a member of the Council n The Mayor i 1 The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: N/A ✓ If no conflicts exist, check here. tjç a January18 C en- 2017 6tre of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 requect and mny recult in nrtinnc taken to rernver theta funrlc, By signing below, you are acknowledging that you have read and understood these requirements. �� --� 4(e,erAti January 18, 2017 ) nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community & Foreclosure Mediation Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Management Hours 2,000 Cases Mediated(Court&Self-Referred) 500 Individual Clients Served(Unduplicated) 850 Active Volunteer Mediators 50 Low Income Residents Served by Mediation sso Workshops and Trainings Offered 15 TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages 8,000 Professional Fees Operations 1,500 Supplies 500 Equipment Other: Benefits and Payroll Taxes Other: Training Costs (incl. mileage and meals) 2,000 Other: Advertising and Promotion 500 Other: Other: TOTAL 12,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Mediation, Inc. dba West Hawai`i Mediation Center Peer Mediation & Conflict Resolution Education 18 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education Agency Director: Zaheva S. Knowles Phone No.: (808) 885 — 5525 Contact Person: Zaheva S. Knowles Phone No.: (808) 885 — 5525 Mailing Address: Address: PO Box 7020 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: 65-1291 Kawaihae Road Address: Suite 202 City,ST,Zip Kamuela, HI 96743 Email Address: zknowles@whmediation.org Fax No.: (808 ) 887 — 5025 Accountant/CPA: John Carbonaro Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: 136 Kinoole Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,500 Geographical Areas To Be Served: (One or more can be checked) E 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $10,000 $7,500 2.Agency Mission Statement: Since its founding in 1988,West Hawaii Mediation Center("WHMC"or the"Center")has provided dispute resolution and education services to empower individuals and build communities that view conflict resolution as a catalyst for positive change. Through our mediation and education programs,WHMC provides tools and opportunities for people to resolve their differences in a safe and neutral environment. 3. Program Description: The Peer Mediation program at WHMC aims to equip Hawaii Island youth in grades K-12 with conflict resolution skills that will enable them to constructively solve problems in their lives,their communities and the world.WHMC believes that by teaching kids to think creatively about resolving their differences with others,we can prepare them to address more complex problems in adulthood as consensus-builders and community leaders. West Hawaii Mediation Center(WHMC or the"Center")is seeking funding for Phase III of our middle school conflict resolution education and peer mediation program.Conflict resolution education entails teaching youth about the nature of conflict and the typical ways people respond to it, recognizing and managing difficult emotions, assertive communication,and understanding and respecting differences. Peer mediation is both a program and a process where students of the same age group mediate disputes between two of their peers. Peer mediators do not"make decisions"but rather work towards a win-win resolution for both sides in order to promote greater understanding and avoid further trouble.The purpose of our project is to reduce the unresolved conflict in our partner schools by a)providing access to a safe,confidential,youth-centered form of conflict resolution, and b)empowering youth with essential life skills that will allow them to navigate conflict in positive and productive ways.We currently partner with six middle schools in the Department of Education's West Hawaii Complex that collectively serve over 1,600 students.Our data indicates that over 90%of peer mediations result in an agreement and over 85%of disputants are satisfied with the mediation process. County of Hawaii funds will be used to provide ongoing training opportunities for students in these partner schools. 4.Total Budget& Position Count: Total Program Budget: 64,300 Total Program Position Count: 1.5 Total Agency Budget: 326,728 Total Agency Position Count: 3.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Grants- Foundations and Government(State and Local) 45,800 Donations- Individuals and Businesses 5,000 Contracts 5,000 Annual Fundraising-Events, Drives and Annual Appeal 8,500 TOTAL: 64,300 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: WHMC is looking to increase revenue for its peer mediation program from a variety of sources, including but not limited to, increasing our annual fundraising efforts with a specific emphasis on peer mediation, individual donor development initiatives, grant writing,and program sponsorship opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Goals for Students:(1)teach conflict resolution skills; (2)help students gain perspective and understanding of themselves and other students; (3)provide a safe forum for kids to resolve differences;(4)reduce suspensions and other disciplinary actions;and (5)address problems and conflict before they escalate into violence. General Program Goals: 1)work with schools to establish peer mediation programs;2)provide ongoing training to peer mediators;3)continuously evaluate and modify our program using the data that we collect;4)develop program sustainability at each partner school;4)expand our relationship with the Hawaii State Department of Education; and 5)serve as a voice for developmentally-appropriate,research-based conflict resolution education and social-emotional skill building in grades K-12. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Peer Mediators Trained(Grades K-12) 304 Peer Mediation Training/Workshops/Meetings; Projected Hours Delivered 210 training hrs; 125 mtg.hrs; 10 workshop hr Students Indirectly Impacted by Peer Mediation Program(all partner schools) 5,440 students Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 26,577 47,448 8,000 Professional Fees 0 3,500 Operations 0 3,394 2,000 Supplies 1,424 4,000 2,500 Equipment 0 0 Other: Travel Expenses (mileage)to Participating Schools 945 3,000 Other: Transportation Costs-Student Mediator Travel to Other Schools 0 500 Other: Lunches and Snacks for Student Mediator Trainings 157 1,200 Other: Peer Mediator Workshop/Mediator Appreciation 0 1,200 Other: TOTAL 29,103 64,242 12,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Zaheva S. Knowles 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 LI Staff appointed by a member of the Council 7 The Mayor n The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: N/A ❑✓ If no conflicts exist, check here. r ► January 18, 2017 11Sign ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai`i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to enroll with 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 rarpuact nnrl mny racult in nrtinnc tnkan to rernver thc'ce funrlc. By signing below,you are acknowledging that you have read and understood these requirements. we �, January 18, 2017 Sig, ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation & Conflict Resolution Education 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Peer Mediators Trained(Grades K-12) 304 Peer Mediation Training/Workshops/Meetings;Projected Hours Delivered 210 training hrs;125 mtg.hrs; 10 workshop hr Students Indirectly Impacted by Peer Mediation Program(all partner schools) 5,440 students TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 8,000 Professional Fees Operations 2,000 Supplies 2,500 Equipment Other: Travel Expenses (mileage)to Participating Schools Other: Transportation Costs-Student Mediator Travel to Other Schools Other: Lunches and Snacks for Student Mediator Trainings Other: Peer Mediator Workshop/Mediator Appreciation Other: TOTAL 12,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Resource Conservation & Development (BIRCD) Junior Forest TEAM (JRFT)/Ho'oulu Lehua (HL) 19 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Junior Forest TEAM (JRFT)/Ho`oulu Lehua (HL) Agency Director: Larry M. Komata Phone No.: (808) 961 — 6425 Contact Person: Jennifer Johansen Phone No.: (808 ) 345 — 8544 Mailing Address: Address: 200 Kanoelehua Ave. Address: PMB 285 City,ST,Zip Hilo. Hawaii 96720 Facility Address: Address: 202 B Chong Street Address: City,ST,Zip Hilo, HI 96720 Email Address: jbjohans@hawaii.edu Fax No.: (808 ) 934 — 0616 Accountant/CPA: Alex J. Smith Phone No.: (808 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $27,500 Geographical Areas To Be Served: (One or more can be checked) r✓] Puna n Hamakua ❑ North Kona ✓ South Hilo North Kohala n South Kona n North Hilo n South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) VI Educational concerns ✓ Youth f Victims of Crimes n Culture and the arts I l Aged Victims of Health or Social Crises n Needs of the poor n Physical/Emotional Disabilities [71 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Junior Forest TEAM JRFT /Ho`oulu Lehua HL 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $5,000 NA NA 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. Forest TEAM(FT):The Forest TEAM was created as a response to community's request for a trained workforce in areas of resource management. In the spirit of E'Imi Pono, our curriculum provides learners with the skills and knowledge that will allow them to become productive and successful members of our community, in ways that are environmentally, economically, and socially beneficial. The Program also incorporates current technology in its course work to allow students to become familiar with upcoming workforce trends. Healthy ecosystems are the backbone of healthy communities. HL: To inspire growth in the native forests and youth of Hawaii. Note: HL is building upon and following the Forest Team (FT)mission.JRFT is an outreach/recruitment program of FT. 3. Program Description: Hawai'i Community College's(HCC)Junior Forest TEAM (JRFT)was established in 2005 and operated until 2010. JRFT's program served approximately 147 youth and had several satellite clubs in different districts on the island of Hawaii. Ho'oulu Lehua(HL) is a non-profit program established in 2011. HL has successfully served over 250 students by providing Hawaii based hands-on environmental education. JRFT and HL joined efforts in 2017 with the intention to revive the JRFT, increase student capacity, and strengthen our ability to reach our common goals. JRFT/HL provides cultural environmental education for youth ages 8-21 (focusing primarily on G9-12)centered on addressing the real needs of Hawai'i's native ecosystems as well as the needs of the surrounding communities.We are committed to providing alternative learning experiences and life skills training for students deemed at-risk of high-school dropout with special emphasis centered on serving disadvantaged Hawaiian youth.The program will take place after-school (Wednesdays/short school days), intersessions,weekends and summer.We facilitate environmental education for Public Charter Schools(PCS) and alternative learning programs during school hours;we hope to work with more DOE teachers. We are also a youth work training site for Alu Like clients. The hands-on, project-based program is currently involved in the following three projects 1) Malama 'Ohi'a[see attached project description]2) Greenhouse/native plant propagation[HCC FT facility]3) Kaniahiku-La'ie'ie, a native lowland forest restoration site at the edge of Pahoa town where we are cultivating 'ie'ie for traditional weaving projects. In addition to the above ongoing projects we will participate in a wide range of island activities that expose youth to a variety of outdoor experiences from the ocean to the mountains. Hawaii Island overnight camps and Kaho'olawe huaka'i will be pinnacle experiences. 4. Total Budget& Position Count: Total Program Budget: $132,000 Total Program Position Count: 2 Total Agency Budget: $37,348 Total Agency Position Count: 1 (PT) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Junior Forest TEAM (JRFT)/Ho`oulu Lehua (HL) S. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Projected Grant Requests Atherton Family Foundation (willing to fund start-up programs) Deadline 4/3/17 30,000 Patagonia Environmental Grant- Deadline 4/30/17 15,000 We are seeking additonal funding sources TOTAL: $45,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program is a new collaborative venture between HCC's and JRFT;work has just begun to get this program off the ground. As a result,we currently do not have additional revenue sources. However,we have an abundance of in-kind support in place from the Forest TEAM Program (providing supplies, greenhouse facility, access to vans/trucks and classroom computer labs), HL brings the past six years of community collaborations which includes community connections with natural resource managers,teachers, established forest-based projects that also includes cultural learning as an integral component. Kua 0 Ka La PCS in the district of Puna on Hawaii Island, is highly interested in collaborating and establishing a satellite campus for the JRFT/HL program and is willing to provide greenhouse facilities and other integral support for Puna Makai-based projects. Contract growers are needed to supply restoration organizations with the quantity of quality native plants needed for their projects. HL has successfully embarked on this path with the Mauna Kea Watershed Alliance and has experience producing high quality native plants with youth involvement.With the FT support and our combined collaborations we will become a significant supplier of native plants for restoration purposes and to help fill this business gap. Monetary support is being sought from private individuals involved in sober-living programs based in CA who have a heart to help at-risk youth maintain healthy life pathways. The JRFT/HL program will run from July 1, 2017 throughout the school year and will culminate with a 2018 summer program. This county non-profit grant is the first funding request we have applied for to establish the program;we will continue to expand upon this as we move into the spring. Updates regarding grants submitted and/or private funding secured could be provided to HI Co. as we move forward.We aim to have 50%of the projected budget secured to implement the program in the 2017-2018 fiscal year.The program has extensive in-kind support. 7. Program Objectives Using County Nonprofit Grant Program Funds: The overarching objective of the program is to cultivate relationships between Hawai'i's native forests and youth through restoration activities based on scientific understanding and cultural traditions. We do this by engaging youth in hands-on forestry/restoration and community service activities that improve our island's native ecosystems and advance traditional knowledge. We will help recruit students for the Forest TEAM Program.As HCC explores the possibility of providing free education, our local youth may be able to progress to earning an A.S. Forest TEAM degree at no-cost. JRFT/HL aims to support and facilitate a seamless transition from high school to college learning. Program participants will have the opportunity to boost math skills(one of the main hurdles to college readiness)through a retired math teacher ready to donate her time. Through HL's ongoing work and our involvement with the Mama 'Ohi'a(MO)project,we are currently engaged with 12 HCC students and 30 youth from three schools that are likely to have further involvement in the JRFT/HL program. Lastly,we aim to support teachers by coordinating activities, providing resources, facilitating transportation to project sites, guiding environmental education curriculum and providing supplementary applied STEAM learning opportunities. HI County Nonprofit grant funds will be used to compensate staff for the time required to run the special program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Junior Forest TEAM (JRFT)/Ho`oulu Lehua (HL) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of youth served 125 youth/year Math skills readiness,targeting G11-12 program participants(pre/post testing) Improved Math skills;HCC testing Environmental awareness(pre/post testing) Increase Cultural Awareness(pre/post testing) Increase Number of indigenous plants propagated Minimum of 1,000 for restoration Total number of community service hours performed by program Minimum of 500+hrs annually Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 104,000 25,000 Professional Fees 3,300(HL) 10,000 Operations 2,500 Supplies 2,500 Equipment Other: General Liability Insurance 1,000 Other: 10%Admin Fee 12,000 2,500 Other: Youth Stipend 800 (HL) Other: Other: TOTAL $4,100 $132,000 $27,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ( ;.ao C.av-Nse_Y-vo.�tor-, `hev�`o ►�ne�-c� Colz_e.n, Program Name:- - - Forest `c'EAJJl (-mu-v.)/(3 )/ \ o \v. t moo. C AL) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Id l If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ("% --E \c^4-•d c c o e-veALD-p (1ei Program Name: Sw�-���r 2��-`�">v ISM C�tz F 0 L), L '- °'- C VAS) ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: E3,45 S's\ro-snd C.Pr,s�-cvCA:gA Program Name: "S',, Qrest TE-NM C FT�r N �.�� h�� � L) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 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 fiiturP funding and may result in nrtinnc tnkPn to rPrnver thPcc,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 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Resource Conservation & Development (BIRCD) Program Name: Junior Forest TEAM (JRFT)/Ho`oulu Lehua (HL) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of youth served 125 youth/year Math skills readiness, targeting G11-12 program participants(pre/post testing) Improved Math skills:HCC testing Environmental awareness(pre/post testing) Increase Cultural Awareness(pre/post testing) Increase Number of indigenous plants propagated Minimum of 1,000 for restoration Total number of community service hours performed by program Minimum of 500+hrs annually TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,000 Professional Fees Operations Supplies Equipment Other: General Liability Insurance Other: 10%Admin Fee 2,500 Other: Youth Stipend Other: Other: TOTAL $27,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Malama `Ohi`a - Using Indigenous Microorganisms to Heal `Ohi`a Introduction `Ohi'a Lehua is the backbone of Hawai'i's native forests and is central to Hawaiian culture. This endemic tree plays a critical role in watersheds and provides food and habitat for many native birds and arthropods. To date, fungal pathogens Ceratocystis spp. (aka 'Ohi'a Wilt and Rapid 'Ohi'a Death/ROD) has killed approximately 50,000 acres of'Ohi'a Lehua (Metrosideros polymorpha), the majority of which has been in the Puna district on the southeastern portion of Hawai'i island. This study was initiated in response to the growing crisis after individual community members witnessed a revival in tree health subsequent to applying solutions of Indigenous Microorganisms (IMO's)to 'Ohi'a trees dying in their yards. This pilot study is being conducted with the scientific rigor needed to objectively document the efficacy of IMO's to confer resistance to Metrosideros polymorpha against Ceratocystis spp. Methods The project site is located in the ahupua'a of Pu'ala'a near the Easternmost point of Hawai'i Island at Kua o Ka La Public Charter School. This area is comprised of approximately 600 acres of lowland `Ohi'a forest growing on 400-750 yrs. old a'a substrate; annual average rainfall is estimated at 2,118mm (Giambelluca et al. 2013). Forty trees showing ROD symptoms will be selected; 20 of these trees will receive IMO treatment and 20 will be left alone as a control. Treatment and control trees will be separated by a yet to be determined distance to prevent control trees from getting IMO's via wind drift or natural propagation of microbes through the substrate. Each treatment tree and 1-2ft. of surrounding ground will be sprayed with IMO solutions eight times within a four-week period. Implementation The project is being implemented by three primary leaders, and has two main advisors (see leadership doc). Volunteers are being recruited to assist with the high frequency application regimen; there are currently 20 registered volunteers. Training sessions will be conducted in Februaru to prepare trial batches of IMO's and test application protocols with treatments beginning in March. There are three youth groups participating in the project, Lanakila Learning Center (based out of Hilo High School), Kua 0 Ka La's high school science class and Orange Moon Homeschool Cooperative. HCC Forest TEAM students will also participate in the project. Malama `Ohi'a Project Leadership and Supporters Leaders Dana Keawe 12-4346 Hilo St, Pahoa, Hawai'i 96778, (808) 315-1237, danakeawe@ gmail.com 2010 Certificate in Korean Natural Farming (K.N.F.) by founder of K.N.F. Master Cho Han Kyu 2010-present Member of Cho Global Natural Farming Hawai'i (C.G.N.F.H.) 2013 Certified in Korean Natural Farming by C.G.N.F.H.; Kim Chang,Jackie Prell (president of CGNFH) 2016 Certificate in JADAM Organic Farming(J.O.F.) by J.O.F. founder/president Youngsang Cho 2016 C.G.N.F.H. Board of Directors advisory member 2010-present K.N.F. practitioner,teacher and food security program development/coordinator in Puna Published Author, Native Hawaiian Cultural Practitioner, Community Volunteer Jennifer Johansen, P.O. Box 1993, Pahoa HI 96778, (808) 345-8544, jbjohans@hawaii.edu B.A., Ecology, Evolution & Conservation Biology, UH Hilo, 2008 A.S., Tropical Forest Ecosystem & Agroforestry Management, Hawaii Community College 2006 2011-present Ho'oulu Lehua Project Coordinator, www.hooululehua.org 2010-2016 UHH Field Tech. studying diversity and distribution of'Ohi`a across the Hawaiian Islands Leila Kealoha, 13-3749 Old Kalapana Rd, Paoa, HI 96778, (808) 937-7991, Ieila@kuaokala.org or leilanjonathan@gmail.com A.S., Tropical Forest Ecosystems & Agroforestry Management, Hawaii Community College 2003 A.A, Liberal Arts, Hawaii Community College 2003 Teaching Certification, Halau Wanana (UH-Hilo) 2008 B.S., Environmental studies, Ashford University 2013 HQT (Highly Qualified Teacher) licensure, Science and Natural Resources 2014 2003-2017 Forest TEAM Advisory Board member 2013-Present Puna Community Development Plan Action Committee member 2013-Present KAPONO, Red Road Scenic Byway Steering Committee Advisors Patrick Hart Ph.D., UH Hilo Professor of Biology,pihart@hawaii.edu, (808) 932-7182 Youngsang Cho Founder and President of JADAM Organic Farming (J.O.F.) in South Korea Rei Yoon 1.O.F. Member/English Translator for Youngsang Cho, rei.yoon@daum.net, (778) 877-6017 Supporters Orlo Steele Ph.D., H.C.C. Forest TEAM Director, orlo@hawaii.edu, (808) 934-2623 Michael W. DuPonte, Extension Agent in Natural Farming & Livestock at the University of Hawai'i at Manoa, CTAHR Komohana Research & Extension Center 875 Komohana St., Hilo, HI 96720, (808) 981- 5199 ext. 218, FAX (808) 981-5211, mduponte@hawaii.edu Drake Weinert, C.G.N.F.H. Board of Directors, K.N.F./JADAM teacher, drakew@gmail.com Kim Chang, C.G.N.F.H. Board of Directors, K.N.F./JADAM teacher, kim.chang@gmail.com Simon Russell, Maui County Rep. to the Hawai'i Board of Agriculture (responsible to eradicate invasive species like R.O.D.), K.N.F. Certified Natural, Biological & Organic Farmer, H.F.U. Foundation President www.hfuf.org, HFUU Haleakala Chapter President http://www.mauifarmershaleakala.com/, HFUU State Legislative Committee Chair president(c�hfuf.orq (808) 269-8162 County of Hawai`i Coqui Frog Control Program, Glenn Sako, glenn.sako@hawaii.edu, Big Island Substance Abuse Council East Hawai'i Substance Abuse Treatment Services 20 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 1 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 297 Waianuenue Avenue Address: City,ST,Zip Hilo, Hawaii,96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPAs Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $76,093 Geographical Areas To Be Served: (One or more can be checked) ✓ Puna ❑✓ Hamakua ❑✓ North Kona ✓Q South Hilo ❑✓ North Kohala E✓ South Kona ❑✓ North Hilo Q✓ South Kohala Q✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns Youth 111 Victims of Crimes ✓ Culture and the arts ❑✓ Aged 71 victims of Health or Social Crises U Needs of the poor Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 2 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 $20,000.00 $21,250.00 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 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 their 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: 1,067,197 Total Program Position Count: 11 Total Agency Budget: $5,434,955 Total Agency Position Count: 61 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 3 County of Hawai`i Nonprofit Grant Application FY2O17-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate SOH, DOH Alcohol and Drug Abuse Division 315,214 SOH,Judiciary(BI Drug Court) &SOH,Judiciary(BI Drug Court) (veterans) 57,140 SOH, Dept. of Public Safety, Hawaii Paroling Authority 40,077 3rd Party Insurance 558,672 Client Fees 10,000 County of Hawaii 76,093 Other Sources 10,000 TOTAL: 1,067,197 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services,and increase efficiency.BISAC's electronic medical records system increased efficiency in both clinical and billing areas. It's capacity to do electronic billing has helped because of a quick turn around time and baseline cash flow. In the last fiscal year, BISAC was able to fully implement the federal IC-10 requirements as well as DSM V changes to comply with federal standards. As a result this improved the third party response time and payment of claims. Implementation of new programs and policies increased revenue and expanded BISAC's capacity to treat clients. Most recently, BISAC has developed a business plan to include a culinary food trailer and BISAC products(e.g. hats,shirts,etc.)with the proceeds going directly to treatment. There has been an expansion of additional services to help feel gaps in resources with the addition of another therapist. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum.These additional revenue streams are an effort to support capacity building,sustainability efforts,and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to assessment and treatment services to any individuals who are assessed and diagnosed with any substance related disorders and/or 2. Increase the availability of extended outpatient and therapeutic living/Clean and Sober program treatment services for uninsured or under-insured individuals who have no funding available for treatment services and/or other specialized services provided by BISAC and/or 3. Identify social support networks and community linkages which support continuity of treatment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 4 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Treatment Service Units 200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 599,228 800,467 49,366 Professional Fees 0.00 21,150 Operations 102,174 179,055 20,093 Supplies 27,519 31,525 6,634.00 Equipment 0 35,000 Other: Other: Other: Other: Other: TOTAL 728,921 1,067,197 76,093 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 2017-2018 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 7 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding rerluect anti may result in nrtinnc taken to rernver theca fiinric. By signing below, you are acknowledging that you have read and understood these requirements. Ll21- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services Page 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Treatment Units 200 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 49,366 Professional Fees Operations 20,093 Supplies 6,634.00 Equipment Other: Other: Other: Other: Other: TOTAL 76,093 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Substance Abuse Council Hawaii Health and Wellness Center- Hilo 21 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 1 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 - 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 - 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 297 Waianuenue Avenue(Bldg.2) Address: City,ST,Zip Hilo, Hawaii,96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 - 7570 Accountant/CPA: Carbonaro CPAs Phone No.: (808) 930 - 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: P.O.Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $46,500 Geographical Areas To Be Served: (One or more can be checked) 0 Puna U Hamakua ❑ North Kona ❑✓ South Hilo ❑✓ North Kohala Lf 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 U Physical/Emotional Disabilities U Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 2 County of Hawai`i Nonprofit Grant Application FY2017-18 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 14-15 FY 15-16 FY 16-17 0 $10,000.00 $15,000.00 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. 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 800 individuals on the island of Hawai'i. HIHWC provides individual,group,couple's and family treatment to adults,children,and adolescents.Licensed therapists use evidenced-based therapies focusing on mental health issues such as depression,anxiety, relationships,parenting,adjustment,smoking cessation,weight management,sleep difficulties,etc.Other components of the program is to assist with closing gaps in service for rural under-served areas and providing training opportunities to Licensure Candidates to gain licensure and provide well needed services. HIHWC is working on credentialing to provide mobile therapy service in rural and underserved communities. Currently,we have 3 licensed professionals, 1 post doc, 1 pre-doc, 1 intern,and 1 pre-licensure. 4.Total Budget&Position Count: Total Program Budget: $294,129 Total Program Position Count: 3.5 Total Agency Budget: $5,434,955.00 Total Agency Position Count: 61 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 3 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Third Party Insurance 237,187 Hawaii Island United Way 10,442 County of Hawaii 46,500 TOTAL: 294,129 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. HIHWC complied with federal law requirements by implemented the IC-10 and DSM V codes to allow for quick turnaround time for insurances to pay on claims. New programs and policies increased revenue and expanded BISAC's capacity to treat clients. HIHWC built their capacity to treat by including a licensure training program to help address needs in services and revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any adults requiring mental health services and/or 2. Increase the availability of psychological services(e.g. individual and groups)to adults who may have no funding for treatment services and/or 3.Provide mobile treatment services in rural areas. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 4 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Mental Health Units too Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 193,384 247,491 30,168 Professional Fees 16,600 Operations 18,350 20,988 13,832 Supplies 3,874 4,050 2,500 Equipment 5,000 Other Other: Other: Other: Other: TOTAL 215,608 294,129 46,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): Member or members of the Council n Staff appointed by a member of the Council n The Mayor The Managing Director The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. G� I/24- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 7 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2018 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 aaency's future requect(inn'may recult in nrtinnc taken to rernver theca funrlc., By signing below,you are acknowledging that you have read and understood these requirements. a,ev l/24/i /- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Health and Wellness Center-Hilo Page 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 loo Mental Health Units TABLE II: FY 17-18. Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 30,168 Professional Fees Operations 13,832 Supplies 2,500 Equipment Other: Other: Other: Other: Other: TOTAL 46,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Substance Abuse Council Hawai'i Health and Wellness Center- Kea'au 22 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center Keaau Page 1 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au,Hawaii 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPAs Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) n Puna C Hamakua ❑✓ North Kona n South Hilo [ North Kohala ❑✓ South Kona ❑✓ North Hilo n South Kohala ❑✓ Ka Ti Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns Youth ✓ Victims of Crimes ❑✓ Culture and the arts n Aged victims of Health or Social Crises ❑✓ Needs of the poor C Physical/Emotional Disabilities U Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center Keaau Page 2 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 $10,000.00 $15,000.00 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 800 individuals on the island of Hawai'i.HIHWC provides individual,group,couple's and family treatment to adults,children,and adolescents.Licensed therapists use evidenced-based therapies focusing on mental health issues such as depression,anxiety, relationships,parenting,adjustment,smoking cessation,weight management,sleep difficulties,etc.Other components of the program is to assist with closing gaps in service for rural under-served areas and providing training opportunities to Licensure Candidates to gain licensure and provide well needed services. HIHWC is working on credentialing to provide mobile therapy service in rural and underserved communities. 4.Total Budget&Position Count: Total Program Budget: $174,755.00 Total Program Position Count: 2.5 Total Agency Budget: $5,434,955.00 Total Agency Position Count: 61 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center Keaau Page 3 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Third Party Insurance $131,255.00 County of Hawaii $35,000.00 Other Sources $8,500.00 TOTAL: $174,755.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services, increase efficiency,and align 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. HIHWC complied with federal law requirements by implemented the IC-10 and DSM V codes to allow for quick turnaround time for insurances to pay on claims. New programs and policies increased revenue and expanded BISAC's capacity to treat clients. HIHWC built their capacity to treat by including a licensure training program to help address needs in services and revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any individuals requiring mental health services and/or 2. Increase the availability of psychological services(e.g. individual and groups)to individuals who may have no funding for treatment services(e.g.DUI classes)or the service is not covered by insurance and/or 3. Provide mobile treatment services in rural areas. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center Keaau Page 4 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Mental Health Units 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 67,509 135,823 21,159 Professional Fees 3,820 Operations 58,287 24,613 11,248 Supplies 5,276 5,500 2,593 Equipment 5,000 Other Other: Other: Other: Other: TOTAL 131,071 174,755 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center Keaau Page 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council I I Staff appointed by a member of the Council I I The Mayor The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I✓I If no conflicts exist, check here. I/i4 ill Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wetness Center Keaau Page 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center Keaau Page 7 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http:/Jwww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rar,uest and mny recult in nrtinnc token to rernver theta flinch 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 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center Keaau Page 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center Keaau 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Mental Health Units 100 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 21,159 Professional Fees Operations 11,248 Supplies 2,593 Equipment Other: Other: Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Substance Abuse Council Kea'au Health and Wellness Garden 23 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 1 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: TMK#1-6-003-007 Address: City,ST,Zip Kea'au, HI 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPAs Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) U Puna ✓ Hamakua ❑ North Kona ❑✓ South Hilo n North Kohala H 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 I Aged yictims 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 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 2 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal is to provide opportunities for individuals to regain identity through land-based interventions that help:restore and nurture native forest and create a viable food garden in a kipuka within the ahupua'a of Kea'au while empowering participants through a variety of hands-on experiences that encourage cultural pride, respect for the'aina,responsible land stewardship and increased awareness of sustainable agricultural practices. 3. Program Description: The Garden is congruent with all aspects of BISAC's mission,vision and values.Operations are currently in the start-up phase of a long-range plan.A license agreement was secured in May of 2015 that enabled BISAC to conduct its cultural,malama'aina and food-based vocational programs in its own outdoor site instead of costly field trips to remote locations.This past summer,more than 50 members of four East Hawaii Rotary clubs along with students from Waiakea High School's Interact Club joined together to spread gravel,paint planter boxes and a pavilion.An anonymous donor contributed funds for a 40 foot-long shipping container to store supplies and equipment.Groups of 30–40 BISAC clients from around the island participate in the Garden experience twice a month.A contracted Garden leader and BISAC counselors facilitate and implement a program that provides an opportunity for individuals to participate in healthy interplay with the land,other individuals and their culture.Clients join in preparing a healthy, nutritious meal that is shared by all at the end of each session. Kalo and Uala currently grow in the raised planter beds as well as in mala'ai on the property.Loose rocks from the clearing of the farming portion of the property were used to build rock walls for garden beds and for the construction of a labyrinth where positive affirmations based on'olelo no'eau are posted. In addition to edible crop ventures,Garden workdays have created the beginnings of a nature trail through the forest section of the property—a small section where mature ohi'a trees have managed to survive the clear-cutting and grading of surrounding areas. 4.Total Budget&Position Count: Total Program Budget: 148,940 Total Program Position Count: 4 Total Agency Budget: $5,434,955 Total Agency Position Count: 61 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 3 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Kamahameha School 87,580 OHA 36,360 County of Hawaii 25,000 TOTAL: 148,940 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC plans to incorporate farm to table(farm to trailer)activities to help support our sustainability plan. This sustainability plan provides opportunities for BISAC to diversify revenue streams to help fund treatment. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Increase opportunities for individuals to participate in land-based interventions that help build a sense of purchase and reclaim identity. 2. Achieve an efficient level of food production and create a viable agricultural enterprise within an existing portion of the parcel that has initially been cleared and designated for farming. 3.Create revenue streams from Garden activities that help sustain the program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 4 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of clients served 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wags NA 91,251 14,628 Professional Fees NA 15,000 Operations NA 31,089 7,662 Supplies NA 6,600 2,710 Equipment NA 5,000 Other: NA Other: NA Other: NA Other: NA Other: NA TOTAL 148,940 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council I I Staff appointed by a member of the Council The Mayor I I The Managing Director n The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. .27172-11/ G►io tl2FII' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 7 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requect and mny recult in artinnc taken to rernver thece funrlc. By signing below, you are acknowledging that you have read and understood these requirements. I 1Z-41— Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Kea'au Health and Wellness Garden Page 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Kea'au Health and Wellness Garden 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of clients served 100 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 14,628 Professional Fees Operations 7,662 Supplies 2,710 Equipment Other: Other: Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Substance Abuse Council Po'okela Vocational Program 24 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 1 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au,Hawaii 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPAs Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) VI Puna ✓ Hamakua III North Kona 0 South Hilo ❑✓ North Kohala ❑✓ South Kona ✓0 North Hilo South Kohala Q✓ KaT1 Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes H Culture and the arts ✓0 Aged 1,11 yictims 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 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 2 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal is to provide vocational learning opportunities for individuals while in treatment. 3. Program Description: The Po'okela Vocational Training Program is a program that provides vocational training opportunities in the form of job seeking skills,training and development,career-planning,and on the job training.The program provides support services to existing adult clients within BISAC's live in program and adolescents within our 32 school based programs island-wide. 4.Total Budget&Position Count: Total Program Budget: 241,247 Total Program Position Count: 7 Total Agency Budget: $5,434,955 Total Agency Position Count: 61 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 3 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Office of Hawaiian Affairs 67,472 Kamehameha Schools 122,264 County of Hawaii 25,000 Other Sources 26,511 TOTAL: 241,247 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. Currently, BISAC's vocational training program has expanded to include vocational tracks which allow for on the job training within the following fields: clerical,garden/maintenance,culinary,and retail. This social enterprise provides revenue to provide more treatment opportunities for individuals to enter treatment(e.g. Big Island Fusion and Koho Pono Products). 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide vocational training opportunities for all individuals within Therapeutic Living Program and school based programs. 2. Increase opportunities for on the job training within the following vocations:clerical, maintenance/gardening,culinary,and retail. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 4 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Vocational Units 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 135,251 15,955 Professional Fees 7,000 Operations 56,591 7,542 Supplies 3,340 1,503 Equipment 39,065 Other: Other: Other: Other: Other: TOTAL 241,247 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I Member or members of the Council Staff appointed by a member of the Council The Mayor n The Managing Director n The Director of Finance I I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓) If no conflicts exist, check here. C oo 1/7A-111- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 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 2017-2018 Page 6 of 8 • County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 7 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program 1i. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and mny recult in artinnc taken to rernver theca funds. By signing below, you are acknowledging that you have read and understood these requirements. t l2,411 7— Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Po'okela Vocational Program Page 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Vocational Units 100 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 15,955 Professional Fees Operations 7,542 Supplies 1,503 Equipment Other: Other: Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Substance Abuse Council Therapeutic Living Programs and Clean and Sober Living Program 25 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 1 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 297 Waianuenue Avenue(main site)-Homes at various sites Address: City,ST,Zip Hilo,Hawaii,96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPAs Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $61,775 Geographical Areas To Be Served: (One or more can be checked) n Puna A Hamakua ❑✓ North Kona I South Hilo ✓ North Kohala 111South Kona 2 North Hilo ✓ South Kohala 2 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns 1 j Youth U Victims of Crimes Culture and the arts III Aged yictims of Health or Social Crises 111 Needs of the poor ✓Z Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 2 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 $14,375.00 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. 3. Program Description: Our Therapeutic Living Program(TLP)for men provides the planned,supportive structure of a 24-hour staffed facility providing ongoing evaluation,care,life skills training,self-help,encouragement,transportation to social activities and therapeutic services.There is also a specialized TLP program for Pregnant, Parenting,Women and Children(PPWC)program that provides a variety of case management and treatment services focused on women with children in order to ensure the wellbeing of the mother and to establish a safe,solid and nurturing foundation for the children to grow.The Clean and Sober Program serves as an interim placement between treatment and transition.Both men and women's programs are supported by a house manager.Clients are expected to attend meetings,seek jobs, and take the appropriate steps to transitioning back into society. 4.Total Budget&Position Count: Total Program Budget: 903,400 Total Program Position Count: 15 Total Agency Budget: $5,434,955 Total Agency Position Count: 61 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 3 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate SOH, DOH Alcohol and Drug Abuse Division 546,931 SOH, Judiciary(BI Drug Court) 153,860 SOH, Dept. Of Public Safety, Hawaii Paroling Authority 40,077 County of Hawaii 61,775 Client Fees 95,713 Other Sources 5,044 TOTAL: 903,400 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services,and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. It's capacity to do electronic billing has helped because of a quick turn around time and baseline cash flow. In the last fiscal year,BISAC was able to fully implement the federal IC-10 requirements as well as DSM V changes to comply with federal standards. As a result this improved the third party response time and payment of claims. Implementation of new programs and policies increased revenue and expanded BISAC's capacity to treat clients. Most recently, BISAC has developed a business plan to include a culinary food trailer and BISAC products(e.g. hats,shirts,etc.)with the proceeds going directly to treatment. There has been an expansion of additional services to help feel gaps in resources with the addition of another therapist. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum.These additional revenue streams are an effort to support capacity building,sustainability efforts,and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Provide funding for placement in sober housing and/or 2. Provide additional support services which help improve quality of care. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 4 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Treatment Units 250 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 666,220 662,332 42,528 Professional Fees 17,500 Operations 143,084 166,736 16,003 Supplies 58,618 21,832 3,244 Equipment 15,000 35,000 Other: Other: Other: Other: Other TOTAL 882,922 903,400 61,775 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council I The Mayor The Managing Director The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Pi If no conflicts exist, check here. (� C/ /1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 7 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rarpuact and mny rPcult in nrtinns tnkan to rernver theca funds. By signing below, you are acknowledging that you have read and understood these requirements. f(24114 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council Therapeutic Living Programs and Clean Sober Living Progam Page 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living Programs and Clean Sober Living Progam 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Treatment Units 250 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 42,528 Professional Fees Operations 16,003 Supplies 3,244 Equipment Other: Other: Other: Other: Other: TOTAL 61,775 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Big Island Substance Abuse Council West Hawai'i Substance Abuse Program 26 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 1 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program Agency Director: Dr. Hannah Preston-Pita Phone No.: (boa) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 74-5555 Kaiwi Sreet Unit F4 Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPAs Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,600 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ✓❑ Hamakua ❑✓ North Kona South Hilo n North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala III Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns III Youth ❑✓ Victims of Crimes ❑Culture and the arts ❑/ Aged U 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 2017-2018 Page 1 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 2 County of Hawai`i Nonprofit Grant Application FY2017-18 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 14-15 FY 15-16 FY 16-17 0 $10,000.00 $12,500.00 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 State and Federal laws prohibiting discrimination against all individuals regardless of their race,color,national origin, religion,creed,gender,sexual orientation,age or disability.The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: BISAC's 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: 458,327 Total Program Position Count: 5 Total Agency Budget: $5,434,955 Total Agency Position Count: 61 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 3 County of Hawai`i Nonprofit Grant Application FY2017-18 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): FY17-18 Revenue Source Estimate SOH, DOH Alcohol and Drug Abuse Division 56,991 SOH,Judiciary(BI Drug Court) &SOH,Judiciary(BI Drug Court) (veterans) 44,640 SOH, Dept. of Public Safety, Hawaii Paroling Authority 25,000 3rd Party Insurance 271,097 Client Fees 5,000 County of Hawaii 45,600 Other Sources 10,000 TOTAL: 458,328 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. BISAC's ability to comply with the recent IC-10 and DSM V Federal requirement conversion will allow for a quick response time in third-party billing. Currently BISAC has implemented a social entrepreneurship program which allows for retail sales of BISAC products and operating a food trailer where all proceeds go directly to treatment. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to assessment and treatment services to any individuals who are assessed and diagnosed with any substance related disorders and/or 2. Increase the availability of extended outpatient treatment services to addicted adults and adolescents who may need treatment services and/or 3. Identify social support networks and community linkages which support continuity of treatment and/or 4. Increase the availability of extended outpatient and therapeutic living/Clean and Sober program treatment services for uninsured or under-insured individuals who have no funding available for treatment services and/or other specialized services provided by BISAC EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 4 County of Hawai`i Nonprofit Grant Application FY2017-18 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 of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Treatment Service Units 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 191,733 343,932 25,337 Professional Fees 10,050 Operations 68,335 88,346 16,526 Supplies 8,489 11,000 3,737 Equipment 5,000 Other: Other: Other: Other: Other: TOTAL 268,557 458,328 45,600 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 5 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director n The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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. Crje' ( 1St IV/— Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 6 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 7 County of Hawai`i Nonprofit Grant Application FY2017-18 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 Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may reciilt in artinnc taken hi rernver these funds. By signing below, you are acknowledging that you have read and understood these requirements. clzl (� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Big Island Substance Abuse Council West Hawaii Substance Abuse Program Page 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 Projected Result Treatment Service Units 100 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,337 Professional Fees Operations 16,526 Supplies 3,737 Equipment Other: Other: Other: Other: Other: TOTAL 45,600 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Boys & Girls Club of the Big Island, Hilo Club Daily Nutritional Security to Support Income Challenged Youth 27 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth Agency Director: Chad Cabral Phone No.: (808) 961 - 5536 Contact Person: Jasmine Branco Phone No.: (808) 961 - 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: jasmineb@bgcbi.org Fax No.: (808 ) 961 - 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ✓❑South Hilo ❑ North Kohala ❑South Kona ✓❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises O✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 None for this project None for this project $6750.00 2. Agency Mission Statement: Our mission,"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment.",has positioned the 65 year old Boys&Girls Club of the Big Island(BGCBI)to be the premier youth development organization in Hawaii County and is the only organization whose sole mission is to provide after-school youth development opportunities.These opportunities include participation in educational, health and wellness and character developing activities that shape participants for life. Many of the 1,000 youth annually served here are daily attendees at one of our Club sites throughout rural Hawaii County(Hilo, Keaau, Pahoa, Pahala and Ocean View).49%of all attendees come from families that are recipients of Free/Reduced lunch at their schools,which is a federal indicator of economic hardship.20%of all attendees are self proclaimed to be in the economic bracket that receives an annual income of less than$5,000.Thus, many of the youth we serve are part of a social crisis impacting their families and our communities,including the economic security which leads to housing insecurity,food insecurity, and resulting in a poor quality of life with high levels of stress. Without our services,many of our 1,000 members would not have the economic capacity to afford after-school programming synonymous to the safe,enriching,quality and life enhancing programming we currently are able to offer for the low annual fee of$10.This cannot be done without the continued support BGCBI receives from our County and local community supporters. 3. Program Description: In our previous grant period,BGCBI was able to redevelop the garden site at our Hilo Club and start the youth led programs in the Seed to Table program which allowed youth to make healthy food choices through having access to healthy,locally grown produce and meal planning and preparing under the direction of a mentor. - This program year,we seek to build upon that structure of the highly successful and popular"Seed to Table"program.We found that the desire of our members to be participants in the Seed to Table program greatly exceeded our capacity to provide for them a safe environment;thus,some members were not able to participate to their capacity or desire.We have additionally found the need that our members have to be a part of knowing where food comes from and how to grow their food is greater than anticipated and BGCBI will expand this program to teach greater food security through nutritional means. Through the"Daily Nutritional Security for Income Challenged Youth"program,we will continue to teach participants about the nutritional importance of food grown versus processed and how to grow and prepare these foods in an age appropriate way so each member,aged 6-17,will be able to benefit from the"Nutritional Security"program daily. Each member with the desire to learn how to grow his or her own food will be given daily time in the garden and will be given a food of choice to replant at home. Each member with the desire to learn how to prepare fresh foods grown in the garden will be given the opportunity to be a part of the meal preparation process. Each member with the desire to learn about the importance of nutrition and how to acquire the daily nutritional requirements through his/her daily diet,will be given the lessons and educational materials needed to understand the capacity and importance of lifelong healthy eating. 4.Total Budget& Position Count: Total Program Budget: 45,000 Total Program Position Count: 3 Total Agency Budget: 1,265,906 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2O17-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of HI Daily Nutritional Security (proposed) 45,000 Cooke Foundation (secured) 10,000 OHA Health Grant(proposed) 300,000 Kamehameha Community Investment Grant(proposed) 750,000 TOTAL: 1,105,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to effectuate change in a community,it starts with the children;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth that need these programs the most in our local,rural communities."When school is out, Clubs are in",is our motto for ensuring that the youth of our community have continuous opportunity to be in a safe and enriching environment. In the past year,BGCBI experienced a drastic decrease in funding from a plethora of long time Funding Sources, thus organizationally we had to make tough decisions to decrease services.We have not advertised for open enrollment and have reached our record high of membership in years;clearly there is a need in our County for after-school youth development and preventative services. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security below is a list of our current supporters: Pizza Hut Literacy for Life(secured) Cooke Foundation(secured) OHA Education Grant(proposed) Kamehameha Community Investment Grant(proposed) 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase the number of program hours from 12 hours a week to 20 hours a week enabling daily participation versus 3 times a week participation. Increase the number of program participants by 50%with the inclusion of another staff to supervise under the program director. To give participants a greater chance to harvest crops and to develop the skills needed to create healthy snacks,this program will increase the number of snacks prepared to 2 a week by program participants. To give participants a greater chance to implement their knowledge of nutritional balance and incorporating it into meal planning, this program will increase the number of meals prepared to 2 a month by program participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Participants in"Food Security" Program 50%increase Increase of Program hours from 12 to 20 each week 8 hour increase Increase number of Snacks prepared weekly from 1 to 2 1 more snack prepared weekly Increase number of Meals prepared monthly from 1 to 2 1 more meal prepared monthly Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 828,432 12,438 Professional Fees 35,400 3,250 Operations 372,574 13,100 Supplies 21,000 4,800 Equipment 8,500 612 Other: contractual-Garden Specialist 10,800 Other: Other: Other: Other: TOTAL 1,265,906 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in nrtinnc taken to rernver these funds.. By signing below,you are acknowledging that you have read and understood these requirements. January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50%increase 8 hour increase 1 more snack prepared weekly 1 more meal prepared monthly TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 12,438 Professional Fees 3,250 Operations 13,100 Supplies 4,800 Equipment 612 Other: contractual - Garden Specialist 10,800 Other: Other: Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Boys & Girls Club of the Big Island, Hilo Club Literacy, Homework & Tutoring Support for Income Challenged 28 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 - 5536 Contact Person: Jasmine Branco Phone No.: (808) 961 - 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Email Address: jasmineb@bgcbi.org Fax No.: (808 ) 961 - 5534 Accountant/CPA: Ann Fukuhara,CPA,MBA Phone No.: (808 ) 961 - 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $13,000. $10,000. $8,750. 2. Agency Mission Statement: Our mission,"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment.",has positioned the 65 year old Boys&Girls Club of the Big Island(BGCBI)to be the premier youth development organization in Hawaii County and is the only organization whose sole mission is to provide after-school youth development opportunities.These opportunities include participation in educational, health and wellness and character developing activities that shape participants for life. Many of the 1,000 youth annually served here are daily attendees at one of our Club sites throughout rural Hawaii County(Hilo, Keaau, Pahoa, Pahala and Ocean View).49%of all attendees come from families that are recipients of Free/Reduced lunch at their schools,which is a federal indicator of economic hardship.20%of all attendees are self proclaimed to be in the economic bracket that receives an annual income of less than$5,000.Thus, many of the youth we serve are part of a social crisis impacting their families and our communities,including the economic security which leads to housing insecurity,food insecurity, and resulting in a poor quality of life with high levels of stress. Without our services,many of our 1,000 members would not have the economic capacity to afford after-school programming synonymous to the safe,enriching, quality and life enhancing programming we currently are able to offer for the low annual fee of$10.This cannot be done without the continued support BGCBI receives from our County and local community supporters. 3. Program Description: Literacy,Homework&Tutoring Support for Income Challenged will provide 3 educational initiatives to support the acute academic needs of our youth participants encouraging greater literacy,better study habits and higher numbers of grade level completion.The proposal utilizes three of Boys&Girls Club of America's nationally certified educational support programs. The 1st initiative,Project"REACH" (Reading Enhances All Children's Hope)engages youth to participate in literacy enhancement activities after-school that help develop their overall reading,spelling and writing proficiency through daily reading and a site wide Spelling Bee. 2nd: "PowerHour",an incentive based homework support program grants participants points for every hour dedicated to homework completion.The more hours dedicated,the greater the points collected to redeem for sought after items including weekly after-school meals at Hilo's new Jackie Rey's restaurant. Nationally,"PowerHour"has proven to effectively engage youth in developing strong, life long learning habits that facilitate daily homework completion and test score improvement. 3rd: "Project Learn", reinforces and enhances the skills and knowledge youth learn at school during their hours spent at the Club.The strategy, based on Dr. Reginald Clark's research,shows that students do much better in school when they spend their non-school hours engaged in fun,academically beneficial activities. Parent,school&Club collaboration has proven to boost the academic performance of youth members through"Ohana Nights"and open communications with schools. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time",there are four types of literacy initiatives: 1) Literacy and development programs,2)Literacy enhancement programs,3)Academic enhancement programs,4)Social development programs.These three programs work together to help establish a strong foundation towards the desire to gain greater knowledge and shape effective lifelong educational learning habits. 4. Total Budget& Position Count: Total Program Budget: 45,000 Total Program Position Count: 4 Total Agency Budget: 1,265,906 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of HI Literacy, Homework&Tutoring Support(proposed) 45,000 Cooke Foundation (secured) 10,000 Pizza Hut Literacy(secured) 25,000 OHA Education Grant(proposed) 300,000 Kamehameha Community Investment Grant(proposed) 750,000 TOTAL: 1,130,000. Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to effectuate change in a community,it starts with the children;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth that need these programs the most in our local, rural communities."When school is out, Clubs are in",is our motto for ensuring that the youth of our community have continuous opportunity to be in a safe and enriching environment.In the past year,BGCBI experienced a drastic decrease in funding from a plethora of long time Funding Sources, thus organizationally we had to make tough decisions to decrease services.We have not advertised for open enrollment and have reached our record high of membership in years;clearly there is a need in our County for after-school youth development and preventative services. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security below is a list of our current supporters: Pizza Hut Literacy for Life(secured) Cooke Foundation (secured) OHA Education Grant(proposed) Kamehameha Community Investment Grant(proposed) 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy amongst the Income Challenged Youth that our organization services through reading programs and spelling bees to aid youth in growing their academic skill set. Participants in our reading program take pre and post tests;our objective will be to see 50%of participants scores improve. BGCBI will host a site wide Spelling Bee that will have participants from each Club.This Club will start with 20 participants in the Spelling Bee. Through providing tutoring to the participants are struggling academically according to their report cards,BGCBI's objective is to aid youth in growing their English skills.50%of participants in our Tutoring Program will see an increase in his/her test scores in accordance to their pre and post tests. Increase the number of program participants that complete their homework daily to ensure the establishment of good study habits through daily participation in"Power Hour"while at the Club.The number of participants in this homework support program will increase by 50%. It is proven that the most effective programs include Clubs,Schools and Families.We will host an"Ghana Night"each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Reading Scores of 50%of participants will increase 50%increase Number of Participants in Spelling Bee 20 English Test Scores of 50%of participants will increase 50%increase Number of Participants that participate in homework support program will increase 50%increase Family Nights 1 an academic year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 828,432 21,064 Professional Fees 35,400 3,250 Operations 372,574 15,286 Supplies 21,000 4,800 Equipment 8,500 600 Other: Other: Other: Other: Other: TOTAL 1,265,906 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council E 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 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiitura funding rPriuest and mny racult in nrtinnc token to rernver theca fundc, By signing below, you are acknowledging that you have read and understood these requirements. (-fY36)1 , fb(— January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50%increase 20 50%increase 50%increase 1 an academic year TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 21,064 Professional Fees 3,250 Operations 15,286 Supplies 4,800 Equipment 600 Other: Other: Other: Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Boys & Girls Club of the Big Island, Kea'au Club Literacy, Homework & Tutoring Support for Income Challenged 29 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Jasmine Branco Phone No.: (808) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 16-565 Keaau Pahoa Road Address: City,ST,Zip Keaau, HI 96749 Email Address: jasmineb@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona South Hilo ❑ North Kohala ❑South Kona North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $20,000 $8,750 2. Agency Mission Statement: Our mission,"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment.",has positioned the 65 year old Boys&Girls Club of the Big Island(BGCBI)to be the premier youth development organization in Hawaii County and is the only organization whose sole mission is to provide after-school youth development opportunities.These opportunities include participation in educational,health and wellness and character developing activities that shape participants for life. Many of the 1,000 youth annually served here are daily attendees at one of our Club sites throughout rural Hawaii County(Hilo, Keaau, Pahoa, Pahala and Ocean View).49%of all attendees come from families that are recipients of Free/Reduced lunch at their schools,which is a federal indicator of economic hardship.20%of all attendees are self proclaimed to be in the economic bracket that receives an annual income of less than$5,000.Thus,many of the youth we serve are part of a social crisis impacting their families and our communities,including the economic security which leads to housing insecurity,food insecurity, and resulting in a poor quality of life with high levels of stress. Without our services,many of our 1,000 members would not have the economic capacity to afford after-school programming synonymous to the safe,enriching, quality and life enhancing programming we currently are able to offer for the low annual fee of$10.This cannot be done without the continued support BGCBI receives from our County and local community supporters. 3. Program Description: Literacy,Homework&Tutoring Support for Income Challenged will provide 3 educational initiatives to support the acute academic needs of our youth participants encouraging greater literacy,better study habits and higher numbers of grade level completion.The proposal utilizes three of Boys&Girls Club of America's nationally certified educational support programs. The 1st initiative, Project"REACH" (Reading Enhances All Children's Hope)engages youth to participate in literacy enhancement activities after-school that help develop their overall reading,spelling and writing proficiency through daily reading and a site wide Spelling Bee. 2nd: "PowerHour",an incentive based homework support program grants participants points for every hour dedicated to homework completion.The more hours dedicated,the greater the points collected to redeem for sought after items including gift certificates and BGCBI items.Nationally, "PowerHour"has proven to effectively engage youth in developing strong,life long learning habits that facilitate daily homework completion and test score improvement. 3rd:"Project Learn",reinforces and enhances the skills and knowledge youth learn at school during their hours spent at the Club.The strategy,based on Dr. Reginald Clark's research,shows that students do much better in school when they spend their non-school hours engaged in fun, academically beneficial activities. Parent,school&Club collaboration has proven to boost the academic performance of youth members through"Ohana Nights"and open communications with schools. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time",there are four types of literacy initiatives: 1) Literacy and development programs,2)Literacy enhancement programs,3)Academic enhancement programs,4)Social development programs.These three programs work together to help establish a strong foundation towards the desire to gain greater knowledge and shape effective lifelong educational learning habits. 4. Total Budget& Position Count: Total Program Budget: 45,000 Total Program Position Count: 4 Total Agency Budget: 1,265,906 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of HI Literacy, Homework&Tutoring Support(proposed) 45,000 Cooke Foundation (secured) 10,000 Pizza Hut Literacy(secured) 25,000 OHA Education Grant (proposed) 300,000 Kamehameha Community Investment Grant(proposed) 750,000 TOTAL: 1,130,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to effectuate change in a community,it starts with the children;these changes do not happen overnight,but over a generation.BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth that need these programs the most in our local, rural communities."When school is out, Clubs are in",is our motto for ensuring that the youth of our community have continuous opportunity to be in a safe and enriching environment. In the past year,BGCBI experienced a drastic decrease in funding from a plethora of long time Funding Sources, thus organizationally we had to make tough decisions to decrease services.We have not advertised for open enrollment and have reached our record high of membership in years;clearly there is a need in our County for after-school youth development and preventative services. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security below is a list of our current supporters: Pizza Hut Literacy for Life(secured) Cooke Foundation(secured) OHA Education Grant(proposed) Kamehameha Community Investment Grant(proposed) 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy amongst the Income Challenged Youth that our organization services through reading programs and spelling bees to aid youth in growing their academic skill set. Participants in our reading program take pre and post tests;our objective will be to see 50%of participants scores improve. BGCBI will host a site wide Spelling Bee that will have participants from each Club.This Club will start with 20 participants in the Spelling Bee. Through providing tutoring to the participants are struggling academically according to their report cards,BGCBI's objective is to aid youth in growing their English skills.50%of participants in our Tutoring Program will see an increase in his/her test scores in accordance to their pre and post tests. Increase the number of program participants that complete their homework daily to ensure the establishment of good study habits through daily participation in"Power Hour"while at the Club.The number of participants in this homework support program will increase by 50%. It is proven that the most effective programs include Clubs,Schools and Families.We will host an"Ghana Night"each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Reading Scores of 50%of participants will increase 50%increase Number of Participants in Spelling Bee 20 English Test Scores of 50%of participants will increase 50%increase Number of Participants that participate in homework support will increase 50%increase Ohana Nights 1 an academic year Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 828,432 24,980 Professional Fees 35,400 4,875 Operations 372,574 9,745 Supplies 21,000 4,800 Equipment 8,500 600 Other: Other: Other: Other: Other: TOTAL 1,265,906 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. 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. (171 January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rer7uect and mny result in nrtinns token to rernver theca fundc. By signing below, you are acknowledging that you have read and understood these requirements. January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50%increase 20 50%increase 50%increase 1 an academic year TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 24,980 Professional Fees 4,875 Operations 9,745 Supplies 4,800 Equipment 600 Other: Other: Other: Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Boys & Girls Club of the Big Island, Kealakehe Club Kealakehe After School Support for Income Challenged Youth 30 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Jasmine Branco Phone No.: (808) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Kealakehe Elementary/Middle School(Upon funding) Address: 74-5118 Kealakaa Street City,ST,Zip Kailua-Kona, HI 96740 Email Address: jasmineb@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $90,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 NONE (New Program) NONE (New Program) NONE (New Program) 2. Agency Mission Statement: Our mission,"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment.",has positioned the 65 year old Boys&Girls Club of the Big Island(BGCBI)to be the premier youth development organization in Hawaii County and is the only organization whose sole mission is to provide after-school youth development opportunities.These opportunities include participation in educational,health and wellness and character developing activities that shape participants for life. Many of the 1,000 youth annually served here are daily attendees at one of our Club sites throughout rural Hawaii County(Hilo, Keaau, Pahoa, Pahala and Ocean View).49%of all attendees come from families that are recipients of Free/Reduced lunch at their schools,which is a federal indicator of economic hardship.20%of all attendees are self proclaimed to be in the economic bracket that receives an annual income of less than$5,000.Thus,many of the youth we serve are part of a social crisis impacting their families and our communities,including the economic security which leads to housing insecurity,food insecurity, and resulting in a poor quality of life with high levels of stress. Without our services, many of our 1,000 members would not have the economic capacity to afford after-school programming synonymous to the safe,enriching,quality and life enhancing programming we currently are able to offer for the low annual fee of$10.This cannot be done without the continued support BGCBI receives from our County and local community supporters. 3. Program Description: With the intense need for after school enrichment programming County-wide, BGCBI has been working with Kealakehe Elementary&Intermediate Schools to create a program that meets the needs of their community. Once funded,the Kealakehe Club will be operational within a month as staff,location&curriculum have been secured. The following 3 programs are designed together to produce well balanced,life long responsible citizens. Funding will support the curriculum,training,staffing&supplies necessary to initiate&implement the most safe&accurate daily programming with the fidelity our keiki&community deserves: The nationally researched,SPARK After School Physical Activity program,will increase the daily moderate to vigorous physical activity(DMVPA)of youth participants.The program has demonstrated success with youth of all backgrounds,not just the athletic or talented,thus removing an important barrier to participation for those who need DMVPA the most."PowerHour",an incentive based homework support program grants participants points for every hour dedicated to homework completion.The more hours dedicated,the greater the points collected to redeem for sought after items including gift cards,school supplies and BGCBI items. Nationally,"PowerHour"has proven to effectively engage youth in developing strong,life long learning habits that facilitate daily homework completion and test score improvement."SMART Moves"initiative(Skills Mastery and Resistance Training)is a nationally recognized prevention awareness program. Participants are exposed to various activities designed to develop their decision-making and critical-thinking skills,as well as to provide them with methods to avoid and resist alcohol, tobacco,drugs and sexual activity pressures.Activities include:anti-bullying and positive body-image campaigns,health awareness workshops,good sportsmanship opportunities, modeling the way recognitions,volunteer/service-learning activities, posting of educational materials(alcohol,drug,peer-pressure prevention strategies). 4. Total Budget& Position Count: Total Program Budget: 90,000 Total Program Position Count: 5 Total Agency Budget: 1,265,906 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of HI Kealakehe Daily Services (proposed) 90,000 OHA Education Grant(proposed) 300,000 Kamehameha Community Investment Grant(proposed) 750,000 TOTAL: 1,140,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to effectuate change in a community,it starts with the children;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth that need these programs the most in our local, rural communities. "When school is out, Clubs are in", is our motto for ensuring that the youth of our community have continuous opportunity to be in a safe and enriching environment. In the past year, BGCBI experienced a drastic decrease in funding from a plethora of long time Funding Sources, thus organizationally we had to make tough decisions to decrease services.We have not advertised for open enrollment and have reached our record high of membership in years;clearly there is a need in our County for after-school youth development and preventative services. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security below is a list of our current supporters: County of HI Kealakehe Daily Services(proposed) OHA Education Grant(proposed) Kamehameha Community Investment Grant(proposed) 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide service for 50 program participants that participate in SPARK and achieve their DMVPA. Provide service for 50 program participants that complete their homework daily to ensure the establishment of good study habits through daily participation in "Power Hour"while at the Club. Provide service for 50 program participants that participate in "SMART Moves"and establish the foundation for good character and citizenship. Host one Ohana Night to ensure family support and effectiveness of the Club programs EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Participants reaching DMVPA in SPARK 50 Number of Participants that participate in PowerHour 50 Number of Participants that participate in SMART Moves 50 Host one Ohana Night 1 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 828,432 51,522 Professional Fees 35,400 9,750 Operations 372,574 19,528 Supplies 21,000 8,000 Equipment 8,500 1,200 Other: Other: Other: Other: Other: TOTAL 1,265,906 90,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ 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. 4111.1"- L • g- January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 rPq iiect rind mny racult in nrtinnc tnkan to rPrnvar theca funric. By signing below, you are acknowledging that you have read and understood these requirements. January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Kealakehe After School Support for Income Challenged Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50 50 50 1 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 51,522 Professional Fees 9,750 Operations 19,528 Supplies 8,000 Equipment 1,200 Other: Other: Other: Other: Other: TOTAL 90,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Boys & Girls Club of the Big Island, Ocean View Club Ocean View Club Daily Services for Income Challenged Youth 31 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Jasmine Branco Phone No.: (808) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Kahuku Park, Paradise Mauka Circle Address: City,ST,Zip Ocean View, HI 96737 Email Address: jasmineb@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑✓ South Kona ❑ North Hilo ❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $3,750. $10,000.00 $7,500.00 2. Agency Mission Statement: Our mission,"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment.",has positioned the 65 year old Boys&Girls Club of the Big Island(BGCBI)to be the premier youth development organization in Hawaii County and is the only organization whose sole mission is to provide after-school youth development opportunities.These opportunities include participation in educational,health and wellness and character developing activities that shape participants for life. Many of the 1,000 youth annually served here are daily attendees at one of our Club sites throughout rural Hawaii County(Hilo, Keaau, Pahoa, Pahala and Ocean View).49%of all attendees come from families that are recipients of Free/Reduced lunch at their schools,which is a federal indicator of economic hardship.20%of all attendees are self proclaimed to be in the economic bracket that receives an annual income of less than$5,000.Thus, many of the youth we serve are part of a social crisis impacting their families and our communities, including the economic security which leads to housing insecurity,food insecurity, and resulting in a poor quality of life with high levels of stress. Without our services,many of our 1,000 members would not have the economic capacity to afford after-school programming synonymous to the safe,enriching, quality and life enhancing programming we currently are able to offer for the low annual fee of$10.This cannot be done without the continued support BGCBI receives from our County and local community supporters. 3. Program Description: With current funding,we are able to implement programming in Ocean View once a week. The nationally researched,SPARK After School Physical Activity Program,will continue to be implemented in Ocean View to increase the daily moderate to vigorous physical activity(DMVPA)of youth participants.The program has demonstrated success with youth of all backgrounds,not just the athletic or talented,thus removing an important barrier to participation for those who need DMVPA the most. "PowerHour",an incentive based homework support program grants participants points for every hour dedicated to homework completion.The more hours dedicated,the greater the points collected to redeem for sought after items including gift cards, school supplies and BGCBI items. Nationally,"PowerHour"has proven to effectively engage youth in developing strong, life long learning habits that facilitate daily homework completion and test score improvement. "SMART Moves"initiative(Skills Mastery and Resistance Training)is a prevention awareness program developed by nationally recognized youth prevention experts. Participants are exposed to various activities designed to develop their decision-making and critical-thinking skills,as well as to provide them with methods to avoid and resist alcohol,tobacco,drugs and sexual activity pressures.Activities include:anti-bullying and positive body-image campaigns, health awareness workshops,good sportsmanship opportunities,modeling the way recognitions,volunteer/service-learning activities,posting of educational materials(alcohol,drug,peer-pressure prevention strategies). These three programs together are designed to produce well balanced, life long responsible citizens. Funding will support the curriculum,training,staffing and supplies necessary to implement the most safe and accurate programming with the fidelity our keiki and community deserves after school every day of the week. 4. Total Budget & Position Count: Total Program Budget: _45,000 Total Program Position Count: 3 Total Agency Budget: 1,265,906 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of HI Ocean View Daily Services (proposed) 45,000 OHA Education Grant(proposed) 300,000 Kamehameha Community Investment Grant(proposed) 750,000 TOTAL: 1,095,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to effectuate change in a community,it starts with the children;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth that need these programs the most in our local, rural communities."When school is out, Clubs are in", is our motto for ensuring that the youth of our community have continuous opportunity to be in a safe and enriching environment. In the past year, BGCBI experienced a drastic decrease in funding from a plethora of long time Funding Sources, thus organizationally we had to make tough decisions to decrease services.We have not advertised for open enrollment and have reached our record high of membership in years;clearly there is a need in our County for after-school youth development and preventative services. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security below is a list of our current supporters: County of HI Ocean View Daily Services(proposed) OHA Education Grant(proposed) Kamehameha Community Investment Grant(proposed) 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase the number of program participants that participate in SPARK and achieve their DMVPA to 65%of all participants. Increase the number of program participants that complete their homework daily to ensure the establishment of good study habits through daily participation in"Power Hour"while at the Club.This number will be 50%of all participants. Increase the number of program participants that participate in"SMART Moves"and establish the foundation for good character and citizenship.This number will be 50%of all participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Participants reaching DMVPA in SPARK,60%increase 65% Number of Participants that participate in PowerHour,50%increase 50% Number of Participants that participate in SMART Moves,50%increase 50% Increase Program service from one day a week to 5 days a week 1 to 5 days a week Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 828,432 25,761 Professional Fees 35,400 4,875 Operations 372,574 9,764 Supplies 21,000 4,000 Equipment 8,500 600 Other: Other: Other: Other: Other: TOTAL 1,265,906 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. r\-- (a„j2_ January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fixture funding requect rind mny result in nrtinnc taken to rernver theca funrlc, By signing below,you are acknowledging that you have read and understood these requirements. January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Ocean View Club Program Name: Ocean View Club Daily Services for Income Challenged Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 65% 50% 50% 1 to 5 days a week TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,761 Professional Fees 4,875 Operations 9,764 Supplies 4,000 Equipment 600 Other: Other: Other: Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Boys & Girls Club of the Big Island, Pahala Club Literacy, Homework & Tutoring Support for Income Challenged 32 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Jasmine Branco Phone No.: (sos) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 96-1149 Kamani Street Address: City,ST,Zip Pahala, HI 96777 Email Address: jasmineb@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $10,000 $8,750 2. Agency Mission Statement: Our mission,"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment.",has positioned the 65 year old Boys&Girls Club of the Big Island(BGCBI)to be the premier youth development organization in Hawaii County and is the only organization whose sole mission is to provide after-school youth development opportunities.These opportunities include participation in educational, health and wellness and character developing activities that shape participants for life. Many of the 1,000 youth annually served here are daily attendees at one of our Club sites throughout rural Hawaii County(Hilo, Keaau, Pahoa, Pahala and Ocean View).49%of all attendees come from families that are recipients of Free/Reduced lunch at their schools,which is a federal indicator of economic hardship.20%of all attendees are self proclaimed to be in the economic bracket that receives an annual income of less than$5,000.Thus, many of the youth we serve are part of a social crisis impacting their families and our communities,including the economic security which leads to housing insecurity,food insecurity, and resulting in a poor quality of life with high levels of stress. Without our services,many of our 1,000 members would not have the economic capacity to afford after-school programming synonymous to the safe,enriching,quality and life enhancing programming we currently are able to offer for the low annual fee of$10.This cannot be done without the continued support BGCBI receives from our County and local community supporters. 3. Program Description: Literacy, Homework&Tutoring Support for Income Challenged will provide 3 educational initiatives to support the acute academic needs of our youth participants encouraging greater literacy,better study habits and higher numbers of grade level completion.The proposal utilizes three of Boys&Girls Club of America's nationally certified educational support programs. The 1st initiative, Project"REACH" (Reading Enhances All Children's Hope)engages youth to participate in literacy enhancement activities after-school that help develop their overall reading,spelling and writing proficiency through daily reading and a site wide Spelling Bee. 2nd:"PowerHour",an incentive based homework support program grants participants points for every hour dedicated to homework completion.The more hours dedicated,the greater the points collected to redeem for sought after items including BGCBI items and school supplies.Nationally,"PowerHour"has proven to effectively engage youth in developing strong, life long learning habits that facilitate daily homework completion and test score improvement. 3rd: "Project Learn", reinforces and enhances the skills and knowledge youth learn at school during their hours spent at the Club.The strategy,based on Dr. Reginald Clark's research,shows that students do much better in school when they spend their non-school hours engaged in fun,academically beneficial activities. Parent,school&Club collaboration has proven to boost the academic performance of youth members through"Ghana Nights"and open communications with schools. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time",there are four types of literacy initiatives: 1)Literacy and development programs,2) Literacy enhancement programs,3)Academic enhancement programs,4)Social development programs. These three programs work together to help establish a strong foundation towards the desire to gain greater knowledge and shape effective lifelong educational learning habits. 4.Total Budget& Position Count: Total Program Budget: 45,000 _ Total Program Position Count: 3 Total Agency Budget: 1,265,906 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of HI Literacy, Homework&Tutoring Support(proposed) 45,000 Cooke Foundation (secured) 10,000 Pizza Hut Literacy(secured) 25,000 OHA Education Grant(proposed) 300,000 Kamehameha Community Investment Grant(proposed) 750,000 TOTAL: 1,130,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to effectuate change in a community, it starts with the children;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth that need these programs the most in our local, rural communities. "When school is out, Clubs are in",is our motto for ensuring that the youth of our community have continuous opportunity to be in a safe and enriching environment. In the past year, BGCBI experienced a drastic decrease in funding from a plethora of long time Funding Sources, thus organizationally we had to make tough decisions to decrease services.We have not advertised for open enrollment and have reached our record high of membership in years;clearly there is a need in our County for after-school youth development and preventative services. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security below is a list of our current supporters: Pizza Hut Literacy for Life(secured) Cooke Foundation(secured) OHA Education Grant(proposed) Kamehameha Community Investment Grant(proposed) 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy amongst the Income Challenged Youth that our organization services through reading programs and spelling bees to aid youth in growing their academic skill set. Participants in our reading program take pre and post tests;our objective will be to see 50%of participants scores improve. BGCBI will host a site wide Spelling Bee that will start with 20 participants from each Club. Through providing tutoring to the participants are struggling academically according to their report cards,BGCBI's objective is to aid youth in growing their academic skills.50%of participants in our Homework Support Program will see an increase in his/her grades. Increase the number of program participants that complete their homework daily to ensure the establishment of good study habits through daily participation in"Power Hour"while at the Club.The number of participants in this homework support program will increase by 50%. It is proven that the most effective programs include Clubs,Schools and Families.We will host an "Ohana Night"each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Reading Scores of 50%of participants will increase 50%increase Number of Participants in Spelling Bee 12 Grades of 50%of participants will increase 50%increase Number of Participants that participate in homework support will increase 50%increase Ohana Nights 1 an academic year Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 828,432 22,014 Professional Fees 35,400 6,500 Operations 372,574 11,886 Supplies 21,000 4,000 Equipment 8,500 600 Other: Other: Other: Other: Other: TOTAL 1,265,906 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director • The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. (1-QA--, 13` January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futures funding request rind mny result in nrtinns triken tri rernver theta funds. By signing below, you are acknowledging that you have read and understood these requirements. 111` January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2O17-18 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50%increase 12 50%increase 50%increase 1 an academic year TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 22,014 Professional Fees 6,500 Operations 11,886 Supplies 4,000 Equipment 600 Other: Other: Other: Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Boys & Girls Club of the Big Island, Pahoa Club Literacy, Homework & Tutoring Support for Income Challenged 33 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 - 5536 Contact Person: Jasmine Branco Phone No.: (808) 961 - 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 15-3003 Kauhale Street Address: City,ST,Zip Pahoa, HI 96778 Email Address: jasmineb@bgcbi.org Fax No.: (808 ) 961 - 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 - 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth 0 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $25,000. $20,000. $8,750. 2.Agency Mission Statement: Our mission,"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment.",has positioned the 65 year old Boys&Girls Club of the Big Island(BGCBI)to be the premier youth development organization in Hawaii County and is the only organization whose sole mission is to provide after-school youth development opportunities.These opportunities include participation in educational,health and wellness and character developing activities that shape participants for life. Many of the 1,000 youth annually served here are daily attendees at one of our Club sites throughout rural Hawaii County(Hilo, Keaau, Pahoa, Pahala and Ocean View).49%of all attendees come from families that are recipients of Free/Reduced lunch at their schools,which is a federal indicator of economic hardship.20%of all attendees are self proclaimed to be in the economic bracket that receives an annual income of less than$5,000.Thus, many of the youth we serve are part of a social crisis impacting their families and our communities,including the economic security which leads to housing insecurity,food insecurity, and resulting in a poor quality of life with high levels of stress. Without our services, many of our 1,000 members would not have the economic capacity to afford after-school programming synonymous to the safe,enriching, quality and life enhancing programming we currently are able to offer for the low annual fee of$10.This cannot be done without the continued support BGCBI receives from our County and local community supporters. 3. Program Description: Literacy,Homework&Tutoring Support for Income Challenged will provide 3 educational initiatives to support the acute academic needs of our youth participants encouraging greater literacy,better study habits and higher numbers of grade level completion.The proposal utilizes three of Boys&Girls Club of America's nationally certified educational support programs. The 1st initiative, Project"REACH" (Reading Enhances All Children's Hope)engages youth to participate in literacy enhancement activities after-school that help develop their overall reading,spelling and writing proficiency through daily reading and a site wide Spelling Bee. 2nd:"PowerHour",an incentive based homework support program grants participants points for every hour dedicated to homework completion.The more hours dedicated,the greater the points collected to redeem for sought after items including BGCBI items and school supplies. Nationally,"PowerHour"has proven to effectively engage youth in developing strong,life long learning habits that facilitate daily homework completion and test score improvement. 3rd: "Project Learn", reinforces and enhances the skills and knowledge youth learn at school during their hours spent at the Club.The strategy, based on Dr. Reginald Clark's research,shows that students do much better in school when they spend their non-school hours engaged in fun,academically beneficial activities. Parent,school&Club collaboration has proven to boost the academic performance of youth members through "Ohana Nights"and open communications with schools. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time",there are four types of literacy initiatives: 1) Literacy and development programs,2)Literacy enhancement programs,3)Academic enhancement programs,4)Social development programs. These three programs work together to help establish a strong foundation towards the desire to gain greater knowledge and shape effective lifelong educational learning habits. 4. Total Budget& Position Count: Total Program Budget: 45,000 Total Program Position Count: 4 Total Agency Budget: 1,265,906 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of HI Literacy, Homework&Tutoring Support(proposed) 45,000 Cooke Foundation (secured) 10,000 Pizza Hut Literacy(secured) 25,000 OHA Education Grant(proposed) 300,000 Kamehameha Community Investment Grant(proposed) 750,000 TOTAL: 1,130,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to effectuate change in a community,it starts with the children;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth that need these programs the most in our local, rural communities."When school is out, Clubs are in",is our motto for ensuring that the youth of our community have continuous opportunity to be in a safe and enriching environment. In the past year, BGCBI experienced a drastic decrease in funding from a plethora of long time Funding Sources, thus organizationally we had to make tough decisions to decrease services.We have not advertised for open enrollment and have reached our record high of membership in years;clearly there is a need in our County for after-school youth development and preventative services. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security below is a list of our current supporters: Pizza Hut Literacy for Life(secured) Cooke Foundation(secured) OHA Education Grant(proposed) Kamehameha Community Investment Grant(proposed) 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy amongst the Income Challenged Youth that our organization services through reading programs and spelling bees to aid youth in growing their academic skill set. Participants in our reading program take pre and post tests;our objective will be to see 50%of participants scores improve. BGCBI will host a site wide Spelling Bee that will start with 20 participants from each Club. Through providing tutoring to the participants are struggling academically according to their report cards,BGCBI's objective is to aid youth in growing their English skills.50%of participants in our Tutoring Program will see an increase in his/her test scores in accordance to their pre and post tests. Increase the number of program participants that complete their homework daily to ensure the establishment of good study habits through daily participation in"Power Hour"while at the Club.The number of participants in this homework support program will increase by 50%. It is proven that the most effective programs include Clubs,Schools and Families.We will host an"Ghana Night"each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Reading Scores of 50%of participants will increase 50%increase Number of Participants in Spelling Bee 20 Test Scores of 50%of participants will increase 50%increase Number of Participants that participate in homework support will increase 50%increase Ohana Nights 1 an academic year Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 828,432 23,630 Professional Fees 35,400 4,875 Operations 372,574 11,095 Supplies 21,000 4,800 Equipment 8,500 600 Other: Other: Other: Other, Other: TOTAL 1,265,906 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. January 31 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 futures funding rarquact nnrl mny result in nrtinnc tnken to rernver thecP funds. By signing below, you are acknowledging that you have read and understood these requirements. January 31 , 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework &Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50%increase 20 50%increase 50%increase 1 an academic year TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 23,630 Professional Fees 4,875 Operations 11,095 Supplies 4,800 Equipment 600 Other: Other: Other: Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Brantley Center, Inc. Job Skills Development Program 34 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Development Program Agency Director: Sheri Salmon Phone No.: (808) 775 - 7245 Contact Person: Sheri Salmon Phone No.: (808) 775 - 7245 Mailing Address: Address: PO Box 1407 Address: City,ST,Zip Honokaa, HI 96727 Facility Address: Address: 45-370 Ohelo Rd Address: City,ST,Zip Honokaa, HI 96727 Email Address: bcenter2@hawaiiantel.net Fax No.: (8o8 ) 775 - 0211 Accountant/CPA: Gail Elizares Phone No.: (808 ) 217 - 1299 Firm (if applicable): Mailing Address: Address: PO Box 246 Address: City,ST,Zip Laupahoehoe, HI 96764 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) E Puna ❑✓ Hamakua El North Kona ❑South Hilo n North Kohala E South Kona North Hilo ❑South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns E Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor 0 Physical/Emotional Disabilities El Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Development Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 40000 0 2. Agency Mission Statement: Our mission is to provide quality rehabilitation services that empower people with disabilities to participate independently within his or her community. 3. Program Description: Brantley Center, Inc.clients receive daily curb-to-curb transportation both to and from the Center free of charge. While at the Center clients receive a thorough job skills readiness assessment. Based on assessment results they are given an appropriate service array. These services include job readiness classes,hands-on job readiness training in the field,competitive employment placement services,and on-the-job follow-up services_ At the Center clients have the opportunity to explore different jobs and skills ranging from janitorial services,yard maintenance,landscaping,agricultural and hydroponic skills,green house maintenance,car wash and detailing,as well as small craft production. Clients are paid based on their productivity levels and are rewarded for increased and improved productivity. Once the necessary skills are obtained clients are then placed in competitive jobs within the community and continue to receive supportive follow-up services for the initial six months of employment. The Job Skills Development staff and clients develop a strong relationship and rapport with community businesses and members leading towards community-based vocational training as well as providing the public with an additional workforce. 4.Total Budget&Position Count: Total Program Budget 121509.60 Total Program Position Count 4 Total Agency Budget 390,000 Total Agency Position Count 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Development Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Greenhouse Services 3,000 Auto Detailing Services 1,500 Fish Bag Manufacturing 3,000 Janitorial Services 16,000 Yard and Landscaping Services 111,300 TOTAL 134,800 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Brantley Center Staff and Board Members have made a collective and concerted effort to expand its fund development capabilities whether it be through pursuing new grants or coming up with fresh ideas on fundraising efforts.Brantley Center will increase revenues and continue to support the Job Skills Development Program through pursuing and securing more community contracts. Examples of currently secured contracts are numerous yard maintenance and landscaping jobs in the Waimea, Kohala,Hilo and Honoka'a areas,approximately five different janitorial contracts within Honoka'a,as well as providing goods in the form of hydroponic greens to numerous restaurants and small craft production for a Kona tropical fish farm. With the funding and intake of more clients we will be able to secure more contracts thus leading to a sustained Program. 7. Program Objectives Using County Nonprofit Grant Program Funds: If funds are awarded,beginning July 1,2017 Brantley Center, Inc.will immediately increase the number of clients brought into the Job Skills Development Program. A full restoration will be made to the Program allowing for more clients getting necessary job-readiness training in the form of vocational evaluations,individualized employment planning services,work adjustment training,occupational skills,competitive job placement within the community,and work transition services. A minimum of fifteen additional clients will be served during the fiscal year that would otherwise not have been provided these beneficial services. With the increase in intake clients Brantley Center will be able to pursue and secure more contracts within the community thus allowing for more revenue. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Development Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of clients who received employment rehab services 20 Number of consumers who improved scores on the vocational evaluation training report 10 Number of consumers with improved productivity percentages 10 Number of consumers who successfully completed the job-readiness classes 15 Number of consumers placed in competitive employment for a minimum of 90 days 5 Number of students who receive work transition services and were placed in competitive 3 employment Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 88,252.41 90,000 Professional Fees 0 0 Operations 0 0 Supplies 4448.68 4000 Equipment 5633.35 4500 Other: Employee Benefits 11,847.69 12,000 Other: Taxes-FICA, MEDICARE, SUTA 7240.28 7300 Other: Taxes-General Excise 3088.19 3100 Other: Automobile Repairs and Maintenance 588.42 500.00 Other: Permits, Fees, Licenses 109.60 109.60 TOTAL 121209.22 121509.60 50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Development Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Valerie Poindexter POSITION: County Councilwoman Hamakua District May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): • Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor [i The Managing Director E 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: Councilwoman Poindexter's daughter attends Brantley center,Inc as a full-time client. ❑ If no conflicts exist, check here. 01/27/17 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Development Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 '- ;c; complete the 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 indude an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Development Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http:/Jwww.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii 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 mny result in nrtinnc tnken to rernver these funds, By signing below,you are acknowledging that you have read and understood these requirements. Y601' 4ir 01/27/17 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Brantley Center, Inc. Program Name: Job Skills Develo•ment Pros ram 12. COUNCIL AWARD WORKSHEET TABLE I: sed PROGRAM PERFORMANCE MEASURES Applt a Councli�� Projected Results Projected Result Number of clients who received employment rehab services 20 Number of consumers who improved scores on the vocational evaluation training report 10 Number of consumers with improved productivity percentages t0 Number of consumers who successfully completed the job-readiness classes t5 Number of consumers placed in competitive employment for a minimum of 90 days s Number of students who receive work transition services and were placed in competitive 3 employment TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Employee Benefits Other: Taxes-FICA, MEDICARE,SUTA Other: Taxes-General Excise Other: Automobile Repairs and Maintenance Other: Permits, Fees, Licenses TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Bridge House Mala 'Ai, food garden project 35 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project Agency Director: Andi Pawasarat-Losalio Phone No.: (808) 322 — 3305 Contact Person: Andi Pawasarat-Losalio Phone No.: (808) 322 — 3305 Mailing Address: Address: P.O. Box 2489 Address: City,ST,Zip Kailua-Kona, HI 96745 Facility Address: Address: 78-6687-B Mamalahoa Hwy, Address: City,ST,Zip Holualoa, HI 96725 Email Address: director.bridgehouse©gmail.com Fax No.: (808 ) 322 — 0809 Accountant/CPA: Brenda Smith Phone No.: (808 ) 960 — 5041 Firm (if applicable): Smart Solutions Mailing Address: Address: P.O. Box 1254 Address: City, ST,Zip Kailua-Kona. HI 96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓ Puna d Ha-rakua I North, 'Kora I South Hilo 1 North Kohaia 1 South Kona I. North Hilo / South Kohala ✓ Kai, Services or Activities To Be Provided: (One or more can be checked) Educational concerns Youth Victims of Crimes ✓i✓i Culture and the arts Aged '✓. Victims of Health or Social Crises 7 Needs of the poor 41 Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 - 2018 Par= 1 c' x County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0.00 $0.00 $0.00 2. Agency Mission Statement: The Bridge House mission is to assist adults in early recovery from drug and alcohol addiction to develop successful living skills through residential and vocational experiences in a safe, structured and supportive environment. 3. Program Description: Many residents come to the Bridge House Clean&Sober Living Program with unhealthy eating habits from years of unstable living often because of substance abuse issues. Many have extreme nutritional deficiencies due to unhealthy eating behaviors due to lack of nutritional knowledge, uninformed food preparation skillsand chaotic lifestyles. We have responded to this by the inclusion of our Mala 'Ai. food garden project. within our Ke Ala Kupono Cu'tura'i Program which has been in existence for over 8 years. Nutritional status plays an important role}n the process of revery.We have noted the benefits of this program by the improved health of our residents.Those markers for improved health include lessened visits to the ER. better sleeping habits. improved energy levels.and enhanced ability to concentrate. The Mae Ai project.with the guidance of our Cultural Garden Coordinator, gives residents an opportunity to learn about where food comes from, how to grow from seed,to care for plants. soil health, harvesting, and learn about the nutritional value of foods and to learn to cook fresh foods. Residents get the opportunity to create something that is worthwhile and beneficial to not only themselves but to others as well.Along with nutritional health education,the additional benefit for residents is a sense of kOleana, responsibility; a sense of malama, caring; and a sense of ha'aheo, pride in themselves, as they grow and nurture food crops. Within this project is also Ka Ho'opulu'Ana,or compost. Residents learn how to care for soil,to make compost, its value as an organic matter and how nutrients added to soil improves its fertility and productivity. Residents will use green waste, food scraps and animal manure to learn how microorganisms feed on the organic matter and how compost turns into nutrient rich soil. 4.Total Budget&Position Count: Total Program Budget: $15,300.00 Total Program Position Count: 1 (contracted) Total Agency Budget: I$489,050.85 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 page 2 cf Q County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawai'i $7,650.00 HMSA, OHA, or Program Fees $7,650.00 TOTAL: $15,300.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We also continue to seek out funds from both private and public foundations. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective for the Mala'Ai project is to educate residents about food sources, improved eating habits, and health to improve the overall health of residents to support a more holistic well-rounded recovery from substance abuse addiction. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 c*3 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Approximately 48 adult(men/women)will be served 90%of participants will agree their knowledge of nutrition has improved At time of completion(graduates): 80%will report they believe their health has improved due to participation At 6-months post-discharge, graduates will report they have improved eating habits/health 60%of clients meet this target Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 1 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees 1 Operations Supplies $4.500.00 i $2.250.00 Equipment Other Contracted Cultural Gardener $10.800.00 $5,400.00 Other: Other Other: Other: TOTAL i $15.300.00 $7.650.00 *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION F`;'2017-2018 :rage 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. President 7-3 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT,^-,PPLICATION F 2017-2018 Faze E County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with 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 F 2017-2018 :age 5 E County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and mny result in nrtinnc tnken to rprnver theta funds. By signing below, you are acknowledging that you have read and understood these requirements. ,.Air / / President /-3 ° —/7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Mala 'Ai, food garden project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90%of part pants will agree Approximately 48 adult(men/women)will be served their knowledge of nutrition has improved 80%will report they believe their health has improved due to participation At 6-months post-discharge,graduates will report they have improved eating habits/health CC%cf ci erts meet this target TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award 1 y Salary and Wages Professional Fees Operations Supplies 82.250.00 Equipment Other: Contracted Cultural Gardener $5.400.00 Other: Other: Other: Other: TOTAL $7.650.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT.APPLICATION FY 2017-2018 Page 8 of 8 Bridge House Vocational Skills Building 36 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) Agency Director: Andi Pawasarat-Losalio Phone No.: (808) 322 — 3305 Contact Person: Andi Pawasarat-Losalio Phone No.: ( 808) 322 — 3305 Mailing Address: Address: P.O. Box 2489 Address: City,ST,Zip Kailua-Kona, HI 96745 Facility Address: Address: 78-6687-B Mamalahoa Hwy. Address: City,ST,Zip Holualoa, HI 96725 Email Address: director.bridgehouse@gmail.com Fax No.: (808 ) 322 — 0809 Accountant/CPA: Brenda Smith Phone No.: (808 ) 960 — 5041 Firm (if applicable): Smart Solutions Mailing Address: Address: P.O. Box 1254 Address: City,ST,Zip Kailua-Kona, HI 96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) n Puna ✓ Hamakua n North Kona ✓ South Hilo ✓ North Kohala n South Kona I North Hilo I South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) (✓I Educational concerns Youth n Victims of Crimes I Culture and the arts ❑Aged 0 Victims of Health or Social Crises ✓� Needs of the poor I Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $25,000.00 $18,000.00 $18,750.00 2.Agency Mission Statement: The Bridge House mission is to assist adults in early recovery from drug and alcohol addiction to develop successful living skills through residential and vocational experiences in a safe. structured and supportive environment 3. Program Description: Ongoing research consistently confirms that employment is one of the strongest correlates with successful recovery from addiction and with re-establishing connection to family and the community.As a result of their substance abuse, approximately 90%of all our new admits are unemployed/unemployable upon arrival to Bridge House. Participation in our Vocational Skills Building Program (VSB)is mandatory for all residents in our clean&sober housing program. All new residents complete a vocational history questionnaire. The results of this evaluation, along with personal observation by staff, help identify skills, attitudes and behaviors that may require remediation. The VSB program provides on-site job training with evaluated performance of job assignments, assists with resume preparation, provides training in the use of basic office equipment and basic computer skills, may conduct mock interviews, facilitates linkages to other community resources for enhancement of works skills as well as educational opportunities, and offers guidance to jobs appropriate to ability.Transportation may also be provided to obtain job applications, attend interviews and attain legal documentation. As an expansion to our program this year we would like to provide more services to assist in navigating the process of, and provide funding for,the attainment of appropriate legal documents for employment(i.e.:state ID, social security cards, birth certificate...). Many of our residents have never had or have lost their legal identification and usually do not have the financial resources to obtain or replace them. The lack of proper identification can be a major barrier to attaining legal employment.We also plan to support program activities though the addition of culturally relevant programming as well as the inclusion of a cultural based financial literacy/education program. 4.Total Budget & Position Count: Total Program Budget: $86,500.00 Total Program Position Count: 1.5 Total Agency Budget: $489,050.85 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai'i Nonprofit Grant Application FY201 i-18 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawai'i $27,500.00 Hawai'i Island United Way $40,000.00 Program Fees $8.500.00 Contributions $500.00 Department of Health , Alcohol and Drug Abuse Division $5,000.00 Agricultural Income $5,000.00 TOTAL: $86.500.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continJe to expand our Ori-site agricultural endeavors garden gro".in vegetable and herbs that are sourced thirc..ggr a c ca. distributor(Adaptations). We are also working towards becoming a supplier for the Food Basket 'Box- program Ai:to:Lion these agricultural pursuits contribute some income, the proceeds from these sales are significantly insufficient to support the program As such, we also continue to seek out funds from both private and public foundations. 7. Program Objectives Using County Nonprofit Grant Program Funds: The VSB program's primary objective is to prepare our residents to enter/re-enter the workforce. As a result of their addiction most individuals have disengaged from mainstream society(e.g. abandoning family, losing employment, engaging in criminal activity). The substance abuser often no longer shares many of the healthy benefits/values that are found within the community. Maintaining employment has consistently been identified as one of the primary components that facilitates successful recovery as well as reconnection with family and community. Every individual who is able to secure employment and begin the process of re-engagement is likely to eliminate self-destructive behaviors, rejoin their family,experience enhanced health, and begin to'give back'to the community.We expect all graduates to have secured employment prior to leaving Bridge House and to report still being employed at 6 months post-discharge. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.; Approximately 48 adult(men/women)will be served by the program and of those4i sO%of graduates(completed program will be graduates: {employed or in schooi/)ob training program At 6-months post-discharge, graduates will be employed or attending school/job training 80%of graduates shall have employment program;report no new arrests; report no new relapses. at 6-month follow-up. Clients will report that culturally relevant programming increased engagement 60%of clients will meet this Clients in the program for more than 60 days will have attained some form of legal ID 100% of clients will attain Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req $48,000.00 ? $48,000.00 j $18.500.00 Salary and Wages Professional Fees $6.800.00 $7,800.00 $ 800.00 Operations $18,600.00 $17,100.00 $2,800.00 Supplies $6,400.00 $6,800.00 $2,500.00 Equipment $2,400.00 $2,600.00 $500.00 Other $1,800.00 Other: Fees to attain client legal documents $2,400.00 $2,400.00 Other. Other: Other: TOTAL $82,200.00 $86,500.00 $27,500.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2017-1 S Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council —" The Mayor The Managing Director (i The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. , President 3 0 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with 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 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FYI017-18 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) 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 on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPriuwct and mny recuit in artinnc taken to rprnver theca funds, By signing below,you are acknowledging that you have read and understood these requirements. President /.,�.i� a, 0 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building (VSB) 12. COUNCIL AWARD WORKSHEET TABLE I: I � PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Approximately 48 adult(men/women)will be served by the program and of those I program)will be employed or the graduates: or in schoollob training program_ it % l ha At 6-months post-discharge,graduates will be employed or attending school/job training 80attaineoftl gtheseraduates benchmshala ksve at 6-Tont"'0 0N-J0 program; report no new arrests; report no new relapses. —bet s Clients will report that culturally relevant programming increased engagement target:''" Clients in the program for more than 60 days will have attained some form of legal ID a ""''a»a P 9 Y 9 same+crr c' TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $18,500.00 Professional Fees $ 800.00 Operations $2,800.00 Supplies $2,500.00 Equipment $500.00 Other: Other: ees to attain client legal documents $2,400.00 Other: Other: Other: TOTAL $27,500.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Child & Family Services Alternatives to Violence 37 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence Agency Director: Howard Garval Phone No.: (808) 681 — 3500 Contact Person: Karen Tan Phone No.: (808) 681 — 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1045A Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 — 5280 Accountant/CPA: N&K CPAs, Inc. Phone No.: (808 ) 524 — 2255 Firm (if applicable): N&K CPAs, Inc Mailing Address: Address: 1001 Bishop Street Address: Suite#1700 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ✓❑ North Kona ❑✓ South Hilo North Kohala ✓❑South Kona ✓❑ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑✓ Youth ✓❑Victims of Crimes ❑Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $30,000 $19,000 $14,375 2. Agency Mission Statement: The Alternatives to Violence(ATV)Program fits perfectly with Child&Family Service's(CFS)mission of"Strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii,ATV program services have been provided for more than seven years.CFS offers 48 programs statewide with a comprehensive array of effective and culturally relevant services for Hawaii's residents in need.The broad spectrum of services provided by CFS include domestic violence intervention, case management, residential group homes,alternative education for alienated youth, prevention and treatment of child abuse, recovery and prevention of substance abuse, and school and community-based counseling services for children and their families. Infants, children,adolescents,young adults, individuals and families in need all have benefited from these services. In Fiscal Year 2016, CFS directly served 10,518 individuals ranging from infants to elderly adults. In addition,the organization has touched the lives of over 43,500 individuals through hot-line calls, educational presentations and providing food and clothing resources 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 34 offices located 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, communities,and individuals we serve. (Continued on Attachment) 3. Program Description: Funding in the amount of$60,000 is being requested to support the total costs of the ATV Program in the County of Hawaii. This funding will be used to support victims of domestic violence by employing 2 part-time Domestic Violence Specialist(DVS) positions(one DVS in East Hawaii and one in West Hawaii for 9 hours of additional direct services weekly in both locations), based on a review of community needs.These two DVS positions will provide a total of 18 additional direct service hours to support participants in addressing identified needs for safety planning,assistance with filing a TRO,strengthening their family's protective factors,obtaining permanent housing, healing from trauma for both the victim and their children with enhanced parenting skills to address recovery from the impacts of domestic violence,and reduction of relapse of abuse among batterers. The DVS positions will provide needed coverage for evidenced based group interventions noted below. CFS understands domestic violence is traumatic. It impacts every family member.National statistics regarding domestic violence available through the Centers for Disease Control and Prevention(CDC)indicate that 1 in 4 women will experience domestic violence during her lifetime; it is the third leading cause of homelessness among families according to HUD; more than 3 million children witness domestic violence annually;children who live in homes with domestic violence also suffer abuse or neglect at high rates(30%-60%);domestic violence costs more than$37 billion a year in in law enforcement involvement,legal work, medical and mental health treatment and lost productivity at work. (Continued on Attachment) 4. Total Budget & Position Count: Total Program Budget: $640,970 Total Program Position Count: 10.5 Total Agency Budget: $6,745,660 Total Agency Position Count: 82 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Judiciary $530,499 County of Hawaii $60,000 VOCA $7,500 HIUW $9,000 Program Fees $15,000 TOTAL: $621,999 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS works hard to maintain, diversify and increase funding for all of our program services.Given the number of individuals and families impacted by domestic violence on the Big Island,domestic violence is a pressing public health and social welfare issue for our community. In an effort to respond to the needs of the Big Island community,CFS has expanded domestic violence services during the past few years. In 2015, CFS was awarded a contract from the State's Department of Human Services to provide domestic violence treatment within the context of the family.This contract supports our Domestic Violence Services for Families program. CFS was also awarded Federal funding from The Violence Against Women Act(VAWA)and the Victims Of Crime Act(VOCA)to support our Domestic Abuse Shelter Programs.This funding has been instrumental to CFS'ability to provide critical domestic violence services to the Big Island community. CFS has been challenged to maintain funding for the ATV program.The program's primary funding source,the State Judiciary, decreased funding by 40%in 2009. In fiscal year 2016,CFS advocated for additional funding from the Judiciary and was granted an additional$65,000 which has been vital for sustaining ATV victim support services. Even with this additional funding,the ATV program receives 33% less than what was received from the Judiciary in 2009.The need for ATV services remains high. Therefore,CFS continues to seek funding from other sources in order to sustain these essential program services. (Continued on Attachment) 7. Program Objectives Using County Nonprofit Grant Program Funds: The Hawaii Island Alternatives to Violence(ATV)Program's goals are to reduce the impact that domestic violence has on families and the community and to break the intergenerational cycle of violence. Funding from the Country of Hawaii would support the following objectives: 1)85%of victims seeking assistance with obtaining a TRO will receive information on how to increase personal safety as well as the safety of her/his family members. (Every victim is given a TRO and Family Court Information packet that includes vital information to consider when planning their safety.DVS positions would support their strengthening of protective factors and parenting skills to address family recovery needs and the impacts of domestic violence.) 2)85%of victims seeking TRO assistance will complete an Abuse Behavior Inventory(ABI)to assess safety risks. If victims report a high safety risk,the DVS will assist the program participant with developing a safety plan and making connections with vital emergency/safety resources,such as the Domestic Abuse Shelter. 3)75%of offenders who enroll in Domestic Violence Intervention(DVI)classes will successfully complete all 26 classes and complete a relapse prevention plan. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of individuals assisted with completing a TRO application 1,300 #of individuals who received information on safety planning 1,300 #of individuals who completed a Abuse Behavior Inventory to assess safety risk 1,105(80%of individuals assisted with TRO) #of individuals who successfully completed the DVI curriculum(all 26 classes) 50 #of individuals who completed a relapse prevention plan 50 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $465,000 $474,300 $33,708 Professional Fees Operations $158,500 $161,670 $24,292 Supplies $5,000 $5,000 $2,000 Equipment Other: Other: Other: Other: Other: TOTAL $628,500 $640,970 $60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council (1 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. 1/27/4,- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's futures funding requect and may recult in artinnc taken to rernver there fundc. 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 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Alternatives to Violence 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result #of individuals who received assistance with applying for a TRO 1,300 #of individuals who received information on safety planning 1,300 #of individuals who completed a Abuse Behavior Inventory to assess safety risk 1.105( i of individuals assistedd wwith TRO) #of individuals who successfully completed the DVI curriculum(all 26 classes) 50 #of individuals who completed a relapse prevention plan 50 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $33,708 Professional Fees Operations $24,292 Supplies $2,000 Equipment Other: Other: Other: Other: Other: TOTAL $60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Attachment Applicant: Child & Family Service Program: Alternatives to Violence 2. Agency Mission Statement (Continued) CFS has years of experience working with the diverse demographics and cultural identities of Hawaii's residents while partnering with funding sources to implement new models of service delivery. The organization's main goals are to (1) Improve an individual's functional and clinical status (emotional, psychological well-being, development and independent living skills); (2) Improve individual's or family system's ability to cope with stressors in their lives; and (3) Improve the health, welfare, and safety of individuals so that they are safe from harm, abuse or neglect. CFS demonstrates our 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 program participants, community stakeholders, direct service staff, management and the Board of Directors. Programs strive to provide a Family-Centered, Full-Service model of care. CFS has organized its programs into impact areas that include Caring for Keiki, Healing from Trauma, Empowering Youth, and Honoring Kupuna. Proving effectiveness of our programs is what drives our organization within these four impact areas. CFS's strategic vision is to become a Family-Centered, Full-Service organization. The organization has established four focus areas to fulfill 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. They include Cultural Competence; Person- and Family-Centered Approaches; Community and Stakeholder Partnerships; Positive Client Outcomes; Commitment to Learning; Quality Monitoring; Employee Excellence; and Coordination of Care. Page 1 of 4 Attachment Applicant: Child & Family Service Program: Alternatives to Violence 3. Program Description (Continued) Through current research we know that children of domestic violence have difficulty processing what has happened. They can internalize their feelings manifesting into guilt, shame, anger, anxiety and sadness; they are at higher risk of achieving poor academics; are at greater risk of child abuse and neglect; and can continue to be involved in the cycle of violence when they are older. According to the Hawaii Department of Health, 9.5% of the adults who responded to the Behavioral Risk Factor Surveillance Survey (BRFSS) in 2013 reported they had been the victim of physical injury by an intimate or ex-intimate partner over the past 12 months, up from 8.8% as reported in 2011. CFS offers ATV services to victims, children, and adolescents, as well as offenders. Funding from the County of Hawaii would support the two much-needed DVS positions that are responsible for implementing the following services: 1) Providing assistance with obtaining Temporary Restraining Order (TRO). This is often a first step victims will take to increase their safety and the safety of their children. In addition to assisting individuals with completing the application for a TRO, DVS's talk with victims about how to make a safety plan, provide a brochure on how to develop and use a safety plan for all family members, assess the victim for risk of further domestic violence and inform victims of their options to stay at a domestic violence shelter; 2) Court Advocacy for program participants during a TRO hearing in Family court; 3) Case Management for victims and facilitation of referrals and warm linkages to community resources that will assist victims with re-building their lives. DVS will work with participants to engage with community partners for needed resources to support them in addressing the need to enhance protective factors; 4) Providing opportunities for social connections among individuals who have experienced domestic violence and are recovering; and 5) Supporting offenders in their development of alternative coping strategies through Domestic Violence Intervention services for Offenders. In order to end the cycle of domestic violence and help families to fully heal, it is critical that those who perpetrate the violence receive comprehensive treatment to include group education and intervention and case management. In many cases, perpetrators of domestic violence were themselves victims at one time or another in their life and domestic violence is deeply entrenched within their childhood upbringing and is what they know to cope with stressors. CFS closely adheres to the Hawaii Batterers Standards, to include providing 26 Page 2of4 Attachment Applicant: Child & Family Service Program: Alternatives to Violence weeks of intensive group intervention that focuses on holding the batterer accountable for their behavior, educating participants about the different forms of domestic violence, increasing participant's awareness of their own thought patterns and triggers for abuse, helping participants to understand the relationship between thought and behavior using cognitive behavioral therapeutic methods and motivational interviewing, providing hands-on strategies for changing unhelpful thoughts and or interrupting learned responses of reacting immediately and in abusive ways, i.e. choosing to take a cool down rather than responding right away and facilitating opportunities for social support with other group participants who understand what it is like to struggle with domestic violence. Both CFS Hawaii Island ATV program sites (Hilo & Kona offices) utilize the Stop Abuse for Everyone (SAFE) curriculum for the men's Domestic Violence Intervention (DVI) program. This is a curriculum that incorporates evidence- based components including motivational interviewing, cognitive behavior therapy and the change theory into our work with offenders. There are separate DVI groups for women and adolescents. All CFS ATV program services are provided through the lens of Trauma-Informed Care. We follow the Risking Connection® model which was developed by the Sidran Institute, to work with individuals and families who have experienced trauma. This model provides a foundation for all the work we do with families and emphasizes the RICH® relationship approach where we offer "Respect, Information Sharing, Connection, and Hope" to everyone we engage within services. In alignment with evidence-based practices and a trauma-informed care framework, staff operate with the understanding that: • Traumatic events can cause overwhelming feelings of horror, terror, and hopelessness; • Caregivers with histories of trauma may avoid experiencing their own emotions, which may impact them and hinder them in responding appropriately to their child's emotional state and needs; • Traumatic stress occurs when exposure to traumatic events overwhelm the individual's ability to cope; • A strong relationship with a trusted caregiver is a potential buffer against traumatic stress; • Positive attachment and connections are essential for healthy child and adolescent development; and • Working with families that have experienced trauma impacts staff, who may also need to be supported and nurtured. ATV program participants are able to access services and resources that can help in building a more secure foundation, with staff assisting them in the development of their protective factors. By walking with program participants through the process of learning to manage the trauma they have experienced, sharing skills and tools, and working with Page 3 of 4 Attachment Applicant: Child & Family Service Program: Alternatives to Violence community partners for needed resources to live a resilient life, our staff provide participants with hope. The goal for our program participants is to recognize that domestic violence in intimate relationships generates disrespect and harm that is inconsistent with the values, beliefs, and conduct of every culture. Our goal is to end domestic violence through providing services, partnering with community resources, and participating in community education about domestic violence, thereby creating a tipping point in our community awareness that healing from trauma is an imperative, and we can't tolerate domestic violence. 6. Explain what plans your agency or program has to increase revenues to support this program (Continued) Funding from the Hawaii Island United Way (HIUW) supports DVI for youth via the Youth Services component of ATV. Additionally, funding from VOCA (Federal Victim of Crime Act) and the Annual Visitor Industry Charity Walk, help to support ATV program services. CFS is continuously engaged in seeking funding from national sources, to include; VOCA, where we have received funding over the last 8 years and the Violence Against Women Act (VAWA), which was not received for ATV services but was received for CFS's Shelter programs. CFS does collect a group fee for our DVI program for men and women of$18 per group session. (This fee can be waived and replaced with work exchange for indigent or unemployed program participants.) In order to ensure that our programs are achieving the highest impact: truly making a positive difference in our participants' lives; program participants are better off as a result of our programs; positive participant outcomes lead to better community health, safety, well-being and productivity; and CFS has high accountability to participants, the community and to funders, CFS is implementing Results-Based AccountabilityTM (RBATM) across all of the programs in the organization. RBATM is a rigorous and dynamic process that requires a willingness for our organization to really look at the truth of how we are performing and the impact of our services. CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS is committed to remaining a leader in the domestic violence field by staying focused on implementing evidence-based programs and outcomes that will attract additional funding resources. Page 4of4 Child & Family Services East Hawai'i Domestic Abuse Shelter 38 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter Agency Director: Howard Garval Phone No.: (808) 681 — 3500 Contact Person: Karen Tan Phone No.: (808) 681 — 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, Hawaii 96706 Facility Address: Address: 1045 A Kilauea Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 — 5280 Accountant/CPA: N&K CPA's Inc. Phone No.: (808) 524 — 2255 Firm (if applicable): N&K CPA's Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite#1700 City,ST,Zip Honolulu, HI.96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna Hamakua ❑✓ North Kona 0 South Hilo 0 North Kohala 0 South Kona ✓❑ North Hilo 0 South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $40,000 $17,500 $60,000 2. Agency Mission Statement: The East Hawaii Domestic Abuse Shelter(EHDAS/Hale'Ghana)Program fits perfectly with Child&Family Service's(CFS) mission of"Strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii, Hale'Ghana services have been continuously providing emergency shelter for victims of domestic violence since 1995,(since 1988 at the West Hawaii Domestic Abuse Shelter.) CFS offers 48 programs statewide with a comprehensive array of effective and culturally relevant services to Hawaii's residents in need.These services include domestic violence interventions,case management, residential group homes,education for alienated youth, prevention and treatment of child abuse, recovery and prevention supports for substance abuse,and school/community-based counseling service for adolescents and their families. Since 1899, CFS has been dedicated to making a difference in the lives of the communities we serve. In Fiscal Year 2016, CFS directly served 10,518 individuals ranging from infants,children,adolescents,young adults, immigrants,to older adults in need across the state. In addition,our organization touched the lives of over 43,500 individuals through hot-line calls for assistance,educational presentations, and the provision of food and clothing for those in need. CFS's programs are responsive,flexible, and focused on positive outcomes. Services are provided in homes,school,and the community, as well as in CFS's 34 office locations on the islands of Oahu, Hawaii,Kauai, Maui, Molokai, and Lanai. (Continued on Attachment). 3. Program Description: Summary of Program/Project Needs Funding in the amount of$60,000.00 is being requested to help provide the following vital resources to shelter participants and their children: 1)Basic,daily necessities for program participants and their children,e.g.,food, clothing and hygiene products, school supplies for children,diapers,car seats, baby food and formula. Even with current funding and community donations combined,we are limited in our ability to provide participants with some of these essential items to meet basic needs. 2) Emergency client assistance,e.g.,taxi fare for victims fleeing domestic violence,who live outside of the area of the contracted service provider and are unable to get to a designated safe pick up location,or emergency accommodations for participants and their children who need to be isolated due to having a communicable illness and assistance with co-pays for vital prescription medications and or medical supplies not covered by insurance.Our current funding does not cover these emergency costs. 3)Support services,e.g.,transportation for participants who are at increased safety risks and avoid the vulnerability of waiting for a bus, some survivors require transportation via the shelter's van, as door to door service can be provided to mitigate the safety risks. Funding for gas and vehicle maintenance is needed to meet the transportation needs of shelter participants as most do not own cars, and have limited to no income.Support services would also be enhanced by education and healing groups using best practice curriculum with materials for group activities.Additionally supplies are needed to create informational brochures and handouts about healing from trauma,or accessing community resources for program participants. (Continued on attachment) 4.Total Budget& Position Count: Total Program Budget: $505,371 Total Program Position Count: 8.55 Total Agency Budget: $6,745,660 _ Total Agency Position Count: 82 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Department of Human Services $345,200 County of Hawaii $60,000 Department of Human Services BESSD HPO Emergency Shelter Grant $13,000 _ Department of AG VOCA $30,000 Department of AG VAWA(7/1/17-2/28/18) $40,000 Private Grants $1,000 TOTAL: $489,200 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to apply for alternative funding sources for CFS programs.The East Hawaii Domestic Abuse Shelter is primarily funded by the Department of Human Services in the State of Hawaii. In fiscal year 2009,the DHS funding for the East Hawaii Domestic Abuse Shelter/Hale'Ohana was decreased from$393,936 to$340,000,with no restoration of this funding.We used to collect shelter fees from participants but this was disallowed with our most recent DHS contract. CFS was awarded funding from VAWA and VOCA to provide intensive case management to shelter participants in FY 2016.These positions were created in response to the trend of shelter residents coming into the program with very high needs and multiple barriers to getting out of domestic violence relationships and rebuilding their lives. A majority of participants who enter the shelter program are living in poverty and qualify for public benefits, many are homeless and or do not have safe and secure housing to go to,and many are unemployed.Additionally many residents struggle with a lifetime accumulation of trauma, mental illness and substance abuse. Many participants rely solely on the shelter for all of their basic needs:food,clothing,transportation etc. Even with the additional funding secured through VOCA and VAWA, CFS struggles to meet the complex needs of shelter participants (Continued on Attachment) 7. Program Objectives Using County Nonprofit Grant Program Funds: 70%of survivors leave the shelter for a secure and safe place. Measurement occurs during anticipated discharge with DAS Safety Questionnaire. 80%of survivors will create a safety plan. The initial safety plan to be developed with Shelter staff at intake, reviewed and updated as needed during shelter stay and reviewed again prior to discharge. 80%of survivors will report that they are Mostly or Always confident in their ability to accomplish safety related goals, i.e., following through on safety plan. The MOVERS/Measure of Victim Empowerment in the Domain of Safety survey will be given to participants at intake, monthly thereafter, and at discharge. 80%of survivors will report that they are Mostly or Always confident that they have the support needed to move towards safety. The MOVERS/Measure of Victim Empowerment in the Domain of Safety survey will be given to participants at intake, monthly thereafter, and at discharge. (Continued on Attachment) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of survivors that receive housing assistance 40 #of survivors who complete a safety plan 128 #of survivors who receive transportation assistance(taxi service or shelter transportation) 80 #of survivors who receive emergency provisions(taxi, hotel, medication co-pays) 10 #of adult survivors served 160 #of children served 120 (Continued on Attachment) Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $326,362 $330,889 $29,720 Professional Fees $100 $100 $0 Operations $162,455 $165,382 $24,280 Supplies $2,800 $3,000 $1,500 Equipment Other: Participant Assist. -Emergency needs for victims&transportation $3,825 $6,000 $4,500 Other: Other. Other: Other: TOTAL $495,542 $505,371 $60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. fa,2-erri /A4^- //2-7/qc Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East 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 Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiiturP funding rPqpuPct rind may recult in nrtinnc taken to rerrwPr these funds. By signing below, you are acknowledging that you have read and understood these requirements. 1/27/J Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of survivors that receive housing assistance 40 #of survivors who complete a safety plan 128 #of survivors who receive transportation assistance(taxi service or shelter transportation) 80 #of survivors who receive emergency provisions(taxi, hotel) 10 #of adult survivors served 160 #of children served 120 (Continued on Attachment) TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 29,720 Professional Fees 0 Operations 24,280 Supplies 1,500 Equipment Other: Other: Other: Other: Other: TOTAL 60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 2. Agency Mission Statement (Continued) In April 2016, the Hawaii Appleseed Center for Law and Economic Justice reported on the State of Poverty in Hawaii which reinforces the challenges Hale 'Ohana families face, including "low wages, high housing costs, and disproportionately high taxes on low-income workers (which) have combined to give Hawai'i the sixth highest rate of poverty in the country. Forty-five percent of families with children do not have enough money to meet their basic needs..." In 2016, participants in the Hale `Ohana program had very low incomes, falling below 30% of HUD median household income figures. CFS's strengths lie not only in the organization's size and ability to share expertise and resources statewide, but also in our ability to adapt services so that they are unique and appropriate to the island, communities, and individuals we serve. CFS has years of experience working with the diverse demographics and cultural identities of Hawaii's residents while partnering with funding sources to implement new models of service delivery to address changing social needs. The organization's main goals are to (1) Improve an individual's functional and clinical status (emotional, psychological well-being, development and independent living skills); (2) Improve individual or a family system's ability to cope with stressors in their life; and (3) Improve the health, welfare, and safety of individuals so that they are free of harm, abuse or neglect. CFS demonstrates our 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 program participants, 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 fulfill 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). To realize our vision, we have organized our programs into impact areas that include Caring for Keiki, Healing from Trauma, Empowering Youth, and Honoring Kupuna. Proving effectiveness of our programs is what drives our experienced staff within these four program areas. The administrative management and service delivery systems of CFS emphasize service excellence. They include Cultural Competence; Person- and Family-Centered Approaches; Community and Stakeholder Partnerships; Positive Client Outcomes; Commitment to Learning; Quality Monitoring; Employee Excellence; and Coordination of Care. Page 1 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 3. Program Description (Continued) 4) A part-time Shelter Worker position to provide 22 hours of additional direct services weekly and coverage during times of high need, allowing for more than one staff to be scheduled during a work shift. The Shelter Worker position would support residents in addressing identified needs for safety planning, assistance with filing a TRO, strengthening their family's protective factors, obtaining permanent housing, healing from trauma for both the victim and their children with enhanced parenting skills to address recovery from the impacts of domestic violence. The Shelter Worker position will provide needed coverage for evidenced based group interventions for residents as well. Our current funding does not allow for us to consistently have two staff available during times of high need. When there is only one staff member scheduled, it is very challenging to provide support services beyond emergency shelter to approximately 40 participants daily. We are unable to provide transportation when only one staff is on shift as the staff member is unable to leave the shelter for safety reasons. Providing group education and individual participant support is also very challenging with only one staff, as the staff has to interrupt service delivery to take calls from the crisis hotline, respond to participants in the shelter who are in crisis, and provide intake and assessment to newly arrived participants. With the added support of the part-time Shelter Worker, both direct service staff will be able to address the recovery needs of the estimated 280 residents per annum (120 children and 160 adults). Summary of Program Services CFS's East Hawaii Domestic Abuse Shelter(EHDAS/Hale `Ghana) and West Hawaii Domestic Abuse Shelter(WHDAS) are the only shelters on the Big Island to serve the immediate needs of residents seeking safety from domestic violence. The Hale `Ohana program provides emergency shelter to single women/men and those with children who are victims of domestic violence (for a maximum of 120 days). The victims accessing program services generally are fleeing from the geographic areas of Volcano to Puna, Puna to Hilo, and Hilo to Hamakua. Victims from West Hawaii often access Hale `Ohana in East Hawaii for safety reasons. CFS understands domestic violence is traumatic! It impacts every family member. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC) indicate that 1 in 4 women will experience domestic violence during her lifetime; it is the third leading cause of homelessness among families according to HUD; more than 3 million children witness domestic violence annually; children who live in homes with domestic violence also suffer abuse or neglect at high rates (30%-60%); domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at work. Through current research we know that children of domestic violence have difficulty processing what has happened. They can internalize their feelings manifesting into guilt, shame, anger, anxiety and sadness; they are at higher risk of achieving poor academics; are at greater risk of child abuse and neglect; and can Page 2 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter continue to be involved in the cycle of violence when they are older. According to the Hawaii Department of Health, 9.5% of the adults who responded to the Behavioral Risk Factor Surveillance Survey (BRFSS) in 2013 reported they had been the victim of physical injury by an intimate or ex-intimate partner over the past 12 months, up from 8.8% as reported in 2011. There are no restrictions to enter the shelter as long as the circumstances of need are identified within 48 hours of a domestic violence incident. Hale `Ghana operates 24 hours a day/365 days a year including holidays, with staff monitoring and oversight of the safety and needs of the residents. The victims are from all walks of life, and all socioeconomic backgrounds. The main goal of the program is to provide a safe environment to residents. Our experienced staff will help families identify their needs, barriers associated with becoming self-sufficient, and develop plans to meet their needs and overcome barriers. The Hale `Ohana program offers education to residents on the dynamics of domestic violence, safe emergency shelter, emergency food, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, housing referrals, employability training and job search supports, Temporary Restraining Order(TRO) assistance, support groups, and personal planning based on individualized needs. Shelter staff also work with program participants to build healthy relationships and strengthen their role as parents without using physical and/or verbal violence towards their children. We are committed to raising the consciousness of our society by educating our families on a violence free lifestyle; promoting family coping and stability; and providing a place of refuge. In addition, Hale `Ohana operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 6 years, the hotline utilization by victims of domestic violence has increased due to the added economic stressors in the communities of the Big Island. The staff provides a safety assessment, makes recommendations and provides referral and resource information for callers. It is expected that the hotline will continue to see a high volume of calls due to the violence resulting from increased poverty and homelessness across the island. The Hale `Ohana facility is set back from the roadway on approximately three acres of agricultural/residentially zoned land in East Hawaii, in a two-story home. The home has three full bathrooms, four bedrooms, with a capacity to serve 20 residents. The downstairs of the shelter facility has a laundry room that is accessed through the covered double car garage entrance. A comfortable sized living room and adjoining bathroom is accessible via the laundry room, and a short walkway connects this area with the spacious kitchen. There is an adjoining dining room and pantry which are also accessible via an entrance off the side of the kitchen that exits into the side yard of the property. Hale `Ohana is ADA compliant; it has an ADA ramp which leads to the lower floor where an ADA bedroom is located. Page 3 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 6. Explain what plans your agency or program has to increase revenues to support this program: (Continued) In order to ensure that our programs are achieving the highest impact for our participants' resiliency: Truly making a positive difference in the lives of program participants; program participants are better off as a result of accessing our services; positive participant outcomes lead to better community health, safety, well-being and productivity; and CFS maintains high accountability to participants, the community and to funders, CFS is implementing Results Based Accountability (RBA)TM across all of the programs in the organization. RBATM is a rigorous and dynamic process that requires a willingness to really look at the truth of how we are performing and the impact of our services. CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS is committed to remaining a leader in the domestic violence field by staying focused on implementing evidence-based programs and outcomes that will attract additional funding resources to address the specific needs of this population. CFS has a strong history of fundraising and is committed to continuing to grow our private donations and grants. We apply for alternative funding sources for our programs and have expanded our efforts to receive funding from private foundation sources dedicated to the belief that everyone deserves a violence free life. 7. Program Objectives Using County Nonprofit Grant Program Funds: (Continued) 80% of survivors will report that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in other areas (domains) of their life. The MOVERS/Measure of Victim Empowerment in the Domain of Safety survey will be given to participants at intake, monthly thereafter, and at discharge. 8. Table 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued) Applicant Projected PROGRAM PERFORMANCE MEASURES Results #of bed days provided (adults and children combined) 6,000 #of survivors that report that they are Mostly or Always confident in 128 their ability to accomplish safety related goals #of survivors that report that they are Mostly or Always confident 128 that they have the support needed to move towards safety #of survivors that report that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in 128 other areas (domains) of their life. Page 4 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET: Table I (Continued) PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of bed days provided (adults and children 6,000 combined) #of survivors that report that they are Mostly or Always confident in their ability to accomplish 128 safety related goals #of survivors that report that they are Mostly or Always confident that they have the support 128 needed to move towards safety #of survivors that report that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in other areas 128 (domains) of their life. Page 5 of 5 Child & Family Services Hale Kahua Pa'a Transitional Housing Program 39 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housin• Pros ram Agency Director: Howard Garval Phone No.: (806) 681 — 3500 Contact Person: Karen Tan Phone No.: (808) 681 — 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI.96706 Facility Address: Address: 1045 Kilauea Avenue Address: Suite A City,ST,Zip Hilo, 96720 Hawaii Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 — 5280 Accountant/CPA: N&K CPAs Inc. Phone No.: (606 ) 524 — 2255 Firm (if applicable): N&K CPAs Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite# 1700 City,ST,Zip Honolulu, HI.96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna Hamakua ✓❑ North Kona 0 South Hilo 0 North Kohala 0 South Kona 0 North Hilo 0 South Kohala 0 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 0 Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $30,000 $13,750 $45,000 2. Agency Mission Statement: The Hale Kahua Pa'a Transitional Housing Program fits perfectly with Child& Family Service's(CFS)mission of"Strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii, CFS's Hale Kahua Pa'a Transitional Housing program services have been provided since 2008.CFS offers 48 programs statewide with a comprehensive array of effective and culturally relevant services for Hawaii's residents in need.The broad spectrum of services provided by CFS include domestic violence intervention, case management, residential group homes, alternative education for alienated youth,prevention and treatment of child abuse, recovery and prevention of substance abuse,and school and community-based counseling services for children and their families. In Fiscal Year 2016, CFS directly served 10,518 individuals ranging from infants to elderly adults. In addition,the organization has touched the lives of over 43,500 individuals through hot-line calls,educational presentations and providing food and clothing resources 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 34 office locations 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,communities,and individuals we serve. (Continued on Attachment) 3. Program Description: The Hale Kahua Pa'a Transitional Housing Program is a program that assists survivors of domestic violence and their children to rebuild their lives,gain stability and independence,while transitioning into a violence-free lifestyle.We are requesting $45,000.00 to supplement funding for a part-time Domestic Violence Specialist(DVS)position that will be responsible for providing case management supports to survivors residing in Hale Kahua Pa'a.The DVS will also assist survivors with accessing resources for basic living/emergency needs,such as transportation,apartment repairs,diapers,food and household supplies, etc. Requested funding would also be used to assist survivors with eliminating barriers to moving into permanent housing, (e.g.,assistance with transition costs with rental deposits, utility bills, and/or household furnishings).With the additional 10 hours weekly of direct services of the part-time DVS,the program anticipates expanding evidenced based group intervention supports,assisting participants in addressing identified needs for safety planning, including filing a TRO, strengthening their family's protective factors,obtaining permanent housing, and healing from trauma for both the victim and their children with enhanced parenting skills to address recovery from the impacts of domestic violence. (Continued on Attachment) 4. Total Budget & Position Count: Total Program Budget: $139,836 Total Program Position Count: 95 Total Agency Budget: $6,745,660 Total Agency Position Count: 82 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate U.S. Department of Justice, Office on Violence Against Women (OVW) $77,000 County of Hawaii (funding requested in this proposal) $45,000 Program Fees $2,000 TOTAL: 124,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hale Kahua Pa'a Transitional Housing Program has been primarily funded by the Department of Justice, Office on Violence Against Women(OVW). In fiscal year 2016,the program received one-time funding through the State of Hawaii Grant-In-Aid (GIA),which ended June 30,2016.CFS is always engaged in seeking new funding opportunities to sustain program services. In order to ensure that our programs are achieving the highest impact:truly making a positive difference in our participants'lives; program participants are better off as a result of our programs; positive participant outcomes lead to better community health, safety,well-being and productivity;and CFS has high accountability to participants,the community and to funders,CFS is implementing Results Based Accountability TM (RBA)across all of the programs in the organization. RBATM is a rigorous and dynamic process that requires a willingness for our organization to really look at the truth of how we are performing and the impact of our services. (Continued on Attachment) 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. 80%of program participants will increase their knowledge of community resources, i.e.;housing,employment and finances, 2. 80%of program participants will report that they are confident in their ability to take precautions and utilize their safety plan to prevent future incidents of domestic violence. 3. 100%of program participants will complete a Safety Plan for themselves and their children. 4. 80%of program participants will secure independent housing after 24 months of safe transitional housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of adults who increased their knowledge of community resources 5 #of adults who completed a safety plan for themselves and their children 6 #of adults provided housing 6 #of children provided housing 5 #of adults that reported that they were confident in their ability to take safety precautions 6 &utilize their safety plan to prevent future incidents of DV. 5 #of adults that secured independent housing after 24 months 5 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary.and Wages $44,742 $45,636 $20,825 Profesjonal Fees. Oper. tiers $85,361 $86,200 $15,675 Supplies $2,074 $2,000 $3,000 _ Equipment Other Participant Assistance(Basic Needs, Emergency) $500 $6,000 $5,500 Other: Other Other: Other: TOTAL $132,677 $139,836 $45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: U If no conflicts exist, check here. /4/1% I/17* Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding rprphost nnrl mny recult in artinnc token to rernver these filmic, By signing below, you are acknowledging that you have read and understood these requirements. 1/4.16/1-t4-1 /arr\- //2-7/ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of adults who increased their knowledge of community resources 6 #of adults who completed a safety plan for themselves and their children 6 #of adults provided housing 6 #of children provided housing s #of adults that reported that they were confident in their ability to take safety precautions 6 &utilize their safety plan to prevent future incidents of DV. e #of adults that secured independent housing after 24 months 6 TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages 20,825 Professional Fees Operations 15,675 Supplies 3,000 Equipment Other: Participant Assistance(Basic Needs, Emergency) 5,000 Other: Other: Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Attachment Applicant: Child & Family Service Program: Hale Kahua Pa`a Transitional Housing Program 2. Agency Mission Statement (Continued) CFS has years of experience working with the diverse demographics and cultural identities of Hawaii's residents while partnering with funding sources to implement new models of service delivery. The organization's main goals are to (1) Improve an individual's functional and clinical status (emotional, psychological well-being, development and independent living skills); (2) Improve individual's or family system's ability to cope with stressors in their lives; and (3) Improve the health, welfare, and safety of individuals so that they are safe from harm, abuse or neglect. CFS demonstrates our 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 program participants, 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 fulfill 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). Programs strive to provide a Family-Centered, Full-Service model of care. CFS has organized its programs into impact areas that include Caring for Keiki, Healing from Trauma, Empowering Youth, and Honoring Kupuna. Proving effectiveness of our programs is what drives our organization within these four impact areas. The administrative management and service delivery systems of CFS emphasize service excellence. They include Cultural Competence; Person- and Family-Centered Approaches; Community and Stakeholder Partnerships; Positive Client Outcomes; Commitment to Learning; Quality Monitoring; Employee Excellence; and Coordination of Care. In April 2016, the Hawaii Appleseed Center for Law and Economic Justice reported on the State of Poverty in Hawaii which reinforces the challenges Hale Kahua Pa'a Transitional Housing Program families face, including "low wages, high housing costs, and disproportionately high taxes on low-income workers (which) have combined to give Hawai'i the sixth highest rate of poverty in the country. Forty-five percent of families with children do not have enough money to meet their basic needs..." In 2016, participants in the Hale Kahua Pa'a Transitional Housing Program had very low incomes, falling below 30% of HUD median household income figures. 3. Program Description (Continued) 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, though predominantly women access supports as they are confronted with financial challenges after fleeing their home with their children. When leaving the batterer, the survivor embarks upon a path that is as fearful for her/him and her/his children as it is to stay with an abusive partner. Many of these victims leave with just the clothes that they are wearing, seeking shelter, safety and, most of all, assurances that they made the right Page 1 of 3 Attachment Applicant: Child & Family Service Program: Hale Kahua Pa'a Transitional Housing Program choice. Many lack the skills, tools and resources needed to sustain themselves and their children away from their batterer. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC) show: • 1 in 4 women will experience domestic violence during her lifetime; • Domestic violence is the third leading cause of homelessness among families according to the U.S. Department of Housing and Urban Development; • More than 3 million children witness domestic violence in their homes every year; • Children who live in homes where there is domestic violence also suffer abuse or neglect at high rates (30%-60%); and • Domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at companies. Through current research we know that children of domestic violence have difficulty processing what has happened. They can internalize their feelings manifesting into guilt, shame, anger, anxiety and sadness; they are at higher risk of achieving poor academics; are at greater risk of child abuse and neglect; and can continue to be involved in the cycle of violence when they are older. According to the Hawaii Department of Health, 9.5% of the adults who responded to the Behavioral Risk Factor Surveillance Survey (BRFSS) in 2013 reported they had been the victim of physical injury by an intimate or ex-intimate partner over the past 12 months, up from 8.8% as reported in 2011. Many women are faced with the reality of no financial resources, and an inability to access resources due to assets being retained by the batterer. Lack of access to financial resources may also represent another barrier to qualifying for public assistance or subsidized housing for victims. Often, victims initially turn to CFS's East or West Hawaii Domestic Abuse Shelters where they can recover and start planning a new life. The Domestic Abuse Shelters provide emergency shelter, safety, basic needs, counseling and support for up to 120 days. This brief period of 120 days is not nearly enough time to find safe affordable housing in Hawaii. On a national average, it is estimated that it takes a survivor 6 to 10 months to secure permanent housing. Securing a safe home for themselves and their children is one of the more serious challenges survivors face in the County of Hawaii due to an expensive rental market and the current economic environment. At the end of the 120 days in a Domestic Abuse Shelter, the survivor must make a decision not only for their own well-being, but for their children as well. Unfortunately that decision is too often a return to the abuser they sought refuge from, or to become homeless as resources for financial and housing supports are limited. Some survivors are referred to Hale Kahua Pa'a Transitional Housing Program by CFS's community partners island-wide, and CFS's East and West Hawaii Domestic Abuse Shelters. The Hale Kahua Pa'a Transitional Housing Program assists survivors of domestic violence and their children in rebuilding their lives over an extended period for healing, up to 24 months, and to build their resiliency for independent living. Specifically, the program works with survivors to help them gain stability and independence while transitioning into a violence-free lifestyle. During their stay, survivors, and their families receive intensive support services that guide them towards greater independence. Survivors may receive assistance with the following: securing housing in the community, safety planning and how to create a safe and nurturing environment Page 2 of 3 Attachment Applicant: Child & Family Service Program: Hale Kahua Pa'a Transitional Housing Program for their children, applying for and accessing public benefits, obtaining employment and learning about educational /training opportunities etc. By providing weekly home visits, case management, individual family service planning, and information and referrals to community resources, the program affords both the survivors and their children the time to heal, and to live safely as they work to strengthen their protective factors. The Hale Kahua Pa'a Transitional Housing Program is in need of a part-time Domestic Violence Specialist (DVS) position. The County of Hawaii funding, matched by other funding sources, will allow for a part-time DVS to be hired to work with program participants, providing case management services, and the ongoing support that survivors need including developing employability skills, and/or accessing educational opportunities in support of their goals for self- sufficiency. Requested funding is also being proposed to supplement a program participant assistance fund for survivors with financial hardships after leaving an abusive relationship. This assistance may include items for basic daily living needs, emergency healthcare assistance, 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 DVS position will offer survivors weekly group and individual educational opportunities to enhance their life skills, including budgeting and money management, job training, nutrition, increasing self-esteem, and emotional and physical health. Support groups facilitated by the DVS will reinforce opportunities for program participants to learn about the effects violence can have on them, as well as their children. Groups are beneficial in building a much needed support system for program participants who may be afraid and/or ashamed of their circumstances while needing the connection with other survivors making progress with their healing. The DVS will use group lessons to reinforce the strength of survivors while addressing many of the barriers they may face in establishing income, safe and permanent housing, and independence. 6. Explain what plans your agency or program has to increase revenues to support this program (Continued) CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS is committed to remaining a leader in providing services to survivors of domestic violence, staying focused on implementing evidence- based programs and outcomes that will attract additional funding resources to address the specific needs of this population. Program fees may be charged to participants, and no one is turned away if they cannot afford to pay. CFS has a strong history of fundraising and is committed to continue growing our private donations and grants. We continue to apply for alternative funding sources for our programs and have expanded our efforts to receive funding from private foundation sources dedicated to the belief that everyone deserves a violence free life. Page 3 of 3 Child & Family Services West Hawai'i Domestic Abuse Shelter 40 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter Agency Director: Howard Garval Phone No.: (808) 681 — 3500 Contact Person: Karen Tan Phone No.: (808) 681 — 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 81-6587 Mamalahoa Hwy, Bldg.C Address: City,ST,Zip Kealakekua, HI 96750 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 — 5280 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: Suite#1700 City,ST,Zip Honolulu, HI.96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ✓❑ North Kona ❑South Hilo ✓❑ North Kohala ❑✓ South Kona ❑ North Hilo ✓❑South Kohala ✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ✓❑Victims of Crimes ❑Culture and the arts ✓❑Aged ❑Victims of Health or Social Crises ✓❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $30,000 $25,000 $18,376 2.Agency Mission Statement: The West Hawaii Domestic Abuse Shelter(WHDAS)ProgramChild&Family Service's(CFS)mission of"Strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii,WHDAS program services have been continuously providing emergency shelter for victims of domestic violence since 1988,with East Hawaii Domestic Abuse Shelter program service funded since 1995.CFS offers 48 programs statewide with a comprehensive array of effective and culturally relevant services for Hawaii's residents in need.The broad spectrum of services provided by CFS include domestic violence interventions,case management, residential group homes,alternative education for alienated youth, prevention and treatment of child abuse, recovery and prevention of substance abuse, and school and community-based counseling services for children and their families. In Fiscal Year 2016,CFS directly served 10,518 individuals ranging from infants to elderly adults. In addition,the organization has touched the lives of over 43,500 individuals through hot-line calls,educational presentations and providing food and clothing resources 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 34 office locations throughout the state on the islands of Oahu, Hawaii, Kauai, Maui, Molokai and Lanai. (Continued on Attachment) 3. Program Description: Funding in the amount of$60,000 is being requested to support a Client Advocate position to ensure that vital services, in addition to emergency shelter,are provided to equip residents at the domestic violence shelter with the tools and support needed to break the cycle of abuse and re-build their lives.We are also requesting funding to increase and improve the quality of the following support services:(1)Transportation: Funding for taxi vouchers due to increased safety risks and the vulnerability of waiting for a bus,some survivors require transportation via the shelter van where door to door service is provided.When the shelter van is not available,funding for Taxi vouchers would offer a viable option. Funding for gas and vehicle maintenance is needed.; (2)Education and Support Groups:curriculum materials, brochures and handouts are needed; (3)Wellness/Activity/Life Skills Groups:arts and craft materials, books and exercise/sporting equipment would enrich opportunities;and(4)Emergency Needs for victims and their children:clothing, baby formula, car seats, etc.are essential things that survivors often lack.With the added support of a Client Advocate providing 19 hours weekly of direct services to approximately 21 participants daily,we will expand evidenced based group intervention services for adults by 100 hours and 75 hours for children, 300 additional hours will be added in case management supports to include safety planning and assistance with filing a TRO if applicable, strengthening the family's protective factors,obtaining permanent housing, healing from trauma for both the victim and their children with enhanced parenting skills to address recovery from the impacts of domestic violence, and transportation assistance for 250 trips per annum to support participant goals for self-sufficiency, health, and safety. (Continued on Attachment) 4. Total Budget& Position Count: Total Program Budget: $520,507 Total Program Position Count: 8.75 Total Agency Budget: $6,745,660 _ Total Agency Position Count: 82 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Department of Human Services $345,200 County of Hawaii $60,000 HIUW $20,000 DHS-BESSD HPO Emergency Shelter Grant $13,000 AG-VAWA(7/1/17-2/28/18) $40,000 AG-VOCA $30,000 Private Grants $1,000 TOTAL: $509,200 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 State of Hawaii. In fiscal year 2009,the DHS funding for the West Hawaii Domestic Abuse Shelter decreased from$377,833 to$340,000 and was never restored. Traditionally,the County of Hawaii, HIUW and Emergency Shelter Grants have supported the Domestic Abuse Shelters in the County of Hawaii.CFS was also awarded funding from VAWA to provide counseling to shelter residents,effective January 1,2016. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.70%of survivors have no incidents of violence during their participation in the Shelter program. Violence=physical,emotional, psychological,financial,verbal,sexual,stalking,threats. a. Measurements occur weekly with DAS Safety Questionnaire. 2.70%of survivors leave 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: Pre/Post Resiliency Survey 4.80%of children/youth(older than 5 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 survivors will identify 3 skills learned to cope with domestic abuse. Domestic abuse=physical,emotional, psychological,financial,verbal, sexual,stalking,threats. a. Measurement occurs with DAS Exit Questionnaire response form. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) See Attached Table Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $335,360 $342,067 $24,846 Professional Fees $100 $100 Operations $171,305 $173,340 $28,754 Supplies $2,805 $3,000 $1,400 Equipment Other: Participant Assist. -Emergency needs for victims &transportation $790 $2,000 $5,000 Other: Other: Other: Other: TOTAL $510,360 $520,507 $60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ri If no conflicts exist, check here. (-41)AI '>0,-,m /1/4-7//4, Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding reriuect and may recult in nrtinnc taken to rernvpr theta funrlc, By signing below, you are acknowledging that you have read and understood these requirements. Yl Gi, v-t ww 1/4-7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result See Attached Table TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $24,846 Professional Fees Operations $28,754 Supplies $1,400 Equipment Other: Participant Assist. -Emergency needs for victims&transportation $5,000 Other: Other: Other: Other: TOTAL $60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 2. Agency Mission Statement (Continued) CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island, communities, and individuals we serve. Since 1899, CFS has been working with the diverse demographics and cultural identities of Hawaii's residents, partnering with funding sources to implement new models of service delivery over the years, and fostering the health and well being of program participants. The organization's main goals are to: (1) improve an individual's functional and clinical status (emotional, psychological well-being, development and independent living skills); (2) improve individual's or family system's ability to cope with stressors in their lives; and (3) improve the health, welfare, and safety of individuals so that they are safe from harm, abuse or neglect. CFS demonstrates our 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 program participants, 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 fulfill 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). Programs strive to provide a Family-Centered, Full-Service model of care. CFS has organized its programs into social impact components that include Caring for Keiki, Healing from Trauma, Empowering Youth, and Honoring Kupuna. Proving effectiveness of our programs is what drives our organization within these four components. The administrative management and service delivery systems of CFS emphasize service excellence. They include: Cultural Competence; Person- and Family-Centered Approaches; Community and Stakeholder Partnerships; Positive Client Outcomes; Commitment to Learning; Quality Monitoring; Employee Excellence; and Coordination of Care. 3. Program Description (Continued) Even with support from several State and County departments, funds for shelter services are extremely limited. As a result, we are not consistently able to schedule more than one staff per shift. With only one staff per shift, it is very challenging to provide support services beyond emergency shelter. These services, which are Page 1 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter essential to helping victims face extreme challenges in order to live healthier, safer lives, have to be interrupted or placed on hold in order to address immediate/emergency needs, such as; hot-line calls, intakes, discharges, and resident crises. Funding for a Client Advocate and supportive service activities would provide additional staffing during the busiest times and funding for supportive service activities would make it possible to enhance and increase the quality of support to victims and their children. CFS's West Hawaii Domestic Abuse Shelter (WHDAS) and East Hawaii Domestic Abuse Shelter(EHDAS/Hale `Ohana) are the only emergency shelters on the Big Island to serve the immediate needs of residents seeking safety due to domestic violence. Funding is being requested to cover costs for a Client Advocate position that provides Domestic Violence Education & Support groups, Health/Wellness & Life Skills groups, therapeutic activities, child care, transportation, advocacy, community outreach and case management supports for program participants. These services will be available to adult and child residents of the shelter. The Client Advocate works closely with the Domestic Violence Specialist (DVS) to support shelter residents in healing from trauma. The Client Advocate provides case management, groups and transportation for most participants, while the DVS provides intensive case management for high-risk participants who present with mental health and substance abuse issues compounded by domestic violence. Within the first few days of entering the shelter, the victim of domestic violence (resident) meets with the Client Advocate or DVS who assess the resident's needs and assist him/her in developing service plan goals. Safety issues are discussed further and a personalized safety plan is developed to address the resident's risks. If applicable, the safety plan will also address his/her children's safety while at the Shelter, and while in the community. Weekly meetings are held to review the progress the resident is making in fulfilling 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 Client Advocate and/or DVS discusses how to transition the resident safely back into the community. WHDAS staff also work with residents to develop an aftercare plan to ensure that needed services are in place, and they are connecting with identified providers and/or resources. Funding from the County of Hawaii would not only support a Client Advocate, but would allow for more than one staff to be scheduled during the busiest times, and/or when resident needs require additional supports. This funding would also make possible enhancements and expansion of the array of services provided by the Client Advocate. Additional support groups and therapeutic activities would be available to both adults and children. Other critical support services such as transportation, case management and childcare could also be provided to promote participation among residents. This additional support would directly address and reduce specific barriers to a survivor's attainment of greater safety and well-being for themselves and her children. Page 2 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 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 fleeing domestic violence come from the geographic areas of Ka'u to Kona, and from Kona to the greater Kohala vicinity. Victims from East Hawaii often access the WHDAS for safety reasons. There are no restrictions to enter the WHDAS as long as the circumstances of need are identified within 48 hours of a domestic violence incident. The WHDAS operates 24 hours a day/365 days a year including holidays. WHDAS staff 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 help families identify their needs, barriers, and work with them to develop plans to overcome these barriers and meet their needs. The WHDAS program offers all residents educational supports on the dynamics of domestic violence, safe residence in the shelter, access to emergency food, transportation, referrals as needed for healthcare, case management, individual counseling, advocacy, outreach services, safety planning, housing resources, employment training/placement supports, Temporary Restraining Order assistance, support groups, and personal planning interventions. CFS understands domestic violence is traumatic! It impacts every family member. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC) indicate that 1 in 4 women will experience domestic violence during her lifetime; it is the third leading cause of homelessness among families according to HUD; more than 3 million children witness domestic violence annually; children who live in homes with domestic violence also suffer abuse or neglect at high rates (30%-60%); domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at work. Through current research we know that children of domestic violence have difficulty processing what has happened. They can internalize their feelings manifesting into guilt, shame, anger, anxiety and sadness; they are at higher risk of achieving poor academics; are at greater risk of child abuse and neglect; and can continue to be involved in the cycle of violence when they are older. According to the Hawaii Department of Health, 9.5% of the adults who responded to the Behavioral Risk Factor Surveillance Survey (BRFSS) in 2013 reported they had been the victim of physical injury by an intimate or ex-intimate partner over the past 12 months, up from 8.8% as reported in 2011. Shelter staff also work with mothers/fathers and their 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, the WHDAS program operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 6 years, the hotline utilization by victims of domestic violence has increased due to the added Page 3 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter economic stressors throughout the communities of the Big Island. The staff provide a safety assessment, make recommendations and provide referrals, and resource information for callers. It is anticipated that the hotline will continue to see a high volume of calls associated with the violence resulting from increased stressors of poverty and homelessness in our community. The WHDAS facility has three bedrooms with a total capacity of 21 beds for families who enter into the program. In addition to the three bedrooms each room has a full bathroom to accommodate residents who share 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 shelter. In addition to these areas for program participants, the WHDAS has two offices, a playground and a children's room. The offices are used for intake and exit interviews assuring participants are afforded confidentiality, and access to case management and individual counseling supports. The shelter also provides residents with a laundry facility, full kitchen, a large living room and a dining area. A large Matson container on site holds furniture items, clothing and household miscellaneous items for participants. These items are donated throughout the year from the West Hawaii community. The Shelter also collaborates with local thrift stores to support participants with items needed while in the shelter, as well as during their transition into housing within the community. 8. Table 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued) Applicant PROGRAM PERFORMANCE MEASURE Projected Results Number of additional adult groups (This includes DV Education & 100 Support groups, Health & Wellness and Life Skills groups) Number of additional child activity groups (This includes DV education 75 & support and therapeutic activities) Number of additional transportation trips 250 Number of additional child care hours 75 Number of additional case management hours 300 12. COUNCIL AWARD WORKSHEET: Table I (Continued) Applicant Council PROGRAM PERFORMANCE MEASURES Projected Proposed Results Projected Result Number of additional adult groups (This includes DV Education & Support groups, Health & Wellness and Life 100 Skills groups) Page 4 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter Applicant Council PROGRAM PERFORMANCE MEASURES Projected Proposed Results Projected Result Number of additional child activity groups (This includes 75 DV education & support and therapeutic activities) Number of additional transportation trips 250 Number of additional child care hours 75 Number of additional case management hours 300 Page 5of5 East Hawaii Cultural Council Emerging Artist Sustainability and Education Program (EASE) 41 r County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: East Hawaii Cultural Council Program Name: Emerging Artist Sustainability and Education Program (EASE) Agency Director: Michael Marshall Phone No.: (808) 333 — 9836 Contact Person: Kanani Daley Phone No.: (808) 430 — 0746 Mailing Address: Address: 141 Kalakaua St. Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 141 Kalakaua St. Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: grants@ehcc.org Fax No.: ( ) N/A — Accountant/CPA: Book Keeper Amy Paikuli Phone No.: (808) 989 — 8499 Firm (if applicable): Mailing Address: Address: P.O.Box 492622 Address: City,ST,Zip Keaau, Hawaii 96749 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 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 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: e s H tivvc i i Cu I turo, t Count Program Name: nncr ;in ICY ,st Svis-1-ai lnctb i t t cin cI Pr/ r4rr 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 1,000.00 2,413.00 n/a 2.Agency Mission Statement: We are an inclusive platform for the expression of the rich and complex cultural diversity that defines our communities through exhibitions, performances,workshops,and creative inquiry. A vibrant and thriving gathering place centered on art and culture where the ever-evolving voices of our local communities inspire dialogue and action toward establishing healthy and generative communities,local and beyond. While we maintain high standards for aesthetic expression,we believe that the creative and cultural expression of all people of our state is of equal value. We are culturally and socially inclusive,providing venue to our host culture and the vast array of voices which comprise our unique community;to inspire wonder,curiosity,new ways of thinking,and civic action as a pathway toward building and sustaining healthy,thriving communities. 3. Program Description: Emerging Artist Sustainability Education(EASE)Program Description We are providing printmakers,local artists,and youth with a non-toxic print studio,the only green printmaking studio on the island.The facility will offer educational workshops to participate in various techniques of printmaking,with paper-making (limited to kapa-hand beaten processes).This program is linked to our Youth Art Series program by offering approachable techniques for ages 6 and up.As a complete program for youth and emerging artists,the East Hawaii Cultural Center Printmaking Studio will be accessible to the community,provide education,and increase sustainable and ecologically sound studio practices. The printmaking workshops will include traditional Hawaiian relief printing,mono-type, relief,intaglio,and encaustic printmaking,with an initiative in locally-made paper-making.Educators in printmaking will teach specialized workshops,with 10 workshops in 1 year,each totaling 16 hours of instruction.The studio will be open for extended hours,accommodating to use after business hours. The paper-making process utilizes locally sourced materials from natural sources,making it a zero-waste and natural product that can be utilized as a substrate for the printmaking medium.Materials for hand made paper will include Hawaiian mulberry bark and papyrus,Methods for this years program will include hand beaten traditional Hawaiian paper-making(kapa) techniques. Access to the studio and workshops will transpire into bi-annual exhibits in our gallery,facilitating the complete experience of making art from material to studio to the public,exhibiting the cultural and sustainable significance of art.This complete cycle of traditional arts in a contemporary realm will link the past and present through the hands of Hawaii's emerging artists.Through ecological practices,we will establish a sustainable and positive economical approach to techniques in art. 4.Total Budget&Position Count: Total Program Budget: 34,000 Total Program Position Count: 3 Total Agency Budget: 73,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 • Agency Name:Fast Hccvvoii Gui{-t,iraI CDt-411C1 i Program Name:Eine rq nq SusfainabiIl-i--tj an] EGl wed-ion Pr'gvam CIA-SE) 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Home Depot Grant for Studio Annex 5,000 Hawaii Community Foundation 1,000 Studio Fees 3,360 Workshop Fees 4,500 Bi-annual Exhibit Sales 2,000 PSBN SFCA Exhibit Sales 2,500 TOTAL: 18,360 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The studio will charge fees for public use to sustain materials,maintenance on equipment,and utilities.These fees include options in monthly,annual,and drop-in costs,that will amount to an annual revenue of $3,360.There will be a series of 10 workshops held in a span of 1 year which include a total of 160 hours of instruction,and amounts to an annual income of$4,500. Currently we exhibit the Pacific State Biennial North American Printmaking Symposium,which generates revenue of$2,500. Selected art works produced in the studio will be shown in two exhibits in 1 year,producing an income from sales,amounting to $2,000. A Go Fund Me crowdfunding campaign will provide additional funds as well as sales generated from prints that are selected to be sold in the SPACE,EHCC exhibit gallery store. If there appears to be a shortfall,other grants and solicitations for underwriting the print studio expenditures will also be a part of the building revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: The EASE Program objective is to provide a non-toxic studio for emerging and young artists to be educated in the practice of printmaking and paper-making techniques,both traditional and modern. Currently the facility is equipped with 80%of supplies and equipment needed to open the studio to the public.The studio has two presses,utility sink,drawing/design tables,drying rack,and miscellaneous supplies.The funds will be used to complete the studio with the 20%of needed materials and equipment to open to the public for studio use and educational workshops. The funds will also provide the public to studio access.This will be possible with a staff of 3 internship positions with printmaking studio experience,each earning a part-time salary of$480 per month for one year.The interns will cooperatively manage the studio to over see that studio participants are taking responsible care of equipment,space,and supplies.Operating hours will be Tuesday through Saturday from 10 a.m.-6 p.m.,with a studio technician intern on-site. The grant will also fund a percentage of the supplies for each participant in each workshop.The objective is to maintain affordable prices,high enrollment,and hire qualified educators. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: EEsf N(vdcn t C u ttu ra ii Cou nci l Program Name: Ell/fro-1g fist Sustciinab it►f, ca nd Ed uca4ir Rog ravn CEASE) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Please see attached document, Program Performance Measures for EASE Attach additional pages as necessary. 9.TABLE H: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages n/a 17,280 17,280 Professional Fees n/a 2,880 2,880 Operations n/a 8,640 8,640 Supplies n/a 1,700 1,700 Equipment n/a 3,500 3,500 Other: Other: Other: Other: Other: TOTAL 34,000 34,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: BO- HaVvai i Cu itu i a I Co u nu I Program Name: Emerq►ng Ari sf Sosfeii n a bi l and [d ULati o n Proof ra to (EM ) 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 l The Mayor ❑ The Managing Director ❑ The Director of Finance E The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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. Pr 4 / • ii-z_,=1 Signature of Auth• ized Person (speci y t tl �e: Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Etist }Ha tAa i'. Cu lti,t ra l COU n u I Program Name: Evac(' i n list St,st�l.n a b) I, and E d u Ca-I-i Dr) Pro rare � 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, 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 L P t __" <, a l f ;ii.goty, complete the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ea si 1-1aviel i i CA I- u ra I Co u n ci I Program Name: g.,vn tr l';n9 rr st S sO I b 1 (011 (MCI E,duCa-I-ion Prrg►am LE 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at /on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaency's firturr funding rarquact and mny result in nrtinnc tnkan to rrrnvar theca funds, By signing below, you are acknowledging that you have read and understood these requirements. / /3//7—. Ar40...„„ 4,411/ Signature of Aut' orized Person (spec— - -ify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name:Eas+ Jo4Ckii Cult-to-al Cuncl I Program Name:Lvnerginq /\r-list SuS-iha1itI and r�IIACGi-ti do PI-Dram (EA-50 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Program Performance Measures for EASE Program 1. Non-toxic implementation Activity: To establish a non-toxic print shop and prohibit the use of any materials that will cause damage to the nervous system and bodily organs. No oil base inks or use of volatile solvents will be permitted in the EHCC print shop. Applicant Projected Result: Provide non-toxic studio access and education to 175 participants by the end of one year. The studio will keep a list of materials that will disclose all non-toxic materials while no oil base inks or use of volatile solvents will be permitted in the EHCC print studio. 2. Administrative Activity: a) Qualified specialists (10)will provide print making instruction to the general population including young adults, youth, and children, in visual art and cultural education, including workshops in the Youth Art Series during the 2017-18 Summer and Spring courses. b) Hire 3 printmaker internships to cooperatively manage studio and oversee responsible use of studio, supplies, and equipment, as well as provide technical assistance. Applicant Projected Result: a) Provide 10 specialized workshops annually with 100 participants in the studio by 1 year. Instruction to 75 youth will proceed during intercession schedules throughout the annual school year,totaling a provision of art and culture education to 175. Additional training may be in the archival care, presentation, and storage of prints with end-of-session pop-up exhibition presentation(s) in the Piko or Annex Galleries. b) Provide 3 student printmakers with experience in managing environmentally safe and non-toxic studio practices and provide employment for 1 year in the field of art and design. 3. Exhibit Activity: Bi-annual Exhibit in the Piko and/or Annex Gallery. Applicant Projected Result: Provide the community/public with bi-annual exhibits with 250 public attendees and a discussion forum for 35 students while simultaneously educating in gallery installation. Individual artists who are part of the EHCC print group will have opportunity for professional juried exhibition EHCC fall juried show, Wailoa Center, Donkey Mill, UHH PSBN, Honolulu Printmakers exhibition tott ti-2, /72—Q4:7 G/ Executive Dire •r Date Michael Marshall Family Support Hawai'i Hamakua Fatherhood Initiative 42 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative Agency Director: Ray Wofford Phone No.: (808) 326 — 7900 Contact Person: Caleb Milliken Phone No.: (808) 747 — 0267 Mailing Address: Address: 75-127 Lunapule Rd#11 Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Rd#11 Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address: crmilliken@hotmail.com Fax No.: ( ) — Accountant/CPA: Phone No.: (808) 242 — 5002 Firm (if applicable): Carbano CPA's&Management Group Mailing Address: Address: 1885 Main St. Address: Suite 408 City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) n Puna Hamakua North Kona n South Hilo I I North Kohala I I South Kona I I North Hilo ✓I South Kohala I I Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓ Educational concerns I Youth Victims of Crimes ✓� Culture and the arts Aged Ill Victims of Health or Social Crises (✓I Needs of the poor ✓ Physical/Emotional Disabilities ✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $12,000 0 2.Agency Mission Statement: Family Support Hawaii(FSH)was founded in 1979 as a grassroots organization providing family support in communities throughout West Hawaii. FSH incorporated in 1981 as a private, non-profit organization whose mission is"to Support Families and Communities in Providing Love and Care for our Children." As are all mission statements,this one is carefully chosen. It embodies two key elements: support for families and support for communities. The first guides us in the direct work of supporting families,which we do through our 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. The mission for the Fatherhood Initiative is for every father on the Big Island to have a healthy and positive relationship with his children because FATHERS MATTER.The WHFI responds to 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 WHFI 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.WHFI 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. 3. Program Description: No child chooses to grow up without a Dad to look up to,with no man to guide them,with no positive role models... Yet, millions do; Divorce rates in Hawaii are nearly 50% ...33%of our children are growing up without a father in their home. Boys without fathers are: 9 times more likely to drop out of school, 10 times more likely to abuse drugs,20 times more likely to go to prison than boys who grow up with a father. There is a direct correlation between low self-esteem,emotional intelligence, and violent crime, particularly among boys and men.Studies have shown that arguably the single greatest indicator of low self-esteem and future success is whether there is a healthy father present. In order to meet this challenge,the West Hawaii Fatherhood Initiative(WHFI)conducts multiple,on site fathering classes and coaching based on the national 24/7 dad curriculum to West Hawaii's most marginalized fathers.The Hamakua program will be based out of Kamulea to serve South Kohala, Kamuela and Hamakua to work closely with the low income families to support the fathers and children to overcome the many challenges they face in finding employment, assimilating into the community, overcoming racism, bullying and maintaining a healthy cultural identity. In addition to providing fathering classes,the WHFI is a resource for fathers in the community and exists to keep more fathers engaged with their children despite separation,divorce and the many other factors that lead to father absenteeism. A typical referral is from a father going through divorce and court ordered to complete a parenting class.Often times the relationship with the mother has deteriorated and communication is difficult leading the father to stop attempting to make contact with their child(ren).Through the WHFI,we are able to support the father to establish healthy communication with the mother and to prioritize his relationship to his child(ren). Keeping fathers engaged with their children makes our whole community safer and models healthy behaviors for generations to come. 4.Total Budget& Position Count: Total Program Budget: $19,720 Total Program Position Count: .5 Total Agency Budget: $2,661,000 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Cash on hand (budgeted for South Kona WHFI for 2017) $4,000 Hawaii Island United Way grant(projected recurring amount for South Kona WHFI for 2017) $2,000 Hawaii County grant(sought for South Kona WHFI for 2017) $10,000 Fundraising Initiative-West Hawaii Fathers Day event $2,000 Fundraising Initiative- Portagee horseshoe tournament $2,000 TOTAL: $20,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The WHFI is now under the direction of Caleb Milliken MBA,former executive director of Boys to Men Hawaii. He has a solid track record developing and generating revenue for programs that support families in West Hawaii. For the WHFI, Caleb intends to continue the successful'Be the Man'campaign launched in 2016 to engage more men in the community to get involved with our keiki. The'Be the Man'campaign invited sponsors and donors to support the'Christmas with our Keiki'event,covered the costs of a full radio campaign and print collateral encouraging men to take the pledge to: stand for domestic harmony, stand against bullying and to mentor the youth. In 2017,the'Be the Man'campaign will focus on creating opportunities for fathers to connect with their children and for sponsors and donors to support the WHFI through a series of community events. The WHFI is establishing the first ever'West Hawaii Portagee Horseshoe Tournament'. Portagee horseshoes is a uniquely Hawaiian twist on traditional horseshoes and very popular with local men. It provides a great opportunity for men to interact with their children and other fathers in the community in a healthy and supportive way. There will be approximately 10 small scale events leading up to Fathers Day and the championship event with a chance to win money and prizes. For the championship event and the Fathers Day event,the WHFI will seek support from the community for prizes,donations and sponsorships to continue to provide this valuable service to the families of West Hawaii with the goal of raising between$5,000 and$10,000 per program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1:To provide 2 monthly fatherhood groups in Kamuela.This will allow the WHFI to expand its reach to Hamakua, Kamuela and South Kohala making the program more accessible to more fathers. Objective 2:To provide services for 20 group participants per month.For every father participating in the program,2-3 children are impacted,20 fathers receiving services directly impacts an average of 50 children. Objective 3:To estalish the number of fathers completing the 8 week program at 5 to 10 for 2017. Completion of the 24/7 dad curriculum is not a program requirement but a goal for the fathers who show up every week.Completion of the program ensures that the fathers are applying the tools and skills discussed in the groups. Objective 4:To provide 2 activities for fathers to participate in with their children. Movie nights, portagee horseshoe tournament, barbeque's, etc bring fathers together to find solutions to challenges they are facing. -60 to 90%of the participants are expected to meet at least one of the following risk factors: Unemployed or under employed, immigrant(English as a second language),welfare recipient,subsidized housing recipient, history of domestic abuse, history of alcohol or drug abuse. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of fatherhood groups in Hamakua area 2 groups per month Number of group participants per month in Hamakua area 20 participants per month Number of fathers completing 24/7 dad curriculum 5-10 fathers completing curriculum Number of events for fathers to participate in with their children 2 events in 2017 Total number of fathers participating and children impacted through events and groups 200 fathers,impacting 600 children for 2017 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $6,000 $1,000 Professional Fees Operations $2,000 $2,000 Supplies $100 $100 Equipment Other: Facilitator Stipend $6,000 $1,300 Other: Mileage $2,400 $2,400 Other: Events (site rentals, PR, design and collateral) $1,500 $1,500 Other: Phone and Internet $500 $500 Other: Food for groups $1,200 $1,200 TOTAL $19720 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Caleb Milliken POSITION: Director - West Hawaii Fatherhood Initiative May have a conflict 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. �►� 3o/ Signature Signature of Author-• •erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiiturP funding nognect and mny rPcult in nrtinnc tnkPn to rPrnver these funds, By signing below, you are acknowledging that you have read and understood these requirements. (iL ) l /3v /17 Signature':f lthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Hamakua Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of fatherhood groups in Hamakua area 2 groups per month Number of group participants per month in Hamakua area 20 participants per month Number of fathers completing 24/7 dad curriculum 5-10 fathers completing curricu Number of events for fathers to participate in with their children 2 events in 2017 Total number of fathers particiating and children impacted through events and groups 2c0fraetnhes2m01p7acting 600 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $1,000 Professional Fees Operations $2,000 Supplies $100 Equipment Other: Facilitator Stipend $1,300 Other: Mileage $2,400 Other: Events (site rentals, PR, design and collateral) $1,500 Other: Phone and Internet $500 Other: Food for groups $1,200 TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Family Support Hawaii Healthy Keiki 43 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Healthy Keiki Agency Director: Ray Wofford Phone No.: (808 ) 334 —4115 Contact Person: Deann Canuteson Phone No.: (808 ) 334 — 4189 Mailing Address: Address: 75-127 Lunapule Road Address: Suite 11 City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: same Address: City,ST,Zip Email Address: dcanuteson@fsswh.org Fax No.: (808 ) 326 —4063 Accountant/CPA: Phone No.: (808 ) 242 — 5002 Firm (if applicable): Carbanaro CPA's&Management Group Mailing Address: Address: 1885 Main Street Address:Suite 408 City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Puna ❑ Hamakua ✓ North Kona South Hilo n North Kohala n South Kona ❑ North Hilo H 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: 1y ppoe--I- +two Program Name: 4 ,y 614 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $0 $0 2.Agency Mission Statement: "To support families and communities in providing love and care for our children" 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 quarters of Hawaii Island-over 4000 square miles. FSH's mission is"to support families and communities in providing love and care for our children". Our mission embodies two elements: support for families and support for communities. The first guides us in our direct work of supporting families,which we do through our occupational„speech and physical therapies, home visiting, infant and toddler day cares, parent eduction,fatherhood initiative, breastfeeding support and youth programs. THe second is assisting communities to develop the capacity to provide a supportive environment for families and individuals. These are achieved through our community development activities, collaboration building and advocacy work for a better quality of life for the people of Hawaii Island. 3. Program Description: Healthy Keiki is a program to provide poverty level parents(who lack transportation or resources of their own)transportation supports to assure that their children are cared for and supported in preventive, maintenance and individual health/medical needs. Public transportation for poverty level pregnant women and families with small children is practically non-existent on the west side of Hawaii Island. There is a"shared ride"taxi coupon available to Hilo residents but there is nothing similar on the west side. A disadvantage to using the Hele-on bus system is it's very limited range of drop off sites and the very limited time schedule. We propose to provide transportation to poverty level families to assure that the children (from conception to age 3)of low income families are receiving: * prenatal care throughout pregnancy(approximately 12 visits if no concerns) * well-baby visits throughout the first three years of life(including immunizations ad regularly scheduled testing such as tuberculosis and lead)(approximately 12 visits in first three years of life if no concerns) * preventive and maintenance dental care(approximately 7 visits if no concerns) * WIC(Women, Infant and Children)nutrition appointments(approximately 12 visits if no concerns) This equals 43 visits for basically recommended care from conception to the age of three; if there are concerns in any of the areas,this amount can multiply quickly. According to the National Center for Health Statistics,2014,6%of live births in the state of Hawaii received late or no prenatal care. The 2011/2012 National Survey of Children's Health shows that in Hawaii, 8.9%of children age 0-5, had no preventive care in the previous year. The State of Hawaii is ranked 20th among the 50 states. (see attached page) 4.Total Budget& Position Count: Total Program Budget: $36750 Total Program Position Count: •5 Total Agency Budget: $2,661,000 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Healthy Keiki Program Description continued: In 2012,fifteen percent of children in poor and near-poor families had unmet dental needs. Forty four percent had not been to the dentist in the past year. WIC provides nutritional support to 53%of all infants born in the United States (there was no Hawaii data on attendance at WIC visits with which to compare). We propose to meet or exceed these statistics for the families we serve within the areas we serve in Hawaii. The geographic areas that we propose to cover are South Kohala, North Kona, South Kona, and Kau. We propose to provide transportation and track attendance to the above appointments for up to 45 families. Page 2a of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Fat04 Sv+1,c1?-4- U i Program Name: Rui% Q t4'; 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 36,750 TOTAL: 36,750 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Family Support Hawaii will review and evaluate the effectiveness and results of this program to determine if it should be supported ongoing. If it is successful at the objective and performance measures,we will seek additional funds from Hawaii Island United Way, Hawaii Community Foundation and other private funds. Transportation programs across the nation will be researched and sought out. In addition, FSH does several fundraising events each year which could supplement funding for such a program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Family Support Hawaii proposes to meet or exceed the State of Hawaii statistics regarding preventive medical/dental/health visits as recommended by the American Academy of Pediatrics and reported by the KIDS COUNT Data Center from the Annie E. Casey foundation; for the geographical areas we serve on Hawaii Island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Pregnant women will receive prenatal care as scheduled by physician 95%(state average is 94%) Children age 0-3 will receive well baby visits as scheduled by pediatrician 95%(state average is 91%) Children age 0-3 will receive dental care as scheduled by dentist 95%(state average is 56%) WIC services will be accessed by those eligible as scheduled by WIC 95%(US average is 54%) Number of families to be served 45 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Reg_ Salary and Wages $22,094 s0LZ,09,4 Professional Fees _Operations $14,656 4-1,&5(49 Supplies __-- -- _J quipment _. Other: Other: _O her, _Other, TOTAL $36,750 #3 SO *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 'a. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor I I The Managing Director The Director of Finance 1 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. si,//y F li ,I ) /. i Signature Authori ed erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPquPct and may result in artinns taken to recnuer theca fundc. 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 2017-2018 Page 7 of 8 ( County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 95%(state average is 94%) 95%(state average is 91%) 95%(state average Is 56%) 95%(US average Is 54%) 45 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 122, coq y Professional Fees Operations �' iq, (050 Supplies Equipment Other: Other: Other: Other: Other: TOTAL3(p "150 Additional Council directives regarding award: t EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Family Support Hawaii North Kona Fatherhood Initiative 44 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative Agency Director: Ray Wofford Phone No.: (808) 326 — 7900 Contact Person: Caleb Milliken Phone No.: (808) 747 — 0267 Mailing Address: Address: 75-127 Lunapule Rd#11 Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Rd#11 Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address: crmilliken@hotmail.com Fax No.: ( ) — Accountant/CPA: Phone No.: (800) 242 — 5002 Firm (if applicable): Carbano CPA's&Management Group Mailing Address: Address: 1885 Main St. Address: Suite 408 City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) Puna Hamakua ✓ North Kona I I South Hilo North Kohala South Kona North Hilo South Kohala I I Kali Services or Activities To Be Provided: (One or more can be checked) III Educational concerns ✓ Youth Victims of Crimes ✓ Culture and the arts I I Aged I✓I Victims of Health or Social Crises III Needs of the poor V Physical/Emotional Disabilities ✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $12,000 0 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 Hawaii. Our mission statement encompasses our work-Dads, Moms, infants,toddlers, youth, homeless,disabled,disenfranchised, living in poverty. We strive daily to make a long lasting positive difference in their lives. The mission for the Fatherhood Initiative is for every father on the Big Island to have a healthy and positive relationship with his children because FATHERS MATTER.The WHFI responds to 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 WHFI 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.WHFI 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. 3. Program Description: No child chooses to grow up without a Dad to look up to,with no man to guide them,with no positive role models... Yet, millions do; Divorce rates in Hawaii are nearly 50% ...33%of our children are growing up without a father in their home. Boys without fathers are: 9 times more likely to drop out of school, 10 times more likely to abuse drugs,20 times more likely to go to prison than boys who grow up with a father. There is a direct correlation between low self-esteem,emotional intelligence, and violent crime, particularly among boys and men.Studies have shown that arguably the single greatest indicator of low self-esteem and future success is whether there is a healthy father present. In order to meet this challenge,the West Hawaii Fatherhood Initiative(WHFI)conducts multiple,on site fathering classes and coaching based on the national 24/7 dad curriculum to West Hawaii's most marginalized fathers.The North Kona program is based out of the Ulu Wini complex and works closely with Marshalese community and other low income families to support the fathers and children to overcome the many challenges they face in finding employment,assimilating into the community, overcoming racism, bullying and maintaining a healthy cultural identity. In addition to providing fathering classes,the WHFI is a resource for fathers in the community and exists to keep more fathers engaged with their children despite separation,divorce and the many other factors that lead to father absenteeism. A typical referral is from a father going through divorce and court ordered to complete a parenting class.Often times the relationship with the mother has deteriorated and communication is difficult leading the father to stop attempting to make contact with their child(ren).Through the WHFI,we are able to support the father to establish healthy communication with the mother and to prioritize his relationship to his child(ren). Keeping fathers engaged with their children makes our whole community safer and models healthy behaviors for generations to come. 4.Total Budget& Position Count: Total Program Budget: $37,800 Total Program Position Count: .5 Total Agency Budget: $2,661,000 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Cash on hand (budgeted for North Kona WHFI for 2017) $10,000 Hawaii Island United Way grant(projected recurring amount for South Kona WHFI for 2017) $4,000 Hawaii County grant(sought for South Kona WHFI for 2017) $20,000 Fundraising Initiative-West Hawaii Fathers Day event $2,000 Fundraising Initiative-Portagee horseshoe tournament $2,000 TOTAL: $38,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The WHFI is now under the direction of Caleb Milliken MBA,former executive director of Boys to Men Hawaii. He has a solid track record developing and generating revenue for programs that support families in West Hawaii. For the WHFI,Caleb intends to continue the successful'Be the Man'campaign launched in 2016 to engage more men in the community to get involved with our keiki. The'Be the Man'campaign invited sponsors and donors to support the'Christmas with our Keiki'event,covered the costs of a full radio campaign and print collateral encouraging men to take the pledge to:stand for domestic harmony, stand against bullying and to mentor the youth. In 2017,the'Be the Man'campaign will focus on creating opportunities for fathers to connect with their children and for sponsors and donors to support the WHFI through a series of community events. The WHFI is establishing the first ever'West Hawaii Portagee Horseshoe Tournament'. Portagee horseshoes is a uniquely Hawaiian twist on traditional horseshoes and very popular with local men. It provides a great opportunity for men to interact with their children and other fathers in the community in a healthy and supportive way. There will be approximately 10 small scale events leading up to Fathers Day and the championship event with a chance to win money and prizes.For the championship event and the Fathers Day event,the WHFI will seek support from the community for prizes,donations and sponsorships to continue to provide this valuable service to the families of West Hawaii with the goal of raising between$5,000 and$10,000 per program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1:To double the number of fatherhood groups(North Kona)from 2 per month to 4.This will provide additional days and alternate locations for fathers to participate making the program more accessible to more fathers. Objective 2:To increase the number of fathers currently participating in the program(North Kona)from 15 group participants per month to 30 group participants per month. For every father participating in the program,2-3 children are impacted.An increase of 15 fathers directly impacts an average of 45 children. Objective 3:To increase the number of fathers completing the 8 week program from 10 in 2016 to 25 in 2017. Completion of the 24/7 dad curriculum is not a program requirement but a goal for the fathers who show up every week. Completion of the program ensures that the fathers are applying the tools and skills discussed in the groups. Objective 4: To increase the number of activities for fathers to participate in with their children from 2 in 2016 to 10 in 2017. Movie nights, portagee horseshoe tournament, barbeque's, etc bring fathers together to find solutions to challenges they are facing. -60 to 90%of the participants are expected to meet at least one of the following risk factors: Unemployed or under employed, immigrant(English as a second language),welfare recipient, subsidized housing recipient, history of domestic abuse, history of alcohol or drug abuse. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of fatherhood groups in North Kona 4 groups per month Number of group participants per month in North Kona 30 participants per month Number of fathers completing 24/7 dad curriculum 25 fathers completing curriculum Number of events for fathers to participate in with their children 10 events in 2017 Total number of fathers participating and children impacted through events and groups 200 fathers,impacting 600 children for 2017 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wags $18,000 $2,000 Professional Fees Operations $4,000 $4,000 Supplies $200 $200 Equipment Other Facilitator Stipend $8,000 $6,500 Other: Mileage $1,200 $1,200 Other: Events (site rentals, PR, design and collateral) $3,000 $3,000 Other: Phone and Internet $1,000 $1,000 Other: Food for groups $2,400 $2,100 TOTAL $37,800 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Caleb Milliken POSITION: Director- West Hawaii Fatherhood Initiative May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council 1 1 The Mayor I I 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/I If no conflicts exist, check here. (6' •0 Signat re of Autho 'zed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerpuect rind may recult in artinnc taken to rPrnver theca funrlc. By signing below, you are acknowledging that you have read and understood these requirements. 4-, , Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: North Kona Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of fatherhood groups in North Kona 4 groups per month Number of group participants per month in North Kona 30 participants per month Number of fathers completing 24/7 dad curriculum 25 fathers completingcurriculur Number of events for fathers to participate in with their children 10 events in 2017 Total number of fathers participating and children impacted through events and groups 2fraetnesr,2iomtp7acting 600 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,000 Professional Fees Operations $4,000 Supplies $200 Equipment Other: Facilitator Stipend $6,500 Other: Mileage $1,200 Other: Events (site rentals, PR, design and collateral) $3,000 Other: Phone and Internet $1,000 Other: Food for groups $2,100 TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Family Support Hawai'i South Kona Fatherhood Initiative 45 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative Agency Director: Ray Wofford Phone No.: (808) 326 — 7900 Contact Person: Caleb Milliken Phone No.: (808) 747 — 0267 Mailing Address: Address: 75-127 Lunapule Rd#11 Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-127 Lunapule Rd#11 Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address: crmilliken@hotmail.com Fax No.: ( ) — Accountant/CPA: Phone No.: (808) 242 — 5002 Firm (if applicable): Carbano CPAs&Management Group Mailing Address: Address: 1885 Main St. Address: Suite 408 City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) Fl 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 n Needs of the poor Physical/Emotional Disabilities ✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $12,000 0 2.Agency Mission Statement: Family Support Hawaii(FSH)was founded in 1979 as a grassroots organization providing family support in communities throughout West Hawaii. FSH incorporated in 1981 as a private, non-profit organization whose mission is"to Support Families and Communities in Providing Love and Care for our Children." As are all mission statements,this one is carefully chosen. It embodies two key elements: support for families and support for communities. The first guides us in the direct work of supporting families,which we do through our counseling, home visiting,school based and parent education and support programs. The second is assisting communities to develop the capacity to provide a supportive environment for families and individuals. These are achieved through our community development activities,collaboration building and advocacy work for a better quality of life for the people of Hawaii. Our mission statement encompasses our work-Dads, Moms, infants,toddlers, youth, homeless,disabled,disenfranchised, living in poverty. We strive daily to make a long lasting positive difference in their lives. The mission for the Fatherhood Initiative is for every father on the Big Island to have a healthy and positive relationship with his children because FATHERS MATTER.The WHFI responds to 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 WHFI 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.WHFI 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. 3. Program Description: No child chooses to grow up without a Dad to look up to,with no man to guide them,with no positive role models... Yet, millions do; Divorce rates in Hawaii are nearly 50% ...33%of our children are growing up without a father in their home. Boys without fathers are:9 times more likely to drop out of school, 10 times more likely to abuse drugs,20 times more likely to go to prison than boys who grow up with a father. There is a direct correlation between low self-esteem, emotional intelligence, and violent crime, particularly among boys and men. Studies have shown that arguably the single greatest indicator of low self-esteem and future success is whether there is a healthy father present. In order to meet this challenge,the West Hawaii Fatherhood Initiative(WHFI)conducts multiple,on site fathering classes and coaching based on the national 24/7 dad curriculum to West Hawaii's most marginalized fathers.The South Kona program is based out of the Kahaluu housing complex and works closely with the predominantly Marshalese community there to support the fathers and children to overcome the many challenges they face in finding employment, assimilating into the community, overcoming racism, bullying and maintaining a healthy cultural identity. In addition to providing fathering classes, the WHFI is a resource for fathers in the community and exists to keep more fathers engaged with their children despite separation,divorce and the many other factors that lead to father absenteeism. A typical referral is from a father going through divorce and court ordered to complete a parenting class.Often times the relationship with the mother has deteriorated and communication is difficult leading the father to stop attempting to make contact with their child(ren).Through the WHFI,we are able to support the father to establish healthy communication with the mother and to prioritize his relationship to his child(ren). Keeping fathers engaged with their children makes our whole community safer and models healthy behaviors for generations to come. 4.Total Budget& Position Count: Total Program Budget: $37,800 Total Program Position Count: .5 Total Agency Budget: $2,661,000 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Cash on hand (budgeted for South Kona WHFI for 2017) $10,000 Hawaii Island United Way grant(projected recurring amount for South Kona WHFI for 2017) $4,000 Hawaii County grant(sought for South Kona WHFI for 2017) $20,000 Fundraising Initiative-West Hawaii Fathers Day event $2,000 Fundraising Initiative- Portagee horseshoe tournament $2,000 TOTAL: $38,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The WHFI is now under the direction of Caleb Milliken MBA,former executive director of Boys to Men Hawaii. He has a solid track record developing and generating revenue for programs that support families in West Hawaii. For the WHFI, Caleb intends to continue the successful'Be the Man'campaign launched in 2016 to engage more men in the community to get involved with our keiki. The'Be the Man'campaign invited sponsors and donors to support the'Christmas with our Keiki'event,covered the costs of a full radio campaign and print collateral encouraging men to take the pledge to:stand for domestic harmony, stand against bullying and to mentor the youth. In 2017,the'Be the Man'campaign will focus on creating opportunities for fathers to connect with their children and for sponsors and donors to support the WHFI through a series of community events. The WHFI is establishing the first ever'West Hawaii Portagee Horseshoe Tournament'. Portagee horseshoes is a uniquely Hawaiian twist on traditional horseshoes and very popular with local men. It provides a great opportunity for men to interact with their children and other fathers in the community in a healthy and supportive way. There will be approximately 10 small scale events leading up to Fathers Day and the championship event with a chance to win money and prizes. For the championship event and the Fathers Day event,the WHFI will seek support from the community for prizes,donations and sponsorships to continue to provide this valuable service to the families of West Hawaii with the goal of raising between$5,000 and$10,000 per program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1:To double the number of fatherhood groups(South Kona)from 2 per month to 4.This will provide additional days and alternate locations for fathers to participate making the program more accessible to more fathers. Objective 2:To increase the number of fathers currently participating in the program(South Kona)from 15 group participants per month to 30 group participants per month. For every father participating in the program,2-3 children are impacted.An increase of 15 fathers directly impacts an average of 45 children. Objective 3:To increase the number of fathers completing the 8 week program from 10 in 2016 to 25 in 2017.Completion of the 24/7 dad curriculum is not a program requirement but a goal for the fathers who show up every week. Completion of the program ensures that the fathers are applying the tools and skills discussed in the groups. Objective 4:To increase the number of activities for fathers to participate in with their children from 2 in 2016 to 10 in 2017. Movie nights, portagee horseshoe tournament, barbeque's,etc bring fathers together to find solutions to challenges they are facing. -60 to 90%of the participants are expected to meet at least one of the following risk factors: Unemployed or under employed, immigrant(English as a second language),welfare recipient,subsidized housing recipient, history of domestic abuse, history of alcohol or drug abuse. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of fatherhood groups in South Kona 4 groups per month Number of group participants per month in South Kona 30 participants per month Number of fathers completing 24/7 dad curriculum 25 fathers completing curriculum Number of events for fathers to participate in with their children 10 events in 2017 Total number of fathers participating and children impacted through events and groups 200 fathers,impacting 600 children for 2017 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $18,000 $2,000 Professional Fees Operations $4,000 $4,000 Supplies $200 $200 Equipment Other: Facilitator Stipend $8,000 $6,500 Other: Mileage $1,200 $1,200 Other: Events (site rentals, PR, design and collateral) $3,000 $3,000 Other: Phone and Internet $1,000 $1,000 Other. Food for groups $2,400 $2,100 TOTAL $37,800 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Caleb Milliken POSITION: Director- West Hawaii Fatherhood Initiative May have a conflict 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: IV I If no conflicts exist, check here. i' I /341W Signa re of Aut o led P rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai`i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPrllPct and mny result in nrtinnc tnken to rernvpr thPce filmic, By signing below, you are acknowledging that you have read and understood these requirements. 1)c CE-D_) / (,?o// Signature of Authorized Per on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Family Support Hawaii Program Name: South Kona Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of fatherhood groups in South Kona 4 groups per month Number of group participants per month in South Kona 30 participants per month Number of fathers completing 24/7 dad curriculum 25 fathers completing curriculur Number of events for fathers to participate in with their children 10 events in 2017 Total number of fathers participating and children impacted through events and groups 200 fathers,impacting 600 P P g P 9 9 p children for 017 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $2,000 Professional Fees Operations $4,000 Supplies $200 Equipment Other: Facilitator Stipend $6,500 Other: Mileage $1,200 Other: Events (site rentals, PR, design and collateral) $3,000 Other: Phone and Internet $1,000 Other: Food for groups $2,100 TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Food Basket, Inc., The Hawai'i Island Emergency Distribution Program 46 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket, Inc. Program Name: Hawaii Island Emergency Distribution Program Agency Director: En Young Phone No.: (808 ) 933 —6030 Contact Person: Kristin Frost Albrecht Phone No.: (808 ) 933 — 6030 Mailing Address: Address: 40 Holomua Street Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: SAME Address: City,ST,Zip Email Address: info@hawaiifoodbasket.org Fax No.: (808 ) 934 — 0701 Accountant/CPA: Matt Crosson Phone No.: (808 ) 933 — 6030 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: $84,460 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket, Inc. Program Name: Hawaii Island Emergency Distribution Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 30000 30000 24500 2.Agency Mission Statement: The Mission of The Food Basket 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 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: Unlike other social service agencies,The Food Basket is a centralized set of infrastructure pieces deployed in a flexible way to alleviate hunger. For example,in times of a hurricane,The Food Basket deploys its trucks and warehouse to meet sudden community needs. In these cases, it is impossible to forecast and budget for this natural disaster,especially within the terms of a grant. However support of our general operations,staffing,warehouse,and utilities,etc., allows The Food Basket to flexibly respond to any community need. The Food Basket,for example,has incubated two burgeoning businesses out of our Honalo warehouse, an'ulu cooperative and a Sharwil avocado market restoration project. Because the speed of business is far beyond the yearly timeline of grant applications,The Food Basket used its own funds and existing staff and resources to support these activities. Our service model is not the deployment of human resources,rather it is the deployment of capital resources that then allow us to leverage a number of different programs. All of our programs rely on our ability to collect and distribute food. Our keiki Back Pack program serves 3001 school aged children island wide,while our Senior programs serve over 2,000. The Food Basket's Emergency Food Program serves over 13,000 people per month,and nearly 42,000 each year. None of these grants currently pay to keep central infrastructure maintained. The Food Basket has plans for several new intiatives that will leverage our existing infrastructure,however these facilities and vehicles need to be maintained. The Food Basket is asking for 10%of general expenses,or$84,460 to support all the programs of The Food Basket. Submitting multiple applications for each program,including staffing and resources,would ask the County for more than $150,000. This ask is more targeted and consists only of resources common to all programs,thus conforming to County allowable expenses. 4.Total Budget&Position Count: Total Program Budget: 844,596 Total Program Position Count: 18 Total Agency Budget: 3,400,000 Total Agency Position Count: 18 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket, Inc. Program Name: Hawaii Island Emergency Distribution Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Contributed Income 682,554 Earned Revenue 162,042 TOTAL: 844,596 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Food Basket has embarked on a number of revenue generating activities that have the potential to improve profitability. As mentioned above,The Food Basket leverages infrastructure to incubate businesses with a social benefit for a small price. Currently,The Food Basket is involved with an additional socially-focused vendor for tenancy and an eventual business partnership. While we are free to discuss this during Council GIA closed-door meetings,we are not free to comment as part of the public record until negotiations are complete. Beyond business ventures,The Food Basket is slowly transforming grant making infrastructure, investing in full time staff to create more revenue. The Food Basket is also working on other initiatives which would assist in wastestream diversion while creating a steady revenue stream that would benefit the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives include: 1)Continuing to serve rural areas:Pahala,Na'alehu,Kapa'au,Ocean View, Pepe'ekeo, Pa'auilo,Miloli'i etc. with at least 2 food drops per year 2)Maximizing community food and partnership through the development of additional Senior Programs 3)Increasing nutrition supplements for schools with over 85%Free and Reduced Lunch 4)Maintain contingency funding projects for individual Council members, including Puna Bodacious ladies,etc. 5)Increase variety of supply for 80+partner agencies,including fresh produce 6)Maintain local buying preferences at over$200,000 in purchases in Hawaii County 7)Use infrastructure to decrease the total food wasted in Hawaii County 8)Decrease the total number of people who need food assistance 9)Incubate local farmers and provide referrals for training and resources EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket, Inc. Program Name: Hawaii Island Emergency Distribution Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase Senior Programs for low-income Seniors additional 1000 Seniors Maintain rural drops At least 2 per rural area,Ka'u,Hamakua, Decrease total food wasted Enroll 3 more stores in redamation Incubate local farmers Add 5 farmers to CSA program Increase variety of supply Ratio of canned to fresh food hits 20% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages n/a 454,560 45,456 Professional Fees n/a 95,018 9,501 Operations n/a 84,766 8,477 Supplies n/a 69,782 6,978 Equipment n/a Other: Utilities and Maintenance 140,480 14,048 Other: Other: Other: Other: TOTAL 844,606 84,460 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket, Inc. Program Name: Hawaii Island Emergency Distribution 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: Chris Schleuter POSITION: Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Ij Member or members of the Council F---1 Staff appointed by a member of the Council The Mayor The Managing Director n The Director of Finance ✓] The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Chris serves as a current Deputy Corp Counsel. In all matters pertaining to this or any other contract,he will recuse himself from matters requiring Board action. n If no co• "i• - -xist, check here. V Afar 1/5°/1/ Signature of thori -d Pe, on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket, Inc. Program Name: Hawaii Island Emergency Distribution Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket, Inc. Program Name: Hawaii Island Emergency Distribution Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 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 artinns taken to rernver these funds, By signing below, you are acknowledging that you have read and understood these requirements. 7 f (-/ .9/(4 L-t D'1.1-4.4-1 4 Signature of Aued P- son (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Food Basket Program Name: Hawaii Island Emer•enc Distribution Pros ram 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result additional 1000 Seniors At least two drops per rural area,Ka'u,Hamakua,PUna Enroll 3 more stores in reclama Add 5 Farmers to CSA Ratio of canned food to fresh food hits 20 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 45,456 Professional Fees 9,501 Operations 8,477 Supplies 6,978 Equipment Other: Utilities and Maintenance 14,408 Other: Other: Other: Other: TOTAL 84,460 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Friends of the Children of West Hawai'i Basic Needs and Enhancement Activities 47 County of Hawai`i Nonprofit Grant Application FY2017-18 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.: (808 ) 331 — 2425 Mailing Address: Address: P.O.Box 9041 Address: City,ST,Zip Kailua Kona, HI 96745 Facility Address: Address: 74-5617 Pawai Street Address: Suite 209 City,ST,Zip Kailua Kona,HI 96745 Email Address: friendscwh@gmail.com Fax No.: (808 )329 — 1188 Accountant/CPA: Rick Pigott Phone No.: (808 ) 331 — 8555 Firm (if applicable): Tax Associates Mailing Address: Address:75-5656 Kuakini Highway Address:Suite 302 City,ST,Zip Kailua Kona HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑✓ Hamakua 0✓ North Kona ❑South Hilo 0✓ North Kohala 0✓ South Kona 0 North Hilo 0✓ South Kohala Q✓ Kai', Services or Activities To Be Provided: (One or more can be checked) Q✓ Educational concerns 0✓ Youth Victims of Crimes 0✓ Culture and the arts 0 Aged 111 Victims of Health or Social Crises 0 Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children of West Hawai'i Program Name: Basic Needs and Enhancement Activities 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $6,000.00 $3,000.00 $3,000.00 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 been witnesses to violent crime;and To assist in the prevention of child abuse through education and collaboration with committed community partners". 3. Program Description: The Basic Needs and Enhancement Program, in partnership with both government and private agencies,will provide children in our community who have been abused and neglected,with assistance with either meeting their Basic Needs(clothing,shoes, school supplies,toiletries,etc.)or providing the financial assistance to allow them to participate in activities that are of interest to them,and that will help them in their social development. The Friends does not provide direct services,but rather we partner with agencies that do,to determine what needs of an abused or neglected child are not being met,and cannot be met,through any other agency.While many of these children may be in Foster Care,many of them are living with extended family,or may even be homeless-in all cases the guardians/parents of these children have very limited resources.The Basic Needs portion of the Program is designed to provide children with items such as clothing,shoes,toiletries etc.in the event that they are removed from their home without the opportunity to retrieve any of their personal belongings;to provide clothing and shoes when they outgrow their existing clothing and there are no financial resources available;to provide the them with all the school supplies needed to begin their school year;to provide a new foster family with necessary baby items while they await funding from the State;or any other basic need they have in order to thrive(excluding food and shelter).The Enhancement Activites is designed to provide these children with opportunities, based on their individual interests,to participate in any type of activity that will help them increase their social skills;learn to trust adults in their lives;enhance their own feeling of self-worth;increase educational opportunities;and in many cases just to have fun!Examples of enhancement activities include swimming lessons,dance/hula lessons;extra ciricular or sports activities, school trips,etc. 4.Total Budget&Position Count: Total Program Budget: $41,000 Total Program Position Count: •75 Total Agency Budget: $100,000 Total Agency Position Count: .75 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children of West Hawai'i Program Name: Basic Needs and Enhancement Activities 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Victoria Geist Foundation $15,000 Teresa F.Hughes Trust $15,000 Friends of Hawai'i Charities $2,000 Visitor Industry Charity Walk $3,000 County of Hawai'i $6,000 TOTAL: $41,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Executivei Director of the Friends of the Children of West Hawai'i consistently searches for other grant opportunities to support children in our community who have been abused and neglected by providing them the opportunity to participate in activities,as well as to meet their basic needs. In addition,she regularly contacts local businesses to become a partner by providing either financial support,or in kind donations.She has been successful in creating a partnership with a local bank, which provides several volunteers to assist with the collection of school supplies from the local community,in order to meet the every growing need to provide children with school supplies to begin their year.The agency will also hold fundraising events to both bring awareness to the issue of child abuse and neglect,and to provide financial support.An annual mailing campaign is done at the end of October,to fund the Christmas Project in which we provide approximately 150 youth between the ages of 10 and 18 with a"Christmas to Remember". Local churches have also assisted in the particular project by asking their parish members to donate much needed items. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of the Program is to meet every request for either a Basic Need,as well as to fund every request for funding an enhancement activity that is submitted through our partner agencies.It is also the objective of the program to let our abused and neglected children know that there are people in the local community who care about them as an individual,and support them in their endeavors to become responsible,community minded adults. Due to the fact that the Friends has been consistently providing this service for over 20 years,our partner agencies understand that each request must be reasonable in both the nature of the request,and the amount requested.It is rare to deny a request, unless it is outside of our financial scope(for example providing braces). It is our objective to serve between 250 and 300 children and youth,with an average of 2-3 requests per year.This is split fairly evenly between Basic Needs Requests and Enhancement Activities.The"SOS-Supply Our Students"Program will supply 175 students with backpacks filled with school supplies."Christmas to Remember"will provide 160 youth with a Christmas gift chosen specifically for them,a ticket to either the theater or for a game of bowling;a gift card to a local retailer;and a stocking filled with treats and necessities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children of West Hawai'i 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 (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Aside from the individual requests for Basic Needs,the Program also encompasses our 175 Backpacks filled with school supplies "SOS"-Supply our Students,which is an annual school supplies;up to 30 volunteers will collect and sort the supplies;community drive held at the local Walmart store Meeting other Basic Needs 150 children/350 requests Providing Enhancement Activities 150 children/300 requests "Christmas to Remember"for youth ages 10- 18; up to 20 volunteers to wrap and sort gifts 160 youth/160 requests Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees $14,406 $20,004 $2,000 Operations Supplies Equipment Other: Basic Needs $19,986 $20,300 $3.300 Other: Enhancement Activities $17,971 $20,700 $3,300 Other: Other: Other: TOTAL $52,363 $61,004 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children of West Hawai'i Program Name: Basic Needs and Enhancement Activities 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council E 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: C If no conflicts exist, check here. ,, 01/28/2017 Si:s atu e of A thoriz' Person (specify title) Date EXHIBIT A NONPROFIT GRA APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children of West Hawai'i Program Name: Basic Needs and Enhancement Activities 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children of West Hawai'i Program Name: Basic Needs and Enhancement Activities 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will imaact the evaluation of your agency's future funding rerruest and may recult in nrtinnc taken to rernver these funds.. By signing below,you are acknowledging that you have read and understood these requirements. ( i2, alj j 01/28/2017 Signature of Author(-d Person (specify title) Date e'OA Wia7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children of West Hawai'i Program Name: Basic Needs and Enhancement Activities 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Friends of the Children's Justice Center of East Hawaii Special Needs, Enhancement, Support, Education and Training 48 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training Agency Director: Robin Benedict Phone No.: (808) 935 — 8755 Contact Person: Robin Benedict Phone No.: (808) 935 — 8755 Mailing Address: Address: P.O. Box 6908 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 1290 Kinoole St Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: fcjceh@hawaii.rr.com Fax No.: (808 ) 935 — 8757 Accountant/CPA: Jennifer L. Gossert CPA Phone No.: (808 ) 969 — 3115 Firm (if applicable): Mailing Address: Address: 688 Kinoole St.,Ste 201 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑ North Kona ['South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth Q Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 20,000.00 12,000.00 12,375.00 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, Constant Contact,and facebook page,which promotes child abuse awareness and prevention.The Program sponsors training, by supporting the attendance of professionals,who work with abused children,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: 197,725 Total Program Position Count: 1 Total Agency Budget: 223,959 Total Agency Position Count: 1 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 20,000 Donations 12,300 Fundraising 14,500 Special Events-Phantom Fundraiser, Charity Walk, Ironman 27,400 Foundations:Teresa Hughes and Victoria and Bradley Geist 100,000 Hawaii Island United Way 5,100 Corporate and other Grants 18,425 TOTAL: 197,725 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Friends do not collect fees for any of our services. We are continuously researching for additional grant funding,striving to increase donations for our annual"Phantom"non-event fundraiser,and working to expand attendance at our annual fundraising dinner event,which includes a silent auction.We also have the ability to accept monetary donations on our web site,which has benefited from our social media exposure on facebook and Constant Contact. 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 registration,dance,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 FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Fill"Special Need&Enhancement"Requests 1200 requests Serve child victims of abuse and or neglect 650 children will be served Volunteers will donate hours to help children receive services 8 volunteers Ongoing Center support for the Children's Justice Center for a child friendly enviornment 184 children and youth comfortably served Abused and neglected children will receive holiday gift cards 250 youth will receive a holiday gift card Participation in community education and training events to prevent child abuse 5 events Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 44,432 46,000 5,000 Professional Fees 14,563 9,700 Operations 4,127 4,200 Supplies 3,330 3,400 Equipment 500 1,500 Other: Special Needs Requests 117,581 124,000 15,000 Other: Center Support 2,291 3,000 Other: Facility Maintenance 67 250 Other: Education and Prevention, Website, Training 2,034 2,675 Other: Insurance General, D&O 2,154 3,000 TOTAL 191,079 197,725 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY20 1 7-1 S Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council O The Mayor ❑ The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in genera!to an Industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: 25 If no conflicts exist, check here. • Preiden+ %i i/1-7 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Pro am Name: Special Needs Enhancement, Su rt, Education and Trainin 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): • Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director • The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probabllty 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: 2 If no conflicts exist,check here. Tr-east/ire(' t I t Signatu of A` ed Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training i .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 lune 30th shall result in loss of all grant funds received daring the grant Period(must be refunded to County)an exclusion from future grant participation fora minimum of one year or until a written report is submitted to.and accepted by.the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at httn j/www,hawaiicountv.eov/fn-nonprofit-arrant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2018 must be returned to the County of Hawaii with the final report.Failure to return these funds In a timely manner yvill impact the evaluation of your agency's fintiro funding rain"?and may rcrllt in nrtlnnc tnlrvn to rernuer HIPCP snrtc By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person(specify title) Date A ) T"s su" EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support, Education and Training 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Fill"Special Need&Enhancement"Requests 1200 requests Serve child victims of abuse and or neglect 650 children will be served Volunteers will donate hours to help children receive services 8 volunteers Ongoing Center support for the Children's Justice Center for a child friendlyenvironment comma children Jo comfortably servedandot Abused and neglected children will receive holiday gift cards 250 youth will receive a holiday gift card Participation in community education and training events to prevent child abuse 5 events TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 5,000 Professional Fees Operations Supplies Equipment Other: Special Needs Requests 15,000 Other: Center Support Other: Facility Maintenance Other: Education and Prevention, Website, Training Other: Insurance General, D&O TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 ATTACHMENT Friends of the Children's Justice Center of East Hawaii AA • OA P. O. Box 6908, Hilo, HI 96720 Bus: (808)935-8755 A Fax: (808)935-8757 E-Mail: fcjceh@hawaii.rr.com A www.fcjcEastHawaii.org Program Description: Founded in 1990, the Friends of the Children's Justice Center, also known as the "Friends", is a private nonprofit organization, with the primary goal of enhancing and protecting the physical and psychological well-being of abused and neglected children. The Friends work in partnership with the Children's Justice Center (CJC), a State of Hawaii Judiciary Program. The CJC provides a safe, neutral homelike atmosphere, where children can be interviewed regarding allegations of abuse, particularly sexual abuse. This Children's Justice Center facilitates and coordinates the system's response to victims of child abuse, to reduce their trauma, through a multi-disciplinary team approach, which involves police, social workers, prosecutors, guardians ad litem, medical professionals, advocates, and others. The Friends support the CJC primarily by helping to provide resources for direct services and programs, for child victims and their families, which are not available through any other public or private source. The Friends accept requests for funding from State and private agencies working with child abuse victims, such as Child Protective Services, Child and Family Services, Hawaii Behavioral Health, Catholic Charities, Parents Inc., and other agencies. The Friends serve children between the ages of 0-18, who are victims of abuse (sexual, physical, emotional, mental abuse or neglect, or are witnesses to crime) residing in East Hawaii. This includes North Hilo, South Hilo, Hamakua, Puna and parts of Ka'u. We serve children with active or documented cases of abuse and neglect. The Special Needs and Enhancement Program is designed to help child victims develop positive self-worth. The Friends provide resources for needs that are not covered by any other public or private source. Funds are used to provide basic essentials (i.e. clothing, diapers, toiletries), special needs (i.e. air/ground transportation, school supplies, correspondence courses) and enhancement support (i.e. sports, music lessons, and tutoring). The Friends also have a holiday gift program for children not covered by other programs. Center Support: The Friends provide resources to help reduce trauma and ensure the safety and comfort of the children that come to the Children's Justice Center for interviews. The Friends maintain the Center's safe, child-friendly and homelike atmosphere with toys, games and snacks. The community supports our efforts with donations of clothing, for our clothes closet, and stuffed animals. The Friends also help maintain the Center's appearance with repairs and refurbishing when needed. 1I1' � ATTACHMENT Friends of the Children's Justice Center of East Hawaii 3�� P. 0. Box 6908, Hilo, HI 96720 — I Bus: (808)935-8755 A Fax: (808)935-8757 E-Mail: fcjceh@hawaii.rr.corn A www.fcjcEastHawaii.org The Prevention and Education Program is designed to educate the community regarding child abuse issues. This program plans events for the public, promoting awareness and prevention of child abuse. The Training Program helps to supports the attendance of various professionals (i.e. social workers, police & therapists) at seminars and conferences to learn state-of-the-art interviewing techniques and refine their overall skills. These professionals work with child victims and their families. Training opportunities enhance the quality of services and prevents victims from being re-traumatized by possible difficiencies in the system's response to the allegations of abuse. Program Objectives: 1) Provide funds for clothing, toiletries, bed/mattress and other necessities for children in emergency or relative foster placement. 2) Provide funds for tutoring, correspondence courses or summer school to allow a child to graduate or progress to the next grade level. 3) Provide funds for ground or air transportation for children to participate in family vacations/reunions, attend school or team events, or to see medical specialists. 4) Provide funds for children to participate in supervised spring and winter intersession activities, or summer camps. 5) Pay for fees, equipment and supplies needed for extracurricular activities i.e.: sports, music, art, drama, dancing lessons, etc. 6) Provide funds for holiday or birthday gifts when a child would otherwise not receive a gift. 7) Provide funds (or gift cards) for gas, to families on a limited budget so children may be able to attend treatment programs. 8) Provide funds for diapers, car seats and other baby supplies for infants who are victims of abuse and neglect. 9) Pay for event fees, prom dresses, senior pictures, yearbooks, etc., to give a student a chance to participate in school functions. 10) Assist police, social workers, and other professionals in keeping up to date with the latest investigative techniques, sensitivity training, forensics and knowledge of resources by helping to sponsor their attendance at training workshops and seminars. 11) Provide privacy, comfort and safety for children and family members who come to the Center, by maintaining its warm environment. 12) Participate with the East Hawaii Coalition for Child Abuse Prevention in community education activities to increase public awareness. 2 � ?' , Friends of the Palace Theater Hawaiian Cultural Legacy Program 49 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Le.ac Pros ram Agency Director: Morgen Bahurinsky Phone No.: (808) 934 — 7120 Contact Person: Morgen Bahurinsky Phone No.: (808) 934 — 7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 38 Haili Street Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: morgen.bahurinsky@hilopalace.com Fax No.: ( ) — Accountant/CPA: Bob Nutt Phone No.: (808 ) 963 — 6160 Firm (if applicable): East Hawaii Business Services Mailing Address: Address: 15 Kahoa Street, Address: City,ST,Zip Hilo Hawaii, 96720-2205 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $58,450 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua ❑ North Kona ❑✓ South Hilo I I North Kohala U South Kona ❑✓ North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth 1 1 Victims of Crimes ✓ Culture and the arts I l Aged ❑Victims of Health or Social Crises n Needs of the poor Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Le•ac Pros ram 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $3,000 $10,000 2.Agency Mission Statement: 58450The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize, restore, and sustain Hilo's historic theater as a venue that will educate, entertain, and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo, and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place, and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists, local and international filmmakers, and for community-based, multi-cultural events. In 1992, the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales, each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture, and multi-generational, multi-ethnic dialogue and discourse. 3. Program Description: The overall intent of the Hawaiian Cultural Legacy Program is to preserve, honor, and perpetuate Hawaiian traditions, and to provide local audiences and visitors a deeper insight into the Hawaiian way of life. This multi-faceted program has two specific components: a.The"Celebration of Hawaiian Music"evening concert series will feature both well-known and up-and Hawaiian musical performers to highlight the musical legacy of Hawaii and its oral tradition of recording history, culture and lifestyle.The performers will include multi-generational practitioners, both internationally renowned and local favorites,who have maintained the tradition of passing their history and culture down through the generations via music and song. Examples include Makaha Sons,the local Waiakae School Ukulele Band, and the Kalapana Awa Band. It is proposed that one or more of the concerts be recorded live at the theater,with CDs created for later sales at the Palace Gift Shop. b.The "Na Hali'a" ('Fond Memories') program will be performed in the daytime from January to April, 2017,during the height of the tourist season.The program will offer authentic Hawaiian culture, music and dance, and will both educate and entertain tourists,visitors, and resident families.Tuesday afternoons have been chosen to specifically target the cruise ship passengers. The 'Na Hali'a'program will be constantly changing, with each week focusing on another Hawaiian cultural aspect. Celebrations to honor deities of the past, agricultural harvests,volcanic eruptions and more will enlighten patrons about the history behind present day practices. This will be especially advantageous for local youth,who will be exposed to authentic traditions and stories that they might not learn about elsewhere. 4.Total Budget& Position Count: Total Program Budget: 113,766 Total Program Position Count: 1 (FT) Total Agency Budget: 411,000 Total Agency Position Count: 3 (FT) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Legacy Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 58,450 Ticket Sales 30,016 Cafe 5,000 CD sales 300 State Foundation on Culture and the Arts (pending request) 20,000 TOTAL: 113,766 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources: Box office revenue, Cafe revenue,donations, major sponsors, grants, rentals,volunteers, and in-kind donations-all of which will be leveraged to support this program. County funding to support artist fees, practitioner honorariums,sound and light engineering and marketing is a key aspect of the program, as a monetary commitment to the artists and practitioners will help lay the framework and encourage other donors to support this important project. The Board of Directors annually establishes a Strategic Plan with strategies to build a strong financial foundation through increased revenue from individual donors, increased partnerships with local schools, businesses and community groups, increased audience numbers and increased revenue from grants.The Board of Directors is actively represented at every Palace event, cultivating prospective audience members and supporters. New branding and marketing strategies are already increasing awareness of the Palace Theater. Continuous advertising to target audiences, assessing customer satisfaction, and adding new performers annually will round out the cumulative results of fundraising to make this program sustainable into the future. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of the Cultural Legacy program is to actively encourage and support native Hawaiian culture, art, artists, and practitioners. Specifically,the program seeks to: -provide opportunities to the public, both local residents and visitors,to experience and appreciate Hawaiian music, dance, and sacred cultural traditions; -create a more accurate portrayal of Hawaiian sacred places, religious beliefs, deities and dance as a means of preserving history; -encourage and develop target audiences for Hawaiian cultural performances; -promote sustainable cultural tourism by providing authentic, place-based experiences. This program incorporates all the elements of cultural and historic interest-the experiential,emotional and visual.Therefore, it is anticipated that increased ticket sales, increased attendance, and a desire of the community,visitors and new performers to repeat the productions in the future will serve as positive indicators of its sustainability into the future. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Le.ac Pros ram 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) increased revenue from ticket sales +20% increased audience size through a targeted marketing strategy +10% increased usage of the Palace Theater as a venue for Hawaiian cultural events +5% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 17,836 Professional Fees 7,950 7,950 Operations 2,050 Supplies Equipment Other: PR: Outreach and Marketing 31,000 15,500 Other: Artist fees (concert series) 27,000 27,000 Other: perdiems/lodging and transportation (concert series) 9,930 Other: Honorariums for practitioners (daytime program) 8,000 8,000 Other: )Administration 10,000 TOTAL 113,766 58,450 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Legacy Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓� If no conflicts exist, check here. January 28, 2017 Signature of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Legacy Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Legacy Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerluect rind mny result in nrtinnc token to rernver there funrdc. By signing below, you are acknowledging that you have read and understood these requirements. CLe, January 28, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Cultural Legacy Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result increased revenue from ticket sales +20% increased audience size through a targeted marketing strategy nor increased usage of the Palace Theater as a venue for Hawaiian cultural events +5% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 7,950 Operations Supplies Equipment Other: PR: Outreach and Marketing 15,500 Other: Artist fees (concert series) 27,000 Other: perdiems/lodging and transportation (concert series) Other: Honorariums for practitioners (daytime program) 8,000 Other: )Administration TOTAL 58,450 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Friends of the Palace Theater Palace Theater Fall Musical 50 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical Agency Director: Morgen Bahurinsky Phone No.: (808) 934 — 7120 Contact Person: Morgen Bahurinsky Phone No.: (808) 934 — 7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo Hawaii,96720 Facility Address: Address: 38 Haili Street Address: City,ST,Zip Hilo Hawaii,96720 Email Address: morgen.bahurinsky@hilopalace.com Fax No.: ( ) — Accountant/CPA: Bob Nutt Phone No.: (808) 963 — 6160 Firm (if applicable): East Hawaii Business Services Mailing Address: Address: 15 Kahoa Street, Address: City,ST,Zip Hilo,Hawaii,96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $21,630 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna (1 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize,restore,and sustain Hilo's historic theater as a venue that will educate,entertain,and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo,and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place,and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists,local and international filmmakers,and for community-based, multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales,each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture,and multi-generational,multi-ethnic dialogue and discourse. 3. Program Description: The Fall Musical is the signature event and biggest fundraiser of the year for the Palace Theater. Proceeds from the Box Office and other donations for this event are used to support productions and operations for the balance of the year. Each year,a different Broadway show is chosen by May.Local performers audition and rehearse from August to October,when the event is held over three weekends.Excitement about the event increases over these months,as word spreads by word of mouth. 2017 will be the 16th consecutive musical. This popular event attracts the residents of East Hawaii,along with visitors from the mainland,who frequently make their vacation plans around the Fall Musical. Due to our current capital campaign for critically-needed physical repairs to the theater,we have not been able to raise the upfront capital to pay our Directors and technicians,or to pay the cost of the orchestra. Not having this upfront capital means that all costs of the musical,including licensing,marketing,wardrobe and sets will have to be paid out of our operating funds. Annual continuity of this popular signature event is critical;skipping it or trying to replace it with something else would place the theater in a precarious financial position,and put other productions and operations at risk. Historically,a major benefactor has contributed and participated in this event;a monetary contribution valued at$20,000. However,that benefactor no longer participates directly in the event;nor we are not able to count on this contribution; necessitating our request to the County. 4.Total Budget&Position Count: Total Program Budget: 45,190 Total Program Position Count: 1 (FT) Total Agency Budget: 411,000 Total Agency Position Count: 3(FT) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 21,630 Box office 21,500 Cafe 2,060 TOTAL: 45,190 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources:Box office revenue,Cafe revenue,donations, major sponsors,grants,rentals,volunteers,and in-kind donations-all of which will be leveraged to support this program.County funding to support Directors'fees,musicians,and technical staff is a key aspect of the program,as a monetary commitment to the Directors and performers will help lay the framework and encourage other donors to support this important program The Board of Directors annually establishes a Strategic Plan with strategies to build a strong financial foundation through increased revenue from individual donors,increased partnerships with local schools,businesses and community groups, increased audience numbers and increased revenue from grants.The Board of Directors is actively represented at every Palace event,cultivating prospective audience members and supporters. New branding and marketing strategies are already increasing awareness of the Palace Theater.Continuous advertising to target audiences,assessing customer satisfaction,and adding a new show and performers annually will round out the cumulative results of fundraising to make this program sustainable into the future. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of this request is to ensure the continuity of this major fundraising event to which the local community and visitors to the island look forward with enthusiasm. This signature event has historically contributed to annual operations,as well as showcasing the Palace Theater as a excellent venue for large theatrical productions. this is vital,since there is a tremendous amount of talent in East Hawaii,but not many places to showcase it. The Fall Musical at the Palace Theater provides an opportunity for artists to perform in front of a live audience. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) increased revenue from ticket sales +20% increased audience participation from targeted marketing strategies +20% increased usage of the Palace Theater as a venue for large productions +5% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations 3,060 3,060 Supplies 5,000 5,500 Equipment Other: marketing 5,300 7,500 Other: licensing 7,190 7,500 Other: Directors'Fees(Director, Musical Director, Choreographer) 6,000 6,000 6,000 Other: Orchestra(9 musicians) 9,180 9,180 9,180 Other- Technical staff 5,200 6,450 6,450 TOTAL 40,930 45,190 21,630 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): n Member or members of the Council n S- taff appointed by a member of the Council • The Mayor E The Managing Director n T- he Director of Finance n T- he Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. CEJ January 28, 2017 Signature of Autho ized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein,including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 (weI understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2018 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 nnri mny rPsiiit in nrtinnc tnkan to rprouPr thPSP firnr/t. By signing below,you are acknowledging that you have read and understood these requirements. January 28, 2017 Signature of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: Palace Theater Fall Musical 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result increased revenue from ticket sales +20% increased audience participation from targeted marketing strategies +20% increased usage of the Palace Theater as a venue for large productions +5% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: marketing Other: licensing Other: Directors'Fees(Director, Musical Director,Choreographer) 6,000 Other: Orchestra(9 musicians) 9,180 Other: Technical staff 6,450 TOTAL 21,630 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Friends of the Palace Theater Spotlight on Youth 51 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth Agency Director: Morgen Bahurinsky Phone No.: (808) 934 — 7120 Contact Person: Morgen Bahurinsky Phone No.: (808) 934 — 7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 38 Haili Street Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: morgen.bahurinsky@hilopalace.com Fax No.: ( ) — Accountant/CPA: Bob Nutt Phone No.: (808) 963 — 6160 Firm (if applicable): East Hawaii Business Services Mailing Address: Address: 15 Kahoa Street Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $21,300 Geographical Areas To Be Served: (One or more can be checked) VI Puna ✓ Hamakua ❑ North Kona n South Hilo ❑ North Kohala n South Kona • North Hilo ❑ South Kohala I I Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ✓ Youth ❑Victims of Crimes ✓ Culture and the arts n Aged I I 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 $5,000 2.Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize, restore, and sustain Hilo's historic theater as a venue that will educate, entertain, and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo, and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place, and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists, local and international filmmakers, and for community-based, multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales, each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture, and multi-generational, multi-ethnic dialogue and discourse. 3. Program Description: East Hawaii is a diverse community with many different age groups, income levels, and enthnicities. The Board of Directors feels that it is vital to discover and assess each group to respond effectively to their unique needs. An emerging interest is the development of arts programming for youth,especially for those under the age of 15. In the summer of 2016, a new program was established for young children in partnership with Volcano Circus Arts. This program utilized a 'summer camp'format for magic camps and circus camps at the Palace Theater in Hilo,a location more convenient for local youth, because Volcano Circus Arts performance venues are not close by. Because of the popularity of the program, it will continue in summer 2017,and be expanded to include activities in performance -using dance, choral music and drama,-throughout the year. Partnerships with five Hilo schools of performance have already been established,and this year's performances showcasing children under 16 years of age at the theater were enthusiastically endorsed by both performers and teachers. Performances with youth can often be sell-out performances. These successful community partnerships will ensure that the needs of the community's young people are addressed and that the Palace Theater is a key partner in fostering the development of an'art'culture among youth.To ensure that these programs are available to youth from all socio-economic levels,two scholarships for each program will be offered. 4.Total Budget& Position Count: Total Program Budget: 45,300 Total Program Position Count: 1 Total Agency Budget: 411,000 Total Agency Position Count: 3 (FT) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 21,300 Palace Theater in-kind donation of space and operating costs 13,000 Participant fees 6,000 volunteer hours 5,000 TOTAL: 45,300 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources: Box office revenue, Cafe revenue,donations, major sponsors,grants, rentals,volunteers, and in-kind donations-all of which will be leveraged to support this program. Lst three years County funding to support programming for youth is a key aspect of the program,as a monetary commitment to the development of an arts culture for youth will underscore its societal importance and will help lay the framework and encourage other donors to support this important project. The Board of Directors annually establishes a Strategic Plan with strategies to build a strong financial foundation through increased revenue from individual donors, increased partnerships with local schools, businesses and community groups, increased audience numbers and increased revenue from grants.The Board of Directors is actively represented at every Palace event, cultivating prospective audience members and supporters. New branding and marketing strategies are already increasing awareness of the Palace Theater. Continuous advertising to target audiences, assessing customer satisfaction, and adding new performance activities annually will round out the cumulative results of fundraising to make this program sustainable into the future. 7. Program Objectives Using County Nonprofit Grant Program Funds: The importance of teaching the arts to young people has been debated at length by educators and youth development professionals. Today,the prevailing wisdom is that an understanding of arts and culture plays an essential role in promoting sustainable social and economic development for future generations. Promoting creativity, collaborative effort, and motivations is therefore a priority to finding solutions to today's challenges. (Culture and Youth Development, United Nations,2014) The youth programs being developed by the Palace theater will not only create new opportunities for a broader engagement of children and their parents, but will serve to test some of these theories and inform programming decisions in the future. Specifically,the programs will provide opportunities for youth to develop and share their gifts and talents in a"hands-on" experiential and exploratory learning environment, and will encourage a sense of pride and self-esteem. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) number of youth participating in the programs 150 number of new patrons(parents, family members,teachers)engaged as audiences 200 new partnerships established within the community 10 percent of positive feedback about the programs from participating audiences 100% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 6,000 6,000 Professional Fees 1,500 3,000 3,000 Operations 800 1,000 Supplies Equipment 800 800 Other: space rental at theater 8,000 12,000 Other: marketing 5,000 10,000 10,000 Other: volunteer hours 4200 5,000 Other: scholarships 500 500 Other: teachers and supplies 11,500 7,000 7,000 TOTAL 37,000 45,300 21,300 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director I The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. (A),/,...veJanuary 28, 2017 Signature of Authod Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPrluPct nnr/mny reciilt in nrtinnc tnken to rernuer theca fllnric, By signing below, you are acknowledging that you have read and understood these requirements. January 28, 2017 Signature of Autktbrized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Friends of the Palace Theater Program Name: S•otli•ht on Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result number of youth participating in programs 150 number of new patrons(parents,family members,teachers)engaged as audiences 200 new partnerships established within the community 10 percent of positive feedback about the programs from participating audiences 100% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 3,000 Operations Supplies Equipment 800 Other: space rental at theater Other: marketing 10,000 Other: volunteer hours Other: scholarships 500 Other: teachers and supplies 7,000 TOTAL 21,300 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Full Life Individualized Career Planning and Employment Services 52 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Plannin• and Em•to ment Services Agency Director: Jim Kilgore Phone No.: (808) 322 — 9333 Contact Person: Jim Kilgore Phone No.: (808) 322 — 9333 Mailing Address: Address: 75-5995 Kuakini Highway, Ste.432 Address: City,ST,Zip Kailua Kona, HI 96740 Facility Address: Address: 120 Keawe Street, Ste. 201 Address: City,ST,Zip Hilo, HI 96720 Email Address: jim@fulllifehawaii.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 Street, Suite 102 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $56,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑✓ Hamakua ❑✓ North Kona Q South Hilo Q North Kohala Q South Kona 0 North Hilo 0 South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑./ Educational concerns n Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑ Victims of Health or Social Crises ❑./ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Planning and Employment Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 8000 15000 10500 2.Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self-determined quality of life. 3. Program Description: Since 2011, Full Life Employment Services Program(ESP)has been successfully assisting persons with developmental and intellectual disabilities find and maintain long-term meaningful customized competitive and self-employment in the community. The proposed Individualized Career Planning and Employment Program features a person-centered approach which includes: career assessment and discovery,career planning, benefits counseling,work exploration and job try-outs,development of foundational and soft-skills,individualized job search assistance,development of partnerships with employers to customize jobs,on the job training and coaching,as well as a popular self-employment service in the arts. With this program, Full Life proposes to expand services in preparing people for customized employment. Full Life's Discovery& Career Planning(DCP)component of the program will diversify employment services by serving a wider range of ages and types of abilities. Through DCP,we will administer specialized career planning services for adults with disabilities and youth in high school with disabilities transitioning to work. In conjunction with the implementation of the new standards of the Medicaid Waiver Employment Services,this dynamic, individualized employment program allows Full Life to collaborate with Department of Developmental Disabilities, Department of Vocational Rehabilitation and Department of Education. Discovery will be completed through a series of interviews and meetings with participants and their circle of supports at their home and job sites in the community. Finally, an individualized Career Plan Report(CPR)will summarize a participant's best abilities and interests for which they have a strong passion. As a guide for the participant,their families, and their advocates, the CPR will be a clarifying tool toward supporting persons with all types of disabilities achieve their goal of competitive integrated employment and/or self-employment. 4. Total Budget& Position Count: Total Program Budget: 286,000 Total Program Position Count: 10 Total Agency Budget: 2,628,553 Total Agency Position Count: 90 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Planning and Empl yment Services 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawai'i Nonprofit Grant-Individualized Career Planning and Employment 56,000 State of Hawai'i Department of Developmental Disabilities 200,000 Art festival(s)donations and table fees 5000 Other Grants 25,000 TOTAL: 283,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: There is an increased emphasis for improving employment opportunities for people with disabilities. Initiatives have been developed at federal,state,and local levels.One of these initiatives is called Employment First,a systems change framework which supports that all people,including individuals with significant disabilities,are capable of participating in integrated employment and enjoying a full life in the community. Because of this emphasis,the State of Hawai'i has proposed employment service reimbursement rate increases and a focus on funding competitive and customized employment for youth and adults with disabilities. Full Life anticipates that the County of Hawai'i Grant Program Funds will support our expansion of Individualized Career Planning and Employment Services and lead to Full Life's ability to access greater funding through our State of Hawaii contracts.Additionally,with this funding Full Life will demonstrate further capability for creative career planning and customized employment services leading to employment outcomes for people served.This will help us build a greater case for additional grant funding and private donations. 7. Program Objectives Using County Nonprofit Grant Program Funds: The National Survey of State IDD Agency Employment Services reports that only 3%of individuals who receive services from the State of Hawai'i Developmental Disabilities Division are working in a competitive job. Those who do work in a competitive job are earning average wages of only $83.40 per week.With the support of the Hawai'i County Nonprofit Grant Program Funds, Full Life hopes to improve these outcomes on the Big Island one person at a time. With County Nonprofit Grant Program Funds Full Life's program objectives include: 1.Implement specialized career planning services for high school students with disabilities transitioning to the workforce. 2. Increase our capacity to serve more people with developmental disabilities to develop a customized career plan leading to competitive integrated employment and/or self-employment. Our goal is to support 15 people to obtain competitive customized employment within 2 years of receiving funds. 3. Become an employment provider able to share a best practice model with other providers for customized career discovery planning and employment. 4. Expand certified work incentive benefit consultation services to people with disabilities who desire to work. This service guides individuals and their families about the impact of work on other benefits essential for their care. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Planning and Em lo ment 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 specific.) Applicant Projected Results Number of career plans developed for people with disabilities 25 People with disabilities earning an income within 1 year as a result of the program 10 High school students with disabilities developing a customized employment transition plan 5 People with disabilities earning an income through self-employment in the arts 15 Number of staff trained to implement customized employment planning and development 10 Number of people with disabilities hired into a competitive customized job by year 2 15 Number of people with disabilities provided certified work incentive benefit consultation 20 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 46,803 Professional Fees 0 Operations 2,666 Supplies 1156 Equipment 220 Other: Mileage Reimbursements 3405 Other: Scholarships for art and craft fair table/vendor fees 1000 Other: Staff training 750 Other: Other: TOTAL 56,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Plannin• and Em•to ment Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: James Kilgore 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 O The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ii -- L c viiLt b rec.. 1/27/2017 el‘ r :nature of Authori d Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Plannin• and Em•to ment Services 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative,or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Plannin. and Em•lo ment Services ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fl/tllrP fiinriing rPrpi ct nod mny result in nrtionc tnkan to rprnvar thPce funds, By signing below, you are acknowledging that you have read and understood these requirements. ..� 1/27/2017 Si,nature of Authori /Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Full Life Program Name: Individualized Career Plannin• and Em•to ment Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of career plans developed for people with disabilities 25 People with disabilities earning an income within 1 year as a result of the program t0 High school students with disabilities developing a customized employment plan 5 People with disabilities earning an income through self-employment in the arts 15 Number of staff trained to implement customized employment planning and development 10 Number of people with disabilities hired into a competitive customized job by year 2 15 Number of people with disabilities provided certified work incentive benefit consultation 20 TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages 46,803 Professional Fees 0 Operations 2,666 Supplies 1156 Equipment 220 Other: Mileage Reimbursements 3405 Other: Scholarships for art and craft fair table/vendor fees 1000 Other: Staff training 750 Other: Other: TOTAL 56,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Going Home Hawaii Hawai'i Island Going Home Consortium 53 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Coin. Home Consortium Agency Director: Irene Nagao, President Phone No.: (808 ) 987 — 8262 Contact Person: Carol Matayoshi, Grant Writer Phone No.: (808 ) 936 —,9328 Mailing Address: Address: 1990 Kinoole Street, Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 1990 Kinoole Street,Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: Fax No.: ( ) — Accountant/CPA: Gail Shioshita,Treasurer Phone No.: (808 ) 938 — 6427 Firm (if applicable): Mailing Address: Address: 1990 Kinoole Street, Suite 102 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: $25,120 Geographical Areas To Be Served: (One or more can be checked) Puna 0 Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona 0 North Hilo 0 South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged E 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: Hawaii Island Going Home Consortium 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 2.Agency Mission Statement: Going Home"is the name given to efforts on Hawaii Island to reintegrate ex-offenders into the community and the workplace. Because this population has such complex needs,we utilize a comprehensive approach that centers on employment and training while addressing other needs such as education, housing,transportation,substance abuse and mental health services. The Hawai'i Island Going Home Consortium(GHC)comprises more than 30 public and private entities and their representa- tives,with a network of over 200 local,state,and national partners. Our mission is to assist Hawai'i Island men,women,and youth released from correctional institutions with reintegration into community life through employment,training,and appropriate supportive services. Accordingly,the overall goal of GHC is to reduce recidivism on Hawai'i Island for our target population of ex-offenders released from jail or prison and returned to Hawai'i Island. Members of the target population—our clients—will be law-abiding and in compliance with the terms of their parole or probation. On November 3,2015,the Hawai'i County Council passed Resolution 268-15,enlisting the County of Hawai'i in Stepping Up,a national initiative to reduce the number of people with mentarlilnesses in jail. GHC's then President and current Executive Chair,Les Estrella, played a key role in getting this resolution passed;Hawaii County is the first in the state to pass this resolution and become a participating county in the Stepping Up Initiative. 3. Program Description: While we have been formally organized since 2004,we trace our initiative back to the late 1990's when the Hawaii Island Corrections Advisory Committee was created to address severe prison overcrowding. Since the Fall of 2004,GHC has met monthly,without fail,for over twelve years to identify issues and challenges,coordinate services,develop new approaches,and promote the need for assisting ex-offenders with their reentry. These meetings are also viewed as.a safe place to share concerns and challenges,as well as to build collaborative relationships with others in the community. Over 30 members actively participate in these meetings,advancing the GHC agenda. Many of our members actively participant on committees,which also meet monthly;these committees include Housing, Educatioand Training,Employer Relations.Criminal Justice Partners, Health and Wellness, Faith-Based Organizations,Community Relations,and the West Hawai'i Coalition. Our membership includes non-profit agencies,criminal justice agencies,mental health and substance abuse treatment providers,educational providers,employment specialists,housing experts,and concerned individuals islandwide. Virtually every agency that works with criminal offenders on Hawai'i Island is a member of or is aligned with GHC. As such,we are ideally situated to address the multiple challenges of the homeless and/or mentally ill inmate who is enmeshed in the State's corrections system. In May of 2015,Going Home received its nonprofit 501(c)(3)designation as Going Home Hawaii(GHH). GHH's role is to procure funds for meetings and trainings that benefit GHC,as well as coordinate and faciitate awareness activities and events. 4.Total Budget&Position Count: Total Program Budget: $25,120.00 Total Program Position Count: 1 Total Agency Budget: $325k(projected) Total Agency Position Count: 7(projected) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-1.8 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Goin• Home Consortium 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawai'i Nonprofit Grant Application $25,120.00 • TOTAL: $25,120.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our hope is that the funding received from this grant will help us to improve GHC's marketing and branding to increase the reach of the organization,thus broadening our funding opportunities. We will continue to seek funding through state and federal grants/contracts,as well as private foundations. GHH also holds an annual dinner and silent auction fundraiser,which has been growing each year. We are currently in the process of planning for our 6th to be held on August 17, 2017. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Faciitate and coordinate monthly GHC meetings, including organizing the general activities and agenda for the meetings, taking notes to document the meetings,and keep members informed of meeting activities and outcomes; 2) Assist with the coordination and facilitation of Committee meetings to keep them on track and moving toward GHC goals; 3) Coordinate and facilitate educational trainings/workshops for GHC members to provide resources and tools for those who work in the field; 4) Coordinate and facilitate awareness events to promote the need for reintegration services; 5) Coordinate and faciitate an anual Employer recognition event to honor those employers who hire ex-offenders. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i • Program Name: Hawai'i Island Coin. Home Consortium 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Facilitate and coordinate monthly Consortium meetings 12 Assist with the coordination and facilitation of Committee meetings 30 Coodinate and facilitate educational trainings/workshops 12 Coordinate and facilitate awareness events 12 Coordinate and facilitate Employer Recognition Lunch 1 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $16,000.00 $16,000.00 Professional Fees $3,400.00 $3,400.00 Operations Supplies $920.00 $920.00 Equipment $1,600.00 $1,600.00 TrainingMaterials Other: $2,500.00 $2,500.00 Other: Mileage @ .535 per mile $700.00 $700.00 Other: Other: Other: TOTAL • $25,120.00 $25,120.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council E Staff appointed by a member of the Council L 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: ❑✓ If no conflicts exist, check here. ��.- -- f :1 January 30, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2018 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 aaency's future fisndinrg rerluect anti may recult in nrtinns taken to reraver these fiindc, 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 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Goin. Home Consortium 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Facilitate and coordinate monthly Consortium meetings 12 • Assist with the coordination and facilitation of Committee meetings 30 Coordinate and facilitate educational trainings/workshops 12 Coordinate and faciliate awareness events 12 Coordinate and facilitate Employer Recognition Lunch 1 TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages $16,000.00 Professional Fees $3,400.00 Operations Supplies $920.00 Equipment $1,600.00 Other: Training Materials $2,500.00 Other: Mileage @ .535 per mile $700.00 Other: Other: Other: TOTAL $25,120.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Going Home Hawaii In-Reach and Reintegration 54 County of Hawai`i Nonprofit Grant Application FY2017-18 • Agency Name: Going Home Hawai'i Program Name: In-Reach and Reintegration Agency Director: Irene Nagao, President Phone No.: (808 ) 987 —8262 Contact Person: Carol Matayoshi, Grant Writer Phone No.: (808 ) 936 — 9328 Mailing Address: Address: 1990 Kinoole Street,Suite 102 Address: City,ST,Zip Hilo, Hawaii 967208 Facility Address: Address: 1990 Kinoole Street,Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: carol.goinghomehawaii@gmail.com Fax No.: ( ) — Accountant/CPA: Gail Shioshita,Treasurer Phone No.: (am ) 938 — 6427 Firm (if applicable): Mailing Address: Address: 1990 Kinoole Street, Suite 102 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: $115,139 Geographical Areas To Be Served: (One or more can be checked) Puna Q Hamakua Q North Kona Ej South Hilo Q North Kohala ❑✓ South Kona Q✓ North Hilo 0✓ South Kohala E✓ 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 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: In-Reach and Reinte•ration 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 N/A N/A $16, 250.00 2.Agency Mission Statement: Our mission is to assist Hawai'i Island men,women,and youth released from correctional institutions with reintegration into community life through employment,training,and appropriate supportive services. • 3. Program Description: In-Reach and Reintegration(IRR)is a pilot project that supports the goals of the National Stepping Up Initiative to reduce the numbers of mentally ill persons in jail. IRR is based on two(2)best practice models for working with homeless and mentally ill offenders. It is designed to reduce the recidivism of homeless and mentally ill offenders and to alleviate overcrowding at the Hawaii Community Correctional Center(HCCC). IRR includes the following evidence-based methods: 1) Pre-booking diversion,which involves developing and maintaining a collaborative effort with the Hawaii Police Department(HPD)to identify and refer low-level offenders to the program instead of arresting and booking them for certain petty offenses;2) Timely jail in-reach,which includes assessing clinical and social needs as well as public safety risks; 3) Re-entry/transition planning,which includes identifying a housing placement and community resources and services;4) Entitlement assistance utiizing the SOAR(SSI/SSDI Outreach,Access,and Recovery)process,a national program designed to facilitate and expedite Supplemental Security Income(SSI)and/or Social Security Disability Insurance(SSDI)applications for individuals who are homeless or at risk for homelessness and have a mental illness and/or a co-occurring substance use disorder or other medical impairments. 5) Coordinating the transition plan to include transportation to the housing placement identified in the plan. Going Home Hawaii(GHH)has an agreement with the Hawaii Sober Living and Recovery Center(HSLRC),a transitional and supportive housing program,to provide bed space and transportation tb court-ordered appointments. GHH will pay for the bed space if program participants are unable to pay until they begin receiving their entitlements or other income;6) Intensive case management to include linkages to supportive services such as mental health and/or substance abuse treatment providers,employment services,and educational activities;7) Volunteer mentors will provide additional support on a community-based level that has been proven to be extremely effective. 4.Total Budget&Position Count: Total Program Budget: $274,733.25 Total Program Position Count: 5 Total Agency Budget: $325k(projected) Total Agency Position Count: 7 (projected) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: In-Reach and Reinte•ration • 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State Grant In Aid Program $159,594.25 County of Hawai'i Nonprofit Grant $115,139.00 TOTAL: $274,733.25 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our hope is that IRR will prove to be a model that the State Department of Public Safety will want to replicate for discharge and re-entry planning. It is widely known that the state has major overcrowding issues at all of its jails and prisons,prompting a recent complaint to the U.S. Department of Justice by the American Civil Liberties Union of Hawaii. IRR will help to alleviate this overcrowding issue while saving the state a great deal of money. According to a June 2e,2016 report by Marisa Yamane of KHON2 News,the state spends about$140 per inmate per day,which includes program services, food, health care,and administrative costs. IRR can house a former offender in the community with support services at the cost of approximately$600 a month or$20 per day. This is a difference of$43,800 a year. This target population is also our chronically homeless people who overutilize our county's emergency services, including HPD and the Hawai'i County Fire Department's Emergency Medical Services(EMS). We expect to alleviate this burden on our county resources as well. GHH will also continue to seek funding through state and federal grants,as well as private foundations. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Meet with HPD and other community stakeholders to obtain"buy in"and determine collaborative efforts; 2) Hire and train case managers(1-East Hawaii, 1-West Hawaii); 3) Purchase a Microsoft Surface Pro 3- 12"-Core i5 for the Case Manager to take"in the field"as it is lightweight and durable with the capabilites of a laptop. The surface pro pen will enable the Case Manager to obtain signatures in the field. 4) Purchase program supplies for program participants, including hygiene and household items as needed. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: In-Reach and Reinte.ration 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Applicant Projected Results Coordinate/facilitate meetings with HPD&other stakeholders for case reviews 12 Enroll&provide intensive case management services for 40 program participants 40(pending funding) Place 80%of participants into transitional or permanent housing 32 Provide substance abuse and mental health assessment for all program participants 40 75%of program participants will report a positive experience with IRR 30 75%of participants will be involved in employment,educational,volunteer or gainful activity 30 Achieve a 25%recidivism rate at the end of the project year 10 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $249,693.25 $110,789.00 Professional Fees Operations $960.00 Supplies $3,600.00 $1,200.00 Equipment $1,500.00 • $750.00 Other: Mileage @ .535 per mile $3,600.00 $2,400.00 Other: Airfare, Inter-Island $400.00 • Other: Liability Insurance $5,000.00 Other: Lease/rental of space $9,480.00 Other: Staff Training $500.00 TOTAL 274,733.25 $115,139.00 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 1 . County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: In-Reach and Reintegration 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): 0 Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. o. . . j2 get, January 30, 2017 Signature of Authorized PersoW(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: In-Reach and Reinte•ration 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application `FY2017-18 Agency Name: Going Home Hawai'i Program Name: In-Reach and Reinte.ration • 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2018 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 firturr funding rPrpuact and mny rpcult in nrtinnc tnkpn to reenvpr thPc funds, By signing below, you are acknowledging that you have read and understood these requirements. 4u4te. Air /0,, ,,, January 30, 2017 Signature of Authorized specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application -FY2017-18 Agency Name: Going Home Hawai'i Program Name: In-Reach and Reinte ration 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Coordinate/facilitate meetings with HPD and other stakeholders for case reviews 12 • Enroll&provide intensive case management services for 40 program participants 40(pending funding) Place 80%of participants into transitional or permanent housing 32 Provide substance abuse and mental health assessments for all program participants ao 75%of program participants will report a positive experience with IRR 30 75%of participants will be involved in employment,educational,volunteer or gainful activity 3° Achieve a 25%recidivism rate at the end of the project year 10 TABLE H: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages $110,789.00 Professional Fees Operations Supplies $1,200.00 Equipment $750.00 Other: Mileage @ .535 per mile $2,400.00 • Other: Airfare, Inter-Island Other: Liability Insurance • Other: Lease/rental of space Other: Staff Training TOTAL $11.5,139.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Going Home Hawaii SOAR (SSI/SSDI, Outreach, Access and Recovery) 55 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawaii Program Name: SOAR (SSI/SSDI, Outreach, Access, and Recovery) Agency Director: Irene Nagao, President Phone No.: (808 ) 987 — 8262 Contact Person: Carol Matayoshi, Grant Writer Phone No.: (808 ) 936 — 9328 Mailing Address: Address: 1990 Kinoole Street,Suite 102 Address: • City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 1990 Kinoole Street, Suite 102 Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: carol.goinghomehawaii@gmail.com Fax No.: ( ) — Accountant/CPA: Gail Shioshita,Treasurer Phone No.: (808 ) 938 — 6427 Firm (if applicable): Mailing Address: Address: 1990 Kinoole Street, Suite 102 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: $53,968 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑✓ North Kona ['South Hilo []✓ North Kohala 0 South Kona Q✓ North Hilo ❑✓ South Kohala D✓ 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 Q✓ Needs of the poor 0✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: SOAR (SSI/SSDI, Outreach, Access, and Recovery 1. Prior Year Award of County Nonprofit Grant Program Funds: • FY 14-15 FY 15-16 FY 16-17 N/A N/A N/A 2.Agency Mission Statement: Our mission is to assist Hawaii Island men,women,and youth released from correctional institutions with reintegration into community life through employment,training,and appropriate supportive services. • 3. Program Description: The criminal justice and behavioral health communities consistently identify lack of timely access to income and other benefits, including health insurance,as among the most significant and persistent barriers to successful community reintegration and recovery for inmates with serious mental illnesses and co-occurring disorders. Without access to entitlements,they lack the funds to pay for essential mental health services and related needs,including housing. Acquiring Supplemental Security Income(SSI)and/or Social Security Disabiity Insurance(SSDI),the Social Security Administration's(SSA)disability programs, and the accompanying Medicare benefit provides the foundation for reentry plans to succeed. However,the SSI/SSDI application process is complicated and difficult to navigate,even for professional social service providers. With SOAR training,mental health and social service providers learn how to prepare comprehensive and accurate SSI/SSDI applications that are more likely to be approved and expedited. On average, providers who receive SOAR training achieve a first-time approval rate of 71%while those who are not SOAR trained achieve an approval rate of 10-15%. The ultimate goal of this one(1)year pilot project is to provide training and support for providers to: 1)develop the means to expedite processing of SSI/SSDI applications for homeless individuals who are justice-involved and may be incarcerated;and 2)improve the qualilty of the information submitted with the application to increase the likelihood of disability benefit award at initial application and to substantially reduce the processing time associated with the application. Although the federal government does not provide direct financial resources to implement this national program(designed to increase access to SSA's disability income benefit programs),training and technical assistance are provided through the SOAR TA Initiative,funded by the Substance Abuse and Mental Health Services Administration (SAMSHA). 4.Total Budget& Position Count: Total Program Budget: $53,968.00 Total Program Position Count: 1 Total Agency Budget: $325k(projected) Total Agency Position Count: 7 (projected) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: SOAR (SSI/SSDI, Outreach, Access, and Recovery) 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawai'i Nonprofit Grant $53,968.00 TOTAL: $53,968.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our hope is that we will be able to train,support,and certify enough social service and mental health providers during this one (1)year pilot project so that there will be no need to continue the project beyond one(1)year. If,at the end of the year,we find that there is still a need for the project,we will seek funding through State departments, including the Department of Health,Adult Mental Health Division and the Department of Public Safety,as well as private foundations. 7. Program Objectives Using County Nonprofit Grant Program Funds: Hire a FTE SOAR Coordinator to achieve the following goals and objectives: Goal One: To establish collaborative relationships and partnerships with individuals and organizations that are involved with SSI and SSDI applications. Objectives: 1)Coordinate and facilitate meetings with community stakeholders, including the local SSA,the Disability Determination Branch(DDB), mental health and social service providers,and Hawaii Community Correctional Center(HCCC) staff. 2)Ensure that SSA and DDB staff understand the challenges that SOAR applicants face and accommodate these applicants. 3)Provide better access to applicants and case managers to increase the number of applications approved and reduce processing time. 4)Identify clear contacts at both the local SSA and DDB for service providers to use as resources. Goal Two: To improve the quality of SSI/SSDI applications for incarcerated individuals to increase The likelihood of disability benefit award at initial application and reduce processing time in order to prevent homelessness upon release. Objectives: 1)Promote and assist with online SOAR trainings for mental health/social service providers and provide support to ensure quality applications. 2)Increase awareness of the need to assist those who are homeless to obtain SSI and/or SSDI. 3) Assist homeless and mentally ill inmates with completing and submitting SSI and/or SSDI applications. Goal Three: Achieve a first-time approval rate of 70%for all SOAR applications completed during the project year. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: SOAR (SSI/SSDI, Outreach, Access, and Recovery) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of contacts with SSA 24 Number of contacts with DDB 24 Number of community meetings coordinated/facilitated 12 Number of trainings/workshops/individual assistance provided 36 Number of individuals trained and certified 40 Number of SSI/SSDI applications submitted 50 Number of initial applications approved 35 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages N/A $47,818.00 $47,818.00 Professional Fees Operations Supplies $1,200.00 $1,200.00 Equipment " $750.00 $750.00 Other: Mileage to cover island-wide travel $4,200.00 $4,200.00 Other: v. Other: Other: Other: TOTAL N/A $53,968.00 $53,968.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: SOAR SSI/SSDI, Outreach, Access, and Recove 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council Staff appointed by a member of the Council C The Mayor ❑ The Managing Director C The Director of Finance C The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. �. lit, 4 O January 30, 2017 Signature of Authorized Pe son (specify title)Pte / Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: SOAR (SSI/SSDI, Outreach, Access, and Recovery) 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Going Home Hawai'i Program Name: SOAR (SSI/SSDI, Outreach, Access, and 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 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fllt:ir flinding rPquPct nnri mny in nrtinnc tnkPn to rPrnver thace finds, By signing below, you are acknowledging that you have read and understood these requirements. January 30, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY201748 Agency Name: Going Home Hawai'i Program Name: SOAR (SSI/SSDI, Outreach, Access, and Recove 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 24 Number of contacts with SSA Number of contacts with DDB 24 Number of community meetings coordinated/facilitated 12 36 Number of trainings/workshops/individual assistance provided 40 Number of individuals trained 50 Number of SSI/SSDI applications submitted 35 Number of initial applications approved TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $47,818.00 Professional Fees Operations Supplies $1,200.00 Equipment $750.00 Other: Mileage to cover island-wide travel $4,200.00 Other: Other: Other: Other: TOTAL $53,968.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Goodwill Industries of Hawaii, Inc. Job Connections 56 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections Agency Director: Laura Smith, President/CEO Phone No.: (808) 836 — 0313 Contact Person: Emily Lau, Senior Director- Mission Services Phone No.: (808) 836 — 0313 Mailing Address: Address: 2610 Kilihau Street Address: City,ST,Zip Honolulu, HI, 96819 Facility Address: Address: 200 Kanoelehua Avenue Address: Suite 102 City,ST,Zip Hilo, HI, 96720 Email Address: ELau@higoodwill.org Fax No.: (808 ) 833 — 4943 Accountant/CPA: Phone No.: (808 ) 524 — 2255 Firm (if applicable): N & K CPAs, Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite 1700 City,ST,Zip Honolulu, Hi, 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna Hamakua ❑❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ✓❑ North Hilo 0 South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns 0 Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged E 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $3,000 $5,000 $8,750 2. Agency Mission Statement: Goodwill Hawaii's mission is to"help people with employment barriers reach their full potential and become self-sufficient."A nationally accredited human services provider, Goodwill Hawaii has served the State as a reputable non-profit organization for over 55 years, providing educational,workforce development,and social services to 11,000 residents annually. 3. Program Description: Goodwill Hawaii's Job Connections Program provides employment services to low-income residents, Native Hawaiians, and re-integrating individuals. Goodwill has a strong relationship with fellow service providers,correctional facilities, and educational institutions such as U.H. Hilo and Hawaii Community College.The strong linkages forged with these organizations have allowed our employment services programs to serve 498 individuals in the past 3 years. We conduct a thorough intake and assessment, provide evidence-based 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. Since 2013,we have helped subsidize tuition/training costs for 166 individuals. 4. Total Budget& Position Count: Total Program Budget: $210,000 Total Program Position Count: 4 Total Agency Budget: $3,150,000 Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Office of Hawaiian Affairs $120,000 Office of Community Services $60,000 County of Hawaii $30,000 TOTAL: $210,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will support an Employment Counselor position in Goodwill's Hawaii County Job Connections program. Goodwill will leverage its existing resources(i.e. facilities, administrative services)and grants that provide employment services and educational support. 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 individuals in East Hawaii.A minimum of 50 individuals will receive services;of these, it is expected 90% (45)will complete the Job Readiness Training class series;of these, it is projected 70%will be placed into employment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific) Applicant Projected Results Intake/Assessment 50 Job Readiness Training 45 Job Placement 32 90-Day Retention 26 180-Day Retention 20 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $90,000 $130,000 $30,000 Professional Fees $1,500 $2,000 Operations $8,600 $15,000 Supplies $12,900 $13,000 Equipment $2,000 $5,000 Other: Tuition Assistance $30,000 $45,000 Other: Other: Other: Other: TOTAL $145,000 $210,000 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council F7 Staff appointed by a member of the Council n The Mayor The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. January 23, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections 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 agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPquPct nnri mny result in nrtinns tnkpn to rPrnver thasp funds. By signing below, you are acknowledging that you have read and understood these requirements. n fAat t,'aa. /t�. t-n7 January 23, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Job Connections 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Intake/Assessment 50 Job Readiness Training as Job Placement 32 90-Day Retention 26 180-Day Retention 20 TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages $30,000 Professional Fees Operations Supplies Equipment Other: Tuition Assistance Other: Other: Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Goodwill Industries of Hawaii, Inc. Work Experience Program 57 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program Agency Director: Laura Smith, President/CEO Phone No.: (808 ) 836 —0313 Contact Person: Felicia Panoncialman, Director of Disability Services Phone No.: (sos ) 836 — 0313 Mailing Address: Address: 2610 Kilihau Street Address: City,ST,Zip Honolulu, HI, 96819 Facility Address: Address: 500 Kalanianaole Ave. Address: Suite 3 City,ST,Zip Hilo, HI, 96720 Email Address: FPanoncialman@higoodwill.org Fax No.: (808 ) 833 — 4943 Accountant/CPA: Phone No.: (808 ) 524 — 2255 Firm (if applicable): N & K CPAs, Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite 1700 City,ST,Zip Honolulu, HI, 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna Hamakua ❑ North Kona ✓❑South Hilo ❑ North Kohala ❑South Kona ✓❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ✓❑ Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $10,000 $15,000 $12,500 2.Agency Mission Statement: Goodwill Hawaii's mission is to"help people with employment barriers reach their full potential and become self-sufficient."A nationally accredited human services provider, Goodwill Hawaii has served the State as a reputable non-profit organization for over 55 years, providing educational,workforce development, and social services to 11,000 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 coupled with the joy and excitement of receiving a paycheck.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 they can grow themselves.The participants learn how to build, maintain,and upkeep a greenhouse nursery. Goodwill's Work Experience Program offers participants choices 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: $345,000 Total Program Position Count: 6 Total Agency Budget: $3,150,000 Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State of Hawaii $300,000 County of Hawaii $45,000 TOTAL: $345,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will be used to broaden the scope and increase the capacity of Goodwill's Work Experience Program, in terms of staffing, supplies, equipment, and materials so that more participants can be served.An increase in program participants will provide increased revenues to assist in financially sustaining this program in the long-term. The Work Experience program is part of Goodwill Hawaii's larger Intellectual/Developmental Disability(ID/DD) 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 ID/DD Program maintains a positive reputation in our community through its various community volunteer involvement and our accessible computer training program. 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 of training to succeed in their employment goals. Three(3)components of the program include: Janitorial Work Training, the Hawaii Design and Art Program Expansion, and the continued development of a Sustainability and Self-Sufficiency Program through gardening and healthy food production. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Applicant Projected Results Janitorial Program-Number of Participants 10 HI Design and Art Program-Number of Participants 10 Sustainability Program-Number of Participants 10 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $200,000 $210,000 $25,000 Professional Fees $3,000 $3,000 $2,000 Operations $44,000 $60,000 Supplies $10,000 $17,000 $1,000 Equipment $5,000 $20,000 $17,000 Other: Specific Assistance to Participants $30,000 $35,000 Other: Other: Other: Other: TOTAL $292,000 $345,000 $45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council ri Staff appointed by a member of the Council [1 The Mayor I I The Managing Director n The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓Q If no conflicts exist, check here. c2zc&ra.- AC1_ January 23, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerquect and mny result in nrtinnc tnken to rernver these funds. By signing below, you are acknowledging that you have read and understood these requirements. (,; ,ei ,� � 1 January 23, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Janitorial Program-Number of Participants 10 HI Design and Art Program- Number of Participants 10 Sustainability Program-Number of Participants io TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $25,000 Professional Fees $2,000 Operations Supplies $1,000 Equipment $17,000 Other: Specific Assistance to Participants Other: Other: Other: Other: TOTAL $45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Grassroots Community Development Group Hawai'i Youth Business Center 58 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center Agency Director: Trina Nahm-Mijo Phone No.: (808) 640 — 5109 Contact Person: same as above Phone No.: (808) 640 — 5109 Mailing Address: Address: PO Box 1772 Address:, City,ST,Zip Keaau, HI 96749 Facility Address: Address: 15-2075 24th St. Address: City,ST,Zip Keaau, HI 96749 Email Address: nahmmijo@hawaii.edu Fax No.: (808 ) 974 — 7757 Accountant/CPA: John Carbonaro Phone No.: (808 ) 968 — 1002 Firm (if applicable): John Carbonaro CPA&Management Group Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑ Hamakua ❑ North Kona ✓❑South Hilo E 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 n Aged ❑Victims of Health or Social Crises ❑ Needs of the poor n Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $5,000 Did not apply 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 years old,from the Puna and Hilo areas.The program provides After-School entrepreneurial,digital media arts,culinary,and workforce training in collaboration with other youth organizations,schoold and non-profits to provide opportunities for skill development and self enrichment. 4.Total Budget& Position Count: Total Program Budget: $17,000 Total Program Position Count: 2 PT Total Agency Budget: $17,000 Total Agency Position Count: 2 PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii $10,000 Donations $2,000 Other Grants $3,000 TOTAL: $15,000 Attach additional pages, if 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 and/or art work products and performances which are youth-driven and which are disseminated to the general public; 3) Collaborate with other organizations serving youth and families on activities which contribute to developing pro-social, healthy communication and lifestyle behaviors, environmental stewardship,community engagement and artistic expression. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 30 youth will receive training and education in environmental stewardship 90%increase skills 20 youth receive training in Culinary 90%increase skills 20 youth receive training in marketing/production/selling 90%increase skills 50 youth participate in digital media and/or performance opportunities 90%increase skills 20+ Families receive food relief Increased sustainability Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 6,000 5,000 Professional Fees 2,000 1,000 Operations 3,000 500 Supplies 3,000 2,000 Equipment 1,500 1,500 Other: Insurance 1,500 Other: Other: Other: Other: TOTAL 17,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 (1 Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director I I The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 171 If no conflicts exist, check here. IWif1 Proms 113, 14-- Signature of Authorize Person (spe ify tit ) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 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 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business 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 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerruPct and mny rPcillt in nrtinnc tnkPn to rPrmier thacP funds, By signing below, you are acknowledging that you have read and understood these requirements. JAA/PtA aikal- 14- Signature of Authoriz d Person ( ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 30 youth will receive training and education in environmental stewardship 90%increase skills 20 youth receive training in Culinary 90%increase skills 20 youth receive training in marketing/production/selling 90%increase skills 50 youth participate in digital media and/or performance opportunities 90%increase skills 20+Families receive food relief Increased sustainability TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 5,000 Professional Fees 1,000 Operations 500 Supplies 2,000 Equipment 1,500 Other: Insurance Other: • Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Green Will Conservancy Inc., The The Green Will Conservancy Inc. 59 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. Agency Director: Frank Capatch Phone No.: (808) 965 — 5349 Contact Person: Sandra Osborne Phone No.: (808) 965 — 5349 Mailing Address: Address: 14-803 Seaview Road Address: P.O. Box 1341 City,ST,Zip Pahoa, Hawaii 96778 Facility Address: Address: 14-803 Seaview Road Address: P.O. Box 1341 City,ST,Zip Pahoa, Hawaii 96778 Email Address: sandraleeosborne@me.com Fax No.: (808 ) 965 — 5036 Accountant/CPA: Nancy Kramer Phone No.: (808 ) 965 — 2729 Firm (if applicable): Mailing Address: Address: 15-2984 Pahoa Village Road Address: P.O. Box 1519 City, ST,Zip Pahoa, Hawaii, 96778 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona n South Hilo ❑✓ North Kohala ❑✓ South Kona ✓❑ North Hilo n South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns n Youth n Victims of Crimes ❑ Culture and the arts n 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 2017 - 2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $5,000 $9,000 $5,500 2. Agency Mission Statement: Our mission statement is to inspire in our youth a fiery determination to persevere, sustain and realize their life's potential. Our vision is to empower our Puna youth,their families and professionals with practical knowledge, life skills and expertise that will support fulfilling and productive lives. Fulfilling the Mission The Green Will Conservancy(GWC)continues to grow, develop and expand our services on the Big Island and beyond in 2017. Our services have progressed locally and globally through our online institute(www.thegreenwill.org) and professional trainings. With continued County support we have been able to proceed with curriculum development and hands-on training for our youth,families, individuals and professionals. Our holistic approach takes our youth from the garden to learning computer skills, leadership and community development. Our professional trainings are designed to bring the best and brightest in our field,to Hawaii with a particular focus on"trauma informed care". Our mental health interventions are evidence based treatments that focus on resiliency not pathology. Friendship House, our Puna facility, welcomes children, families,volunteers, interns and professionals. GWC continues to be a consistent and reliable resource on the Big Island. 3. Program Description: Existing Programs Fully qualified Mental Health Therapists assess youth, families and individuals. Together,the therapist and client(s)collaborate on treatment plans with a focus on overcoming barriers to success. Common challenges such as domestic violence, substance abuse and poor self esteem are addressed confidentially and individually. Youth attend pro-social groups twice weekly to participate in projects, relationship and leadership building.Older youth assist in mentoring the younger children (kids helping kids) under the guidance of skilled therapists. Interested family/community members are welcomed to participate in activities when appropriate. GWC continues to offer stipends to our youth (13-18 yrs) as incentives to gain a sense of accomplishment as well as to motivate them to commit to our programs. As Green Will Mental Health Professionals,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 21st century.We assist our youth to connect with organizations that support education and growth.We are a bridge to other community/state agencies and services that link our youth to our communities. Community outreach and collaboration in 2017-18 includes the Liliuokalani Trust(formerly the Queen Liluokalani Children's Center), Hawaii Island Recovery(residential addiction and treatment facility), Department of Education and Pacific Quest (wilderness therapy for teens and young adults), Child Welfare Services (CWS), YWCA Teen Court and the Victims Assistance Program. We openly encourage and welcome cooperation and collaboration with like minded organizations. Our model of individual and group counseling combined with practical skills development is designed to significantly improve the quality of the lives of the youth and families we serve. 4. Total Budget & Position Count: Total Program Budget: 20,000 Total Program Position Count: 1 Total Agency Budget: 68,000 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Program Service Revenue $10,000 Public Contributions: County of Hawaii Grant $20,000 Atherton Grant $10,000 Public contributions (Training, Cash, Clinical Revenue) $28,000 TOTAL: $68,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Green Will Conservancy Inc. (GWC)continues to offer professional mental health services and programs on a sliding scale as well as billable treatment to health insurance agencies. In addition,we will continue to collaborate with other like-minded community agencies and schools through practical, skills based workshops and professional trainings on resiliency and trauma informed care. We will offer at least two specialized psychotherapy trainings for mental health specialists in 2017, both focused on"trauma informed care and treatment". GWC will also co-host Irene Siegel's upcoming retreat in Puna that examines"a Cross Cultural Perspective where East meets West". In addition to our online forum, mental health therapists are invited to attend weekly peer reviews at no charge. Peer support and supervision are important links for therapists to connect and compare knowledge. GWC will also continue to offer consulting services, both group and individual,to our experienced and newly trained trauma specialists from intensive trainings hosted by Green Will since 2012. As new research is published it is our intention to make as much current information available as possible to our mental health professionals and the general public. In 2017 the Green Will Conservancy(GWC)envisions a critical group of professionals that will be better prepared to serve the community during both traumatic incidents and times of crisis. The fall out from hurricanes, potential lava challenges, and storms are enough to give careful attention to how we manage natural disasters. GWC proposes to develop and present a professional training that will focus specifically on effective ways for"first responders"to approach trauma victims of all descriptions as well as developing a customized protocol for first responders such as police officers(Reprocessing Debrief). 7. Program Objectives Using County Nonprofit Grant Program Funds: The Green Will Conservancy Inc. (GWC) is committed to serving our community and the Big Island at large. With the support of County Grant funds Green Will is committed to expanding our knowledge and resource base through continued professional trainings for mental health therapists and our online institute(thegreenwill.org). The latest psychological research is distilled for our professional and public communities and posted online for easy, 24 hour access. In 2017 GWC will focus on First Responder (police, ambulance,veterans, civil defense, etc.)training to deal with"critical incidents"and specific protocols to address victim needs as well as the impact on the first responder. It is our vision to collaborate with first responder organizations to inform the public and our youth as well as to offer practical, hands-on tools for victims and first responders. County funding will also allow us to offer free workshops on the island to special interest groups such as foster parents,community organizations and youth. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) EMDR Level 2 Training (January 2017) Professional Training x 1 EMDR-Transpersonal Therapy, a Cross Cultural Perspective ... (May 2017) Professional Training x 1 EMDR Level 1 Training (August 2017) Professional Training x 1 Department of Education:Adverse Childhood Experience (ACE) Professional Training x 1 Youth and Family Therapy and Group Skills 200 units Youth Fund Raising $1,000 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wags $32,886.06 0 0 Professional Fees $2,530.04 $1,000 $1,000 Operations $5,649.04 $1,000 $1,000 Supplies - $1,000 $1,000 Equipment $1,180.58 $1,000 $1,000 Other: Broad Range Service Delivery Costs -- $8,000 $8,000 Other: Electronic Medical Records/Billing/Net Corn $365.00 $1,500 $1,500 Other Student Stipends/Honorariums $2,900.00 $3,000 $3,000 Other: Food - $3,500 $3,500 Other: TOTAL $45,510.72 $20,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. 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): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. /(9t2 January 30, 2017 sAij ignature of Aut razed Pefson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv•Rov/fn-nonprofit-grant-forms]on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiitarP fiinding rPgIPct and may rPcult in artianc takan to rprnvPr thPcP funric, By signing below, you are acknowledging that you have read and understood these requirements. /,LL I .1L A S January 30, 2017 Signature of Autiorized erson(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Green Will Conservancy Inc. Program Name: The Green Will Conservancy Inc. 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Professional Training x 1 Professional Training x 1 Professional Training x 1 Professional Training x 1 200 units $1,000 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees $1,000 Operations $1,000 Supplies $1,000 Equipment $1,000 Other: Broad Range Service Delivery Costs $8,000 Other: Electronic Medical Records/Billing/Net Corn $1,500 Other: Student Stipends/Honorariums $3,000 Other: Food $3,500 Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Habitat for Humanity West Hawaii Blitz Build 2017 60 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 Agency Director: Patrick F. Hurney Phone No.: (808) 331 — 8010 Contact Person: Isobel Donovan Phone No.: (808) 938 — 1328 Mailing Address: Address: PO Box 4619 Address: City,ST,Zip Kailua Kona Hawaii, 96745 Facility Address: Address: 73-4161 Ulu Wini Place Address: City,ST,Zip Kailua Kona Hawaii 96740 Email Address: pat@habitatwesthawaii.org Fax No.: (808 ) 331 — 8020 Accountant/CPA: Chad Unrein Phone No.: (808) 331 — 8010 Firm (if applicable): Mailing Address: Address: PO Box 4619 Address: City,ST,Zip Kailua Kona Hawaii, 96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $150,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts n 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 40,000 20,000 41,250 2.Agency Mission Statement: Habitat for Humanity West Hawaii is a non-profit, community-based organization whose mission is: "Seeking to put God's love into action, Habitat for Humanity brings people together to build homes, communities and hope". Habitat West Hawaii is the only provider of affordable housing that addresses the needs of the lower-income population on the Big Island.A Habitat mortgage is designed so that no family is paying more than 30%of their monthly income on housing. Habitat builds homes for families earning between 30%and 80%of the median income on a no-interest, no-profit basis. To ensure that families become sustainable homeowners, and to break the cycle of poverty,the family support component of the Habitat program provides ongoing assistance with budgeting, financial literacy, house repair and maintenance. Since 2002, Habitat West Hawaii has been dedicated to creating a Hawaii where everyone has a safe and affordable place to live by building 32 homes for over 80 deserving residents, many of whom have young children or elderly adults. Additionally, 24 families have been assisted with critical home repairs to alleviate safety, health, and environmental concerns. 3. Program Description: The 2017 Blitz Build project is an extension of our home building program, as well as a celebration of the founding of our affiliate in 2002. From September 13 through September 23, 2017, Habitat West Hawaii, and all of its community partners and volunteers will come together to build ten homes in just ten days in the Kailua-Kona neighborhood of Lai Opua,where lots have been made available through our partnership with the Department of Hawaiian homelands. This Blitz Build is an opportunity to greatly increase our capacity to serve families in the West Hawaii area, and to make an even bigger impact on the need for affordable housing. The Habitat model provides home ownership opportunities to families earning between 30%and 80%of the County AMI on a no-interest, no-profit basis. Habitat homeowners have a low monthly mortgage payment(between$350 and$450)and have money left over for other life necessities, such as health care, transportation and recreational activities. Since 2002, our affiliate has completed 32 new homes, and made critical home repairs to another 24. But the need for affordable housing still exists, and is becoming more critical every year. A Blitz Build is an opportunity for communities and all their partners. For professional home-builders and contractors, it is a way to make a significant contribution to the communities they work in. For local businesses an corporations, it is a way to support growth in the communities they serve. And for individual volunteers, it is a way to build up the neighborhoods that make up the communities they live in. Overall, it is a way to make lasting partnerships that will continue to benefit Habitat West Hawaii and the families it serves. For the County, funding the foundations of these homes signals an understanding of, and commitment to, building a firm foundation for families in need. 4.Total Budget& Position Count: Total Program Budget: 1,584,000 Total Program Position Count: 2 (10 contracted) Total Agency Budget: $1, 712,000 Total Agency Position Count: 15 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Department of Hawaiian Homelands (on cost recovery basis) 1263000 County of Hawaii 150,000 GN Wilcox Foundation 9,000 Hawaii Community Foundation FLEX grant 25,000 Habitat West Hawaii 45,500 Fundraising events 50,000 Corporate/Service Club/Faith Community sponsorships 41,500 TOTAL: 1,584,000 Attach 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 donors, State and Foundation grant awards,and corporate donations. County funding is a key aspect of the program, as a monetary commitment from the County will help lay the framework and provide encouragement for other private and government donors to support this important project. Habitat West Hawaii's Board of Directors has endorsed a 5 year Strategic Plan that is reviewed annually. It is aimed at increasing the affiliate's capacity to provide ever increasing homeownership opportunities, as well as to maximize its potential to support all of its programs through the strategic solicitation of funds, investment in human resources, and acquisition of land.The Habitat model also provides for all mortgages to be put into a revolving"Fund for Humanity",which is then used to build additional homes every year, and which allows each Habitat family to"pay it forward". The affiliate also operates two ReStores,which sell gently used products to the community at greatly reduced prices. The revenue from these two ReStores has been increasing annually, and$30,000 per home is transferred to the homebuilding program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Habitat West Hawaii recognizes the importance of homeownership, and works hard to make it a possibility for as many people as possible. This project will provide safe and affordable housing for 10 low-income families. By funding a portion of the cost of these homes, in effect"laying the foundation", a priority goal of the County Consolidated Plan -improving the lives of 10 local families-will be achieved. Through many different programs, Habitat for Humanity West Hawaii has helped countless families in West Hawaii communities and neighborhoods build themselves a future. Community-based social capital is a key outcome of the homebuilding program of Habitat for Humanity. Homeownership is much more than having a sturdy roof over one's head. It affects a person's health and overall state of well-being. For children especially, having a permanent place where they can do something as simple as their homework, or have their school friends over to play and spend time together, creates a monumental difference in their futures. Typically,students with a stable home are healthier, have higher grades, and increased participation in social activities. Families have a chance to experience stability, build equity wealth,and have something tangible to pass on to their children. Communities are improved, because homeowners tend to be more active, and pay into the tax base. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) number of families responding to outreach 120 number of families served 10 number of individual served 50 volunteer hours donated 96,000 number of corporate sponsorships 5 number of faith community/service club sponsorships 5 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 45,000 Professional Fees 238,000 Operations Supplies 817,000 Equipment 50,000 Other: Foundations(incl. concrete, foundation accessories and labor) 150000 150,000 Other: Site Prep (plans, temp facilities, civil work, grading and excavation) 138,000 Other: site supervisors 70,000 Other: marketing 26,000 Other: hospitality and on site facilities for volunteers 50,000 TOTAL 1,584,000 150,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council n Staff appointed by a member of the Council n The Mayor I The Managing Director n The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. �./ 7. 161,7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future fuming rPquect nnri may recult in nrtinnc taken to rernuer thece funic, By signing below, you are acknowledging that you have read and understood these requirements. ) ` , 2. _ 4 � / 7 Signature of Authorized Person (specify title)----2 itle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Habitat for Humanity West Hawaii Program Name: Blitz Build 2017 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result number of families responding to outreach 120 number of families served 10 number of individuals served 50 number of volunteer hours donated 96,000 number of corporate sponsorships e number of faith community/service club sponsorships e TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Foundations(incl. concrete, foundation accessories and labor) 150,000 Other: Site Prep (plans, temp facilities, civil work, grading and excavation) Other: site supervisors Other: marketing Other: hospitality and on site facilities for volunteers TOTAL 150,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hale Aikane The Kona Paradise Club 61 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club Agency Director: Steven G. Pavao, MA Phone No.: (808) 327 - 9530 Contact Person: Steven G. Pavao, MA Phone No.: (808) 960 - 5070 Mailing Address: Address: 77-6435 Kuakini Highway Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Facility Address: Address: Same Address: City,ST,Zip Email Address: thekonaparadiseclub@gmail.com Fax No.: (808 ) 327 - 9534 Accountant/CPA: Paula Donovan,AIPB Phone No.: (808 ) 929 - 7551 Firm (if applicable): N/A Mailing Address: Address: P.O. Box 6904 Address: City,ST,Zip Ocean View, Hawaii 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: $11,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑ South Hilo ❑ North Kohala ❑✓ South Kona ❑ North Hilo H South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns ❑Youth ❑Victims of Crimes n Culture and the arts Uj Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities H Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 $6,500.00 2. Agency Mission Statement: The Kona Paradise Club,the"Clubhouse"is first and foremost a local community center that offers people who have mental illness hope and opportunities to achieve their full potential. Much more than simply a program or a social service,the Clubhouse is most importantly a community of people who are working together to achieve a common goal. The Clubhouse is organized to support people living with mental illness. During the course of their participation at the Clubhouse, members gain access to opportunities to rejoin the worlds of friendships,family,employment and education,and to the services and support they may individually need to continue their recovery.The Clubhouse provides a restorative environment for people whose lives have been severely disrupted because of their mental illness, and who need the support of others who are in recovery and who believe that mental illness is treatable. 3. Program Description: Clubhouses are a powerful demonstration of the fact that people with mental illness can and do lead normal, productive lives. Clubhouses are local community centers that provide members with opportunities to build long-term relationships that, in turn, support them in obtaining employment,education and housing, including:: •a work-ordered day in which the talents and abilities of members are recognized and utilized within the Clubhouse; • participation in consensus-based decision making regarding all important matters relating to the running of the Clubhouse; •opportunities to obtain paid employment in the local labor market through a Clubhouse-created Transitional Employment Program. In addition,members participate in Clubhouse-supported and independent programs; •assistance in accessing community-based educational resources; •access to crisis intervention services when needed; •evening/weekend social and recreational events; and •assistance in securing and sustaining safe, decent and affordable housing. The Kona Paradise Club is an accredited Clubhouse. Hale Aikane is a 501(c)3 non-profit that is attached to the Clubhouse. 4. Total Budget & Position Count: Total Program Budget: $15,000.00 Total Program Position Count: 5 Total Agency Budget: $520,203.60 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Christmas in July(Silent Auction) $1500 Kalua Pig/Haupia sales $2200 Christmas Campaign $300 TOTAL: $4,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our agency is in the process of recruiting community leaders to join our advisory board. This board will as a part of its duties assist Hale Aikane in generating a fund development plan with borh long ans short term goals. We are currently working on enhancing our existing fundraising efforts and have set increased goals for all of the activities for 2017. 7. Program Objectives Using County Nonprofit Grant Program Funds: • The Kona Paradise Club is an accredited Clubhouse and therefore must meet the standards of Clubhouse International to retain its accreditation. One of the standards is that Clubhouse staff must be trained at a certified Clubhouse International Training base. The Kona Paradise Club has two staff members that have not been trained. The County Nonprofit Grant funds requested would cover the cost of the training as well as the cost of travel to the training base in South Carolina. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Two staff and one member will attend Clubhouse International Training. Meet Accreditation Standards Staff and member will be create an action plan at training Implement action plan at Clubhouse Clubhouse will be re-accredited for three years Continue as an accredited Clubhouse Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees 350 350 Operations Supplies 18,500 Equipment Other: Salaries and wages are paid for by auspice agency(see attached) Other: Operations are paid by auspice agency(see attached) Other: Clubhouse International Training 14,400 15,000 11,000 Other: Other: TOTAL 11,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): [1 Member or members of the Council ❑ Staff appointed by a member of the Council (i The Mayor [l The Managing Director ❑ The Director of Finance IT The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. 31 -- ( Signature of Au orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club 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 June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these fiends. By signing below, you are acknowledging that you have read and understood these requirements. 0—,rt.-4-Q ,- ! — 31 Signature cf A thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hale Aikane Program Name: The Kona Paradise Club 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Two staff and one member will attend Clubhouse International Training. Meet Accreditation Standards Staff and member will be create an action plan at training Implement action plan at Clubhouse Clubhouse will be re-accredited for three years Continue as an accredited Club TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Salaries and wages are paid for by auspice agency(see attached) Other: Operations are paid by auspice agency(see attached) Other: Clubhouse International Training 11,000 Other: Other: TOTAL 11,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hamakua Youth Foundation Hamakua Youth Center 62 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center Agency Director: t. Mahealani Maiku'i Phone No.: (808) 775 - 0976 Contact Person: t. Mahealani Maiku'i Phone No.: (808) 775 - 0976 Mailing Address: Address: POB 381 Address: City,ST,Zip Honokaa, HI 96727 Facility Address: Address: 45-3396 Mamane St Address: City,ST,Zip Honokaa, HI 96727 Email Address: hamakuayouthcenter@gmail.com Fax No.: ( ) — Accountant/CPA: Bonnie Bibeault Phone No.: (808 ) 930 - 6850 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala [' South Kona n North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) dQ 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 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $32,500 $15,000 $9,500 2. Agency Mission Statement: The Hamakua Youth Center(HYC)was started as a grassroots project in 1996 by a group of community members who saw the need for youth to have a safe place to be during non-school hours. For 13 years,the YWCA sponsored and partially supported the HYC. The Hamakua Youth Foundation, Inc. (HYF),a community grassroots 501(c)3 organization,that took over management of the Center on July 1,2009 consisted of a core staff together with a growing group of community volunteers. Since its conception, HYF has been dedicated to creating a free and nurturing youth service program for ages 7-18 during non-school hours. We engage youth in environmental sustainability and stewardship, provide Hawaiian culture and arts education,developing youth leadership skills,offer academic tutoring, mentoring, and connecting youth and their families with social service agencies. The Center offers programs daily after-school,during intersessions,occasional weekends and summer breaks to school age youth in Honokaa. HYC continually strives to encourage life skills guided by traditional Hawaiian values-aloha, kokua, malama &mahalo. HYC is the only facility in the Hamakua District that focuses primarily on programs for elementary through high school youth. After-school alternatives for youth are limited and our youth are at risk for unhealthy behaviors based on the family economic and dynamics in our community. Our basic objectives are to 1)expand the scope of our cultural programs to acquaint youth with the multi-cultural nature of the Hamakua District,2)provide both traditional and contemporary agricultural opportunities,3)offer a wider range of creative training in the arts,4)initiate a comprehensive internship program for older youth to connect them with local business, professional and agricultural opportunities,and 5)establish a permanent teen center in Honoka'a. 3. Program Description: HYF is currently in process of purchasing a permanent facility for the HYC. The new facility, located right across the Honokaa High, Intermediate and Elementary school,will triple our facility space to include a 1,500 sq ft youth center for elementary students,a separate 1,500 sq ft teen age students and an additional 500 sq ft kitchen facility to serve after-school snacks for both the youth and teen center. The new facility includes 3/4 acre for the student center so we will have an outdoor area where the youth can play without worrying about being too close to the road. The separate facilities will allow us to expand our service to include teens by having a student lounge, media room, music studio and a meeting area. The youth center includes a homework area, game room and an arts&crafts room. We plan to make the kitchen a certified kitchen for our use and offer it to community groups for fundraising events because there are no community use kitchens available now. Since 2015, HYC has been collaborating with a new local"farm to table"non-profit organization, Hamakua Harvest Incorporated(HHI). The partnership will allow local youth to understand the deep connection that Hawaiian people have to the elements. They will plant,grow, market and sell agriculture products at HHI's farmers'market. This ongoing organizational partnership will help our youth to connect to the'aina and learn the importance of sustainability and culturally related activities that shape the community of Hamakua. More recently, HYC has been collaborating with the Honoka'a Hongwanji Buddhist Temple in initiating a Hamakua multicultural program for youth. Each of the six major cultures represented in the Honoka'a area (Japanese, Filipino, Portuguese, Hawaiian/Polynesian,and American/European)will be given a focus for about eight weeks through experiential activities such as preparation of food and contemporary music. 4.Total Budget& Position Count: Total Program Budget: $334,000 Total Program Position Count: 21 Total Agency Budget: $334,000 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii Community Foundation $ 20,000 County of Hawaii - Non Profit $ 60,000 State of Hawaii - Office of Youth Services $ 80,000 State of Hawaii - Grant-in-aid Capital funding $ 140,000 USDA, Rural Development grant $ 50,000 USDA, Rural Development loan -capital fund $ 595,000 Other grants/fundraising -building renovations&operations $ 210,000 TOTAL: $1,155,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: To provide sustainability, Hamakua Youth Foundation, Inc. promotes three fund-raising events each year(including our annual Hula Festival),all of which emphasize expanding our group of long-term benefactors. While the Hula Festival is primarily a cultural event, it raises both funds and community awareness of HYF's programs. HYF strives to build community partnerships that seek joint funding and will continue to collaborate with other community organizations throughout Hawaii to ensure our keiki learn the value of utilizing the many Hawaiian (&other cultural)specialists,community artists,and kupuna that our island has to offer. We have strengthened our grant writing team so that we can increase our capabilities to apply and receive foundation, state and federal government support. To fund the new facility,we are going through a USDA loan process that requires us to complete a new business plan, update our strategic plan,and use the small business development center to conduct a feasibility study. We also are applying for a USDA capital grant of$50,000 to help with the considerable number of needed renovations. Once this is accomplished we will move into the 1938 building which will provide additional streams of revenue, including renting out an apartment that is part of the facility and having a certified kitchen to rent, as well as use for our own fundraising efforts. The process to finance the permanent HYF facility sets us up to qualify for federal funds that we have not applied for in the past. The new business plan will help us identify additional funding sources and establish a better pledge management. We also plan to solicit larger funders via social media and expand our marketing by increasing community awareness. Programs like Kickstarter and Go Fund Me will help with the capital funds program for the new facility renovation. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. To complete renovations of our new facility. We are requesting county assistance to complete the required new wiring, plumbing and interior renovations that will exceed$150,000 over the purchase price. 2. To create a new facility that will house a separate teen center,an expanded youth center, a certified kitchen and a safe play yard for students. 3. To continually promote an environment of Aloha, Kokua, Malama,&Mahalo. 4. To strengthen life/leadership skills of our youth to ensure they make healthy choices. 5. To provide expanded, interesting,compelling and relevant program to our youth and teens. 6. To have our youth build self awareness with respect to the multi-culture environment of Hamakua and strengthen their self-identity by knowing how they fit within our community. 7 To explore the many cultures of Hamakua including Hawaiian, Filipino,Japanese, Korean, Portuguese,American/European, Chinese, Latino, Micronesian/Marshallese, and Samoan/Tongan. 8. To incorporate Blue Zone philosophy to encourage involvement that leads to healthier, happier&longer lives. 9. To provide a locally based internship program for teens desiring work experience and preparation for education beyond high school 10. To increase our existing programs,organization&partners through improved fundraising,fiscal management& transparency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Youth involved in inter-generational events while learning cultural differences 90 youth involved in training Youth center increases reach into community events and participants 40 new youth involved in HYC Strengthen youth programs provided by Hamakua Youth Center New program provided for Hamakua youth 6 workshops to examine music,food&history of 6 different cultures of Hamakua workshops involve center youths in cultures 18 volunteers working to produce 6 multi-cultural workshops for youth center participants 18 new community volunteers involved Expand operations to new facilities that will more than double our capacity increase from 30 to 60 daily users Open teen center than will complement and enhance our current youth operations add 15 daily teen aged users Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $65,327 $92,000 $16,000 Professional Fees 6,370 14,000 5,000 Operations 28,282 40,000 11,000 Supplies 5,733 9,000 4,000 Equipment 0 6,000 0 Other: Transportation/travel 1,128 6,000 1,000 Other; Food/Beverage 2,261 5,000 2,000 Other: Employee Benefits/payroll management 7,960 10,000 1,000 Other: Other programs 2,007 2,000 0 Other: Building renovation 0 150,000 20,000 TOTAL $119,069 $334,000 $60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 El 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. IA e-4-« �/r7(t7 Sig ture of A orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 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 2017-2018 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of 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.govgn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rpqupct and may recult in artinnc taken to rPrnvpr thpcp filmic, By signing below, you are acknowledging that you have read and understood these requirements. —� /7 7/lSiga6441-K re of A orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Youth involved in inter-generational events while learning cultural differences 90 youth involved in training 40 new youth involved in HYC New program provided for Ham workshops involve center youths in cultures 18 new community volunteers involved increase from 30 to 60 daily users add 15 daily teen aged users TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $16,000 Professional Fees 5,000 Operations 11,000 Supplies 4,000 Equipment 0 Other: Transportation/travel 1,000 Other: Food/Beverage 2,000 Other: Employee Benefits/payroll management 1,000 Other: Other programs 0 Other: Building renovation 20,000 TOTAL $60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii County Economic Opportunity Council Drop Out Prevention Program 63 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM Agency Director: Jay Kimura Phone No.: (808) 961 — 2681 Contact Person: Courtney Hamakawa Phone No.: (808) 961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: chamakawa@hceoc.net Fax No.: (808 ) 935 — 9213 Accountant/CPA: Mary Namauu, Fiscal Officer Phone No.: (808 ) 961 — 2681 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: Geographical Areas To Be Served: (One or more can be checked) E✓ Puna (] Hamakua Li North Kona ❑South Hilo [ North Kohala 0 South Kona Q North Hilo ❑South Kohala []✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns 1:1 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $58,500 $20,000 $30,000 2.Agency Mission Statement: Hawaii County Economic Opportunity Council's(HCEOC)mission is to prevent, alleviate,and eliminate poverty in the County of Hawaii. 3. Program Description: The Drop Out Prevention Program's aim and purpose is to help at-risk and low-income school and court referred high schools students attending Hilo, Pahoa, Kau,and Konawaena high schools 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 helping them graduate from high school. 4. Total Budget& Position Count: Total Program Budget: $188,954 Total Program Position Count: 10 Total Agency Budget: $2,900,000 Total Agency Position Count: 63 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate STATE OF HAWAII GRANTS-IN-AID $188,954 TOTAL: $188,954 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 grant-in-aid monies,seek federal monies as well as form 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 referred senior clients graduate. 75%of the referred student clients will attend 85%of school days. 75%of the referred student clients will not have suspensions exceeding three consecutive days. 75%of the referred underclassmen students grades 9-11 will be promoted to the next grade level. 70%of the clients will make a 10% increase in GPA or attain a 2.0 GPA. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 26 clients enrolled and 50 referrals assisted at each school by 5/30/18 100%by 5/30/18 95%of senior clients will graduate 95%by 5/30/18 75%of clients in grades 9-11 will be promoted 75%by 5/30/18 75%of all clients will attend 85%of school days 75%+by 5/30/18 75%of all clients will have no suspensions exceeding three consecutive days 75%+by 5/30/18 70%of all clients will improve 10%in GPA or attain a 2.0 GPA 70%BY 5/30/18 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $168,611 $168,611 ProfessiortaLFeps $900 $900 Operations $5,793 $5,793 Supplies $4,500 $4,500 Equipment $0 $0 Other: MILEAGE $7,650 $7,650 Other: FIELD TRIPS $1,500 $1,500 Other: Other: Other: TOTAL $188,954 $188,954 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): • Member or members of the Council Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. 7 Si gnatur of uthorized Person (specify title) ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's fiiturr funding rPgIIPct and mny rpcult in nrtinnc tnkan to rprnvpr thing,fiindc. By signing below,you are acknowledging that you have read and understood these requirements. I., ( 1 Rk Signatu of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: DROP OUT PREVENTION PROGRAM 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 26 clients enrolled and 50 referrals assisted 100%by 5/30/18 95%of senior clients will graduate 95%by 5/30/18 75%of clients grades 9-11 will be promoted 75%by 5/30/18 75%of all clients will attend 85%of school days 75%+by 5130/18 75%of all clients will have no suspensions exceeding three consecutive days 75%+by 5/30/18 70%of all clients will improve 10%in GPA or attain a 2.0 GPA 70%BY 5/30/18 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $168,611 Professional Fees $900 Operations $5,793 Supplies $4,500 Equipment $0 Other: MILEAGE $7,650 Other: FIELD TRIPS $1,500 Other: Other: Other: TOTAL $188,954 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii County Economic Opportunity Council Language Arts Multicultural Program 64 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL PROGRAM Agency Director: Jay Kimura Phone No.: (808) 961 — 2681 Contact Person: Courtney Hamakawa Phone No.: (808). 961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: chamakawa@hceoc.net Fax No.: (808 ) 935 — 9213 Accountant/CPA: Mary Namauu, Fiscal Officer Phone No.: (808 ) 961 — 2681 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: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna E Hamakua n North Kona ✓ South Hilo E North Kohala r7 South Kona North Hilo (l South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ❑✓ Youth n Victims of Crimes ✓❑Culture and the arts ❑ Aged Victims of Health or Social Crises ✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL PROGRAM 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $0 $21,250 2.Agency Mission Statement: Hawaii County Economic Opportunity Council's(HCEOC)mission is to prevent, alleviate, and eliminate poverty in the County of Hawaii. 3. Program Description: The Language Arts Multicultural Program is designed to help school-referred underachieving and low-income third and fourth grade students in select public schools based on a combination of reading and math test scores, percentage of students receiving free lunch, and percentage of English as second language learners to receive both in-school and after school assistance to help them improve in reading,writing, academics, social skills, and multicultural knowledge with the ultimate goal of creating well-rounded life long independent learners and thinkers 4. Total Budget & Position Count: Total Program Budget: $340,085 Total Program Position Count: 14 Total Agency Budget: $2,900,000 Total Agency Position Count: 63 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL PROGRAM 5. Program Funding Sources(identify all sources of funding applied to this program): • FY17-18 Revenue Source Estimate STATE GRANTS-IN-AID $200,000. TOTAL: $200,000 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 grant-in-aid monies, seek federal monies,and seek funding and potential partnerships with the state Department of Education. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives are the following: READING COMPREHENSION IMPROVEMENT: 70%of the participants will improve from"Well Below"to"Approaches"or "Met"as measured by the Hawaii Common Core reading assessment administered by the schools. This objective shall be met by the end of the school year. WRITING IMPROVEMENT: 80%will score a 4.5 out of 7 or make a 1.0 improvement between the pre and post Stanford Achievement Test(Writing) SPEAKING AND LISTENING IMPROVEMENT: 70%will score a 4.5 out of 7 or make a 1.0 improvement between the pre and post Keaukaha Oral Language Test(KOLT) MULTICULTURAL KNOWLEDGE AND ATTITUDE ASSESSMENT: 80%will score 80%or make a 10% improvement between the pre and post teacher-made socialization improvement assessment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL PROGRAM 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 26 STUDENTS ENROLLED AT EACH SITE 80%will have 20+students by 9/30/17 70%will improve from'Well Below'to"Approaches"or"Met"in HCC reading assessment 70%+by 5/30/17 80%will score 4.5 out of 7 or improve 1.0 between pre and post SAT Writing Test 80%+by 5/30/17 70%will score 4.5 out of 7 or improve 1.0 between pre and post KOLT Speaking/Listening 70%+by 5/30/17 80%will score 80%or improve by 10%on teacher-made multicultural assessment 80%+by 5/30/17 90%will improve by 10%between pre and post teacher-made socialization assessment 90%+by 5/30/17 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 $297,919 $297,919 Professional Fees 0 $1,350 $1,350 Operations 0 $12,216 $12,216 Supplies 0 $5,000 $5,000 Equipment 0 $0 $0 Other: Mileage 0 $1,000 $1,000 Other: Airfare 0 $500 $500 Other: Vehicle Gas and Oil 0 $12,600 $12,600 Other: Vehicle Maintenance and License 0 $4,500 $4,500 Other: Vehicle Insurance and Registration 0 $5,000 $5,000 TOTAL 0 $340,085 $340,085 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL 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. 77/ 3//117 Signature .1 uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL PROGRAM 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements.as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL PROGRAM ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's filturp funding rpr,rrpct and mny rpcult in nrtinnc tnkpn to rprnvpr thpcp filnr/c, By signing below,you are acknowledging that you have read and understood these requirements. /011/ 7.-• CP/f------- V/ VI 7 Signature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: LANGUAGE ARTS MULTICULTURAL PROGRAM 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 26 CLIENTS ENROLLED AT EACH SITE 80%will have 20+students by 9/30/17 70%will improve from"Well Below"to"Approaches"or"Met"in HCC Reading assessment 70%+by 5/30/17 • 80%will score 4.5 out of 7 or improve 1.0 between pre and post SAT Writing Test 80%+by 5/30/17 • 70%will score 4.5 out of 7 or improve 1.0 between pre and post KOLT/Speaking/Listening 70%+by 5/30/17 80%will score 80%or improve by 10%on teacher-made multicultural/attitude assessment 80%+by 5130/17 90%will improve by 10%between pre and post teacher made socialization assessment 90%+by 5/30/17 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $297,919 Professional Fees $1,350 Operations $12,216 Supplies $5,000 Equipment $0 Other: Mileage $1,000 Other: Airfare $500 Other: Vehicle Gas and Oil $12,600 Other: Vehicle Maintenance and License $4,500 Other: Vehicle Insurance and Registration $5,000 TOTAL $340,085 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawai'i County Economic Opportunity Council Transportation Program 65 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program Agency Director: Jay Kimura Phone No.: (808 ) 961 — 2681 Contact Person: John Saplan Phone No.: (808 ) 961 — 2681 Mailing Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 47 Rainbow Drive Address: City,ST,Zip Hilo, Hawaii 9672) Email Address: hceocdirector@hceoc.net Fax No.: (808 ) 961 — 2812 Accountant/CPA: Mary Namauu, Fiscal Officer Phone No.: (808 ) 961 — 2681 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: Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua H North Kona n South Hilo (:7] North Kohala H South Kona F21 North Hilo n South Kohala n Kai) Services or Activities To Be Provided: (One or more can be checked) 11/1 Educational concerns Youth 1✓I Victims of Crimes f Culture and the arts ✓ Aged 111 Victims of Health or Social Crises ✓ Needs of the poor n Physical/Emotional Disabilities ✓ Public Health and Welfare of the People and the Environment EXHIBi NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $58,000 $38,000 $56, 875 2. Agency Mission Statement: The mission of HCEOC is to prevent, alleviate and eliminate poverty in the County of Hawaii. To this end,the transportation program is to provide mobility to seniors, disabled, eloerly,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 doctor's offices, hospitals,government offices,financial institutions,and senior centers.This helps to improve independence and quality of life as many are unable to drive themselves nor can they afford the cost of a taxi or private transportation. The disabled people in the community benefit by having transportation equipped with wheel chair lifts to accomodate their disabilities. Working poor benefit by receiving transportation to and from work especially those without any vehicles of their own or without the ability to drive. The youth in the community benefit by having transportation home from after school programs as the cost of transportation and busy work schedules often serve as a barrier for many youth to participate in positive after school programs or activities. 4. Total Budget & Position Count: Total Program Budget: $834,260 Total Program Position Count: 25 Total Agency Budget: $2,900,000 Total Agency Position Count: 63 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Community Services Block Grant $77,660 County of Hawaii Mass Transit $592,000 County of Hawaii Office of Aging $159,600 Logisticare $5,000 TOTAL: $834,260 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$77,660 of annual Community Services Block Grant funding from the State Department of Labor, Office of Community Services to HCEOC Transportation Program staff salaries and fringe benefits. HCEOC will also seek$592,000 of operational funding from County of Hawaiii Mass Transit, and$159,600 from County of Office of Aging for daily transportation of clients to County Nutrition centers for congregate dining. Based upon recent experiences over the past four years,we expect Logisticare to generate at least$100,000.00. Logisticare reimburses HCEOC for providing medical transportation service for elderly and disbabled clients 7. Program Objectives Using County Nonprofit Grant Program Funds: ELDERLY-a minimum of 350 elderly will be provided transportation to medical and other professional services,consumer, and recreational sites, adult care and/or nutritional sites for an estimated total of 65,000 trips DISABLED- a minimum of 60 disabled persons will be provided transportation to rehabilitative and independent centers for an estimated total of 15,000 trips. WORKING POOR-a minimum of 30 employed low-income persons will be transported to and from work for an estimated total of 4, 500 trips. YOUTH-a minimum of 65 youths will be provided transportation home from after school programs for an estimated 10,500 trips. Passenger trips= Discrete segment of travel from passenger boarding to disembarking. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 350 ELDERLY transported/65,000 trips 350 elderly transported for 65,000 trips 60 DISABLED transported/15,000 trips 60 disabled transported for 15,000 trips 30 WORKING POOR transported/4,560 trips _ 30 working poor transported for 4,000 trips 65 YOUTH transported/10,500 trips 65 youths transported for 10,500 trips Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees _Operations Supplies Equipment $530,000 Other: Other: Other. Other: Other: TOTAL $530,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below • need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council 1 The Mayor ri The Managing Director The Director of Finance 1 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: !✓I If no conflicts exist, check here. i� j o u D, -r '12O l 7 Signature .f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai`i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-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, 2018 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerluecLanrl may recult in artinnc taken to rernver these funrlc. By signing below, you are acknowledging that you have read and understood these requirements. J � Otiw l o/i 7 Signa re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii County Economic Opportunity Council Program Name: Transportation Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 350 elderly transported for 350 ELDERLY transported/65,000 trips 65,000 trips 60 DISABLED transported/15,000 trips 60 disabled transported for 1 s,000 taps 30 WORKING POOR transported/4,500 trips 30 WP transported/4.500 trips 65 youths transport,rd for 65 YOUTHS transported/10/500 trips 10,530 trips TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment $530,000 Other: Other: Other: Other: Other: TOTAL $530,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawai'i Institute of Pacific Agriculture Ha Ike Pono Youth Education in North Kohala 66 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala Agency Director: Dashiell Kuhr Phone No.: (808) 889 — 6316 Contact Person: Lauren Ruotolo Phone No.: (808) 333 — 8664 Mailing Address: Address: PO Box 497 Address: City,ST,Zip Kapaau, HI, 96755 Facility Address: Address: 53-378 Pratt Rd Address: City,ST,Zip Kapaau, HI,96755 Email Address: hipagriculture@gmail.com Fax No.: ( ) — Accountant/CPA: Erika Kuhr Phone No.: (808 ) 889 — 6316 Firm (if applicable): Mailing Address: Address: PO Box 497 Address: City,ST,Zip Kapaau, HI, 96755 YOU ARE RESPONSIBLE TO KEEP THE 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: The Hawaii Institute of Pacific Agriculture(HIP Ag) is a farm and educational center located in rural, historic North Kohala, on the northern tip of Big Island of Hawaii. Our mission is to practice and teach ecologically conscious agriculture, empowering individuals and communities to cultivate alternative systems of living that restore human and environmental health. 3. Program Description: The Hawaii Institute of Pacific Agriculture(HIP Ag) requests support of$30,000 for our youth education program. Our main campus is a 7-acre living and learning environment in North Kohala, where we cultivate a diverse collection of native Hawaiian and Polynesian plants,tropical fruit orchards and perennial vegetable crops, in addition to raising small scale poultry and livestock.This working farm is the base of operations for our educational programs, and provides a steady supply of food and medicine to those living on the land as well as our local farmers'market. Our youth education program, Ha'Ike Pono: Pathways to Conscious Agriculture, is an initiative that provides interactive, hands- on, place based learning opportunities for students, grades K-12,to explore the land where we live,the food that we eat, and the impact that our choices and actions have on our community, our environment and ourselves. Ha'Ike Pono features in- school presentations, farm field trips, overnight campouts, internships and farmer trainings. Working with students as they travel through the educational system, HIP Ag engages students to help prepare them for college, careers and community involvement.Our students learn about sustainability, agriculture, economics,global awareness, environmental stewardship, health and nutrition and civic engagement. As part of their learning experience, HIP Ag is committed to engaging our students and their families. We do this by providing each student in our program with a food voucher from the farm to be used at the local farmers'market, where HIP Ag provides fresh produce to the community. This food voucher has a value of$5.00 per student.The voucher encourages participation and increases the access to healthy foods not only to the youth of the community but their families as well, reaching a significant portion of our North Kohala residents. With full participation, we will provide$4,320 of fresh food free of charge to our local community.With an average of two parents per household we can reach an additional 1,728 people. North Kohala,the area we serve, has a population of 6,000 residents.These programs have the potential to reach 2,592 residents, roughly 43%of the population. 4.Total Budget & Position Count: Total Program Budget: $86,110 Total Program Position Count: 6 Total Agency Budget: $128,361 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Kohala'Aina Festival $15,000 O'io Grant(applied 1/17- not yet rewarded) $10,000 Private Donors $5,000 21st Century $3,000 TOTAL: $33,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIP Ag has a strategic plan to increase its revenue capacity through:a)increase of individual donors, b) increase grant and foundation gifts, c)increase fundraising capacity and d)outreach to private schools to secure fee for service contracts. Increase individual donors: HIP Ag will increase donor base expansion through targeted appeals to existing and new potential donor groups as part of an effort to develop a much more robust annual fund and major gift program. Prior to this year, we did not have a fundraising and communication plan in place to consistently engage with our current donors. Constant contact over the year will allow us to increase awareness and in turn support for our programs. We will also target new individuals who support education,our community and our work. Increase grant and foundation gifts:We will increase grant and foundation support by focusing on a broader pool of foundation prospects that support K-12 education, environmental work and increasing ask amounts to current funders. Increase fundraising capacity:This year we have hired a development consultant to help with fundraising strategy and planning, to work in tandem with our communications manager.The addition of both a dedicated fundraising consultant and a communications manager throughout this year will help increase our capacity to reach donors. Outreach to private schools to create new contracts:HIP Ag aims to partner with area private schools to obtain fee for service contracts for our work in the schools.This will be a project that our executive director in conjunction with heads of school will have the opportunity to bring our classroom workshops, attend farm field trips and campouts for their students. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIP Ag is preparing our children using a community minded approach to meet the critical need to train the next generation of farmers, consumers and environmental stewards. It will take a community wide effort to make real changes that benefit our youth, their health, environment and future.At the heart of HIP Ag is a commitment to personal health to empower individuals to be activated leaders for change. Through the empowerment of our island's youth, we are working to create the next generation of farmers,teachers, and community leaders in health and environmental sustainability. We measure the success of our programs through an end of program survey that we administer to both teachers and students. We also track statistics of student engagement, log of program activities and learning objectives. HIP Ag's continued commitment to community and education creates a tangible connection to our land, its farmers and benefits of healthy eating. Our education programs raise students'awareness of where foods come from, and increase preferences for fruits and vegetables, learning about the importance of eating all the colors and identifying healthy choices. Students learn about many aspects of growing their own produce, including how fruits, vegetables, and nuts grow from seed to a plant. During farm field trips, we have local fruit and vegetable snacks such as coconuts, bananas, greens,cucumbers for our students to sample and enjoy. HIP Ag is already partnered with the Department of Education in the schools of North Kohala, involved with the after- school garden program through the 21st Century program.The schools are currently in process of implementing the"Fresh Fruit and Vegetable" Program and our program will assist the overall goals of this federal program. Currently our education programs are partially funded by the 21 Century federal grant which covers the cost of students to attend after school programming. But part of our Ha Ike Pono programs take place during the school day and the staffing, supplies and transportation are not covered through our educational partners.Again, we ask for your support of$30,000 to benefit our children, the North Kohala community and impact the future of Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Workshops N. Kohala K-5(Volunteer) 400 Students/15 hours N. Kohala K-12 Students Served(Volunteer) 864 students Farmer Trainees 24 Farmer Trainee Graduates Immersion Course Trainees 24 Immersion Course Graduates Food Voucher Program 2,592 Residents/$4,320 in vouchers In-School Presentations(Volunteer) 39 classrooms x 1 hr=39 teaching hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $30,868 $57,575 $13,310 Professional Fees $7,789 $4,484 $2,242 Operations $13,425 $10,140 $5,070 Supplies $3,243 $9,066 $4,533 Equipment $0 $525 $525 Other: Food Vouchers $0 $4,320 $4,320 Other: Other: Other: Other: TOTAL $55,325 $86,110 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala 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 agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 fl/tiirF funding rp(iupct and may recult in nrtinnc taken to rernVar theca fundc, By signing below, you are acknowledging that you have read and understood these requirements. Q7,ta,4_1, 01/23/17 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: Ha Ike Pono Youth Education in North Kohala 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Workshops in North Kohala K-5(Volunteer) 400Students/16hours North Kohala K-12 Students Served(Volunteer) 864 students Farmer Trainees through our Bi-Annual Internship Program 24 Farmer Trainee Graduates Immersion Course Trainees 24 sionCourse Gradduateuates 2592 Food Voucher Program vouchers in 39 classrooms x 1 hr=39 In-School Presentations(Volunteer) teaching hours TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $13,310 Professional Fees $2,242 Operations $5,070 Supplies $4,533 Equipment $525 Other: Food Vouchers $4,320 Other: Other: Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii Island Adult Care, Inc. Adult Day Care 67 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers Agency Director: Paula Uusitalo Phone No.: (808) 961 — 3747 Contact Person: Paula Uusitalo Phone No.: (808) 961 — 3747 Mailing Address: Address: 34 Rainbow Drive Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 34 Rainbow Drive Address: City,ST,Zip Hilo, HI 96720 Email Address: Puusitalo@hawaiiislandadultcare.org Fax No.: (808 ) 961 — 3740 Accountant/CPA: Ann Fukuhara CPA,CGMA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: PO Box 6691 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua n North Kona ❑✓ South Hilo ❑✓ North Kohala ❑South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $30,000.00 $20,000.00 $13,750.00 2.Agency Mission Statement: To provide quality, community-based care for elders and challenged adults and support for their families on the Island of Hawaii. 3. Program Description: Our Adult Day Care Centers in Hilo and Honomu provide two safe, socially-active daytime programs for aging elders and challenged adults.These programs provide a structured daily schedule six days a week which includes movement and exercise, activities for mental and artistic stimulation,games,socialization, meals,snacks,excursions, celebrations and fun. The goals are to keep kupuna living at home for as long as possible,to allow them to have dignity and independence,deter premature institutionalization,and additionally,and to provide support for families/caregivers to be able to continue their employment/careers and/or have much needed time off from caregiving, to be able to recharge to continue caring for their loved ones. Hawaii Island Adult Care, Inc. received CARF International accreditation in 2014 through March 2017.With this recognition, CARF officially recognizes Hawaii Island Adult Care as an adult day services provider meeting high standards for quality of service and continuous improvement. Recertification process begins February 2017. 4.Total Budget& Position Count: Total Program Budget: $1,781,250 Total Program Position Count: 35 Total Agency Budget: $1,801,425 Total Agency Position Count: 35 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Tuition& Fees $1,070,550 State/Federal (Medicaid) 380,000 County of Hawaii 30,000 Templeton Hopper Fund 70,000 Hawaii Island United Way 16,500 Other Tuition Assistance Grants 44,500 Other(see Attachment A) 169,700 TOTAL: $1,781,250 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 low income elders and challenged adults who require daytime supervision and socialization. They are above Medicaid income levels and do not qualify for Medicaid-paid services, yet are unable to pay full costs of tuition for care that they need. To increase revenues,we increase our rates on daily tuition,transportation and other fees to keep up with increasing costs of labor, health care, food, and other program needs.We also work closely with the Office of Aging to identify additional financial and resource supports for participants and their families. Many times families are not aware of the Medicaid requirements or that Medicaid does pay for adult day care if qualified. We also write to several other grant sources to fill this tuition assistance need, because this low income"gap group"need is about 50%of the population at large and our participants as well. The best scenario would be if Medicare broadened its eligibility requirements and began paying for low-income adults who require daytime supervision and socialization.The alternative to adult day care is long-term care institutionalization,which is very costly for the Medicare/Medicaid programs, is generally medically unnecessary.The cost of long term care compared to adult day care is$10,000 per person per month to$1,000 per person, per month. Reality is,that often, an elder is home alone all day, has a fall,ends up in the hospital and then into long term care,with Medicaid picking up the bill after savings have been depleted. It would be excellent for low-income elders if Medicaid would pay for the adult day services they need. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of this grant request is to provide tuition assistance for adult day care for low income elders and challenged adults who are also financially ineligible for Medicaid due to income/asset levels and cannot afford to pay full costs to be able to attend adult day care. These individuals need to attend, either because of their doctor'orders or family concerns about socialization and the lack of safety being at home alone all day long. Tuition assistance funding helps close the gap and allows all our Kupuna and challenged adults to attend adult day care regardless of ability to pay. Most of of our kupuna are between 80 and 100 years old. This tuition assistance program is offered on a cost-share basis, Each participant's tuition assistance application is reviewed for income,expenses and savings to determine eligibility and to define their monthly cost-share portion. The income is verified against the USDA application that each participant is required to complete and submit annually. Expenses are reviewed for accuracy. If they have large savings or assets more than their own home,they are not eligible. If they are eligible for Medicaid to assist them,they are directed to the state office and to Office of Aging. The funds are used to assist as many participants as possible, if they are eligible. Each tuition assisted applicant will pay some cost share based on their income and expenses. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (Le.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Applicant Projected Results Number of Participants able to attend daycare 20-40 Total#Units(months)of funding assistance 100-150 Number of Elders who maintained/improved their self-care 20-40 Number of Elders who alleviated depression 20-40 Number of Families who received respite 20-40 Number of Families/Caregivers able to continue employment 18-30 Number of Elders who are able to remain living at home 20*40 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 1,202,282 1,225,000 Professional Fees 10,428 11,000 Operations 223,853 225,250 Supplies 100,949 102,000 Equipment 54,905 57,000 Other: Tuition Assistance for adult day care 145,505 161,000 30,000 Other: Other: Other: Other: TOTAL 1,737,921 1,781,250 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council I 1 Staff appointed by a member of the Council 7 The Mayor ❑ The Managing Director n The Director of Finance 7 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. Date � Signature of Authorized Person (specify title) D EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requect and may recult in at-tit-mg taken to rerrwer thece 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 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of Participants able to attend daycare 20-40 Total#Units(months)of funding assistance 100-150 Number of Elders who maintained/improved their self-care 20-40 Number of Elders who alleviated depression 20-40 Number of Families who received respite 20-40 Number of Families/Caregivers able to continue employment 18-30 Number of Elders who are able to remain living at home 20'40 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Tuition Assistance for adult day care 30,000 Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii Island Adult Care, Inc. For Page 3,#5 - Program Funding Sources, Attachment A County of Hawaii Human Services Grant - Fiscal Year 2017-18 Additional Program Funding Sources FY2017-18 Estimate USDA Lunch Reimbursement $ 90,000 Donations 6,850 Memorial Donations 3,000 Fundraising 45,000 PIN Management Fees 4,200 Other Grants 20,000 Interest 450 Other 200 $ 169,700 Hawaii Island HIV/AIDS Foundation Sexually Transmitted Disease Education & Testing 68 co f County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing Agency Director: Bruce Merrell Phone No.: (808) 331 - 8177 Contact Person: Teri Hollowell Phone No.: (808 ) 331 - 8177 Mailing Address: Address: Palani Court Address: 74-5620 Palani Road Suite 101 City,ST,Zip Kailua Kona, Hawaii 96740 Facility Address: Address: as above Address: City,ST,Zip Email Address: bmerrell@hihaf.org Fax No.: (808 ) 331 - 0762 Accountant/CPA: Carbonaro CPA and Associates Phone No.: (808 ) 930 - 6850 Firm (if applicable): Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) Puna I—I Hamakua ❑✓ North Kona I South Hilo ❑✓ North Kohala ❑✓ South Kona fI North Hilo I✓I South Kohala 17] Ka`u Services or Activities To Be Provided: (One or more can be checked) 7 Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑ Culture and the arts [I Aged ❑✓ Victims of Health or Social Crises n Needs of the poor Physical/Emotional Disabilities 7 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $10,000 $5,200 2. Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation is a nonprofit organization dedicated to assisting those affected by HIV/AIDS to maximize their quality of life and to ending the spread of HIV. We also utilize the lessons learned in the HIV epidemic to care and advocate for others in the fight against related diseases. 3. Program Description: HIHAF continues to work on the front lines testing for HIV, Hepatitis C, Syphilis,and educating the at-risk population in Big Island high schools , colleges, and Health Fairs across the island about screening and prevention.As you are aware, there are great challenges to being seen by a health care professional and treated quickly for STD testing at community health centers or Department of Health, especially if you are a resident in West Hawaii. HIHAF's program will help address the need to be at an equivalent level across the island. Now that our offices have certified phlebotomists-we are able to do the confirmatory testing for Hepatitis, HIV and Syphilis, so that the lab referral for blood draws are unnecessary. Once the confirmatory test is done,we can refer for linkage to medical care and medicine. Now with increased awareness about Hepatitis C and the medication to be cured of this dangerous virus, HIHAF can do the multilevel testing and case management. Through county funding for this program,we will also begin implementation for testing for Gonorrhea and Chlamydia with the support and training from Department of Health's Department of Harm Reduction Services Branch.We will also use county funding to continue important STD Education through social media websites, high schools and colleges, public forums and community meetings across the Big Island. Hawaii Department of Health 2015 Summary of reported cases of notifiable disease in the State of Hawaii: AIDS 35 people Hepatitis C 16,000 people Syphylis 163 people Gonorrhea 1,252 people Chlamydia 7,109 people 4. Total Budget& Position Count: Total Program Budget: 25,000 Total Program Position Count: 6 Total Agency Budget: 825,863 Total Agency Position Count: 16 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Department of Health Prevention Grant $10,000.00 Council Contingency Funds $6,200.00 Visitor Industry Charity Walk $4,000.00 TOTAL: $19,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to find and write grants even when we receive much needed funding.We have been working with CMS and exploring avenues to open up direct billing with Medicare and insurance agencies to provide HIHAF with program sustainability. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our program objectives are to provide early diagnosis for Sexually Transmitted Diseases,so that public health doesn't have to foot the bill for expensive treatment later on. We must continue to educate the public about prevention and transmission-as well as the severe health consequences of not getting tested and subsequent treatment. CDC estimates that nearly 20 million new sexually transmitted infections occur every year in this country-half among young people aged 15-24. Our mission is to educate our youth"where they are at"-whether it be social media, radio, print or the classroom.We will do what it takes to educate,test treat and refer all people on the Big Island that need our services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Training for staff for STD lab collection and case management 6 staff members trained Syphilis tests offered to all people testing for HIV and Hepatitis C 100 syphilis tests conducted Website updates and facebook posts done frequently to promote STD education minimum 1 web update and 2 posts per month STD education meetings/events for public 4 meetings/events STD education events for high school students 6 events STD education events for college students 4 events Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $4,188 $15,000 $15,000 Professional Fees Operations $2,500 $2,500 Supplies $392 $3,500 $3,500 Equipment Other: Staff Mileage $75 $1,000 $1,000 Other: Advertisement $545 $2,000 $2,000 Other: Training $1,000 $1,000 Other: Other: TOTAL $5,200 25,000.00 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. °1 ' r t...- 31 )--e /7 Signature of Authorized Person (specify title) 47:); Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rpqupct nnrl mny racult in nrtinns tnken to rarnver theca funrIc. By signing below, you are acknowledging that you have read and understood these requirements. )4,_ 31 xc>t? Signature of Authorized Person (specify title) -1), ec Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education & Testing 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 6 staff members trained 100 syphilis tests conducted minimum 1 web update and 2 F 4 meetings/events 6 events 4 events TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $15,000 Professional Fees Operations $2,500 Supplies $3,500 Equipment Other: Staff Mileage $1,000 Other: Advertisement $2,000 Other: Training $1,000 Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawai'i Island HIV/AIDS Foundation SISTA and BRADDA programs 69 v County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs Agency Director: Bruce Merrell Phone No.: (808) 982 — 8800 Contact Person: Bruce Merrell Phone No.: ( ) — Mailing Address: Address: 16-204 Melekahiwa PI #1 Address: City,ST,Zip Kea'au, HI 96749 Facility Address: Address: as above Address: City,ST,Zip Email Address: bmerrell@hihaf.org Fax No.: (808 ) 982 — 8802 Accountant/CPA: Carbonaro CPA and Associates Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓ Puna ❑✓ Hamakua ❑ North Kona n South Hilo n North Kohala n South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) WI Educational concerns ❑✓ Youth I I Victims of Crimes n Culture and the arts n Aged 171 Victims of Health or Social Crises ✓ Needs of the poor n Physical/Emotional Disabilities ✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $10,000 $6,625 2. Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation is a nonprofit organization dedicated to assisting those affected by HIV/AIDS to maximize their quality of life and to ending the spread of HIV.We also utilize the lessons learned in the HIV epidemic to care and advocate for others in the fight against related diseases. 3. Program Description: Integral components of HIHAF's comprehensive HIV/Hep C Prevention Program are the highly successful SISTA(Sisters Informing Sisters on the Topic of AIDS)women's program and BRADDA(Braddas Reinforcing Awareness Dealing with Diseases like AIDS)men's program. These exceptionally well received, highly successful and culturally-sensitive programs were specifically designed for young Asian/Pacific women and men and utilizing previous County Nonprofit Grant funding, both have been further developed, updated and modernized to more appropriately address the concerns and issues facing today's Big Island young men and women. These two Programs fulfill a need for realistic disease prevention information for young men and women on the Big Island, which has a history of early onset, unsafe sexual activity. Schools do not have the resources to provide the in-depth information required to arm youth with the tools necessary to make behavior changes,to practice safe sex and prevent the spread of HIV, Hepatitis C and other STD's. In addition,these programs meet the needs of young men and women who become at risk because of the changing family, personal or community situations. Changing young people's attitudes about health promotion requires presenting the complete picture as it relates to healthy lifestyles, including sexual activity.These programs provide a strong life-long foundation of knowledge and skills that promote a healthy lifestyle resulting in reduce disease transmission within our community. In addition,the programs assist and educate young men and women in preventing and/or coping when faced with health crises, housing loss, family crises, etc. HIHAF propose to redouble our efforts in providing these invaluable programs to the community. Further, HIHAF will continue our on-going collaborations with a wide variety of community groups and organizations to support their members and create a healthier, more vigorous community. 4. Total Budget& Position Count: Total Program Budget: $25,000 Total Program Position Count: 4 Total Agency Budget: $825,863 Total Agency Position Count: 16 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii Women's Legal Foundation $5000.00 Elizabeth Tayler AIDS Foundation $5000.00 Hawaii Island United Way $3000.00 TOTAL: $13,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: To obtain and increase revenue to support and sustain these vital SISTA and BRADDA programs, HIHAF will continue to seek and apply for grants from private corporate sponsor and federal, state and local government agencies such as Hawaii Island United Way and the State Department of Health,to help underwrite these critical programs focusing on the prevention of HIV and hepatitis C in the young adults within our community. as an example, recently, HIHAF has been successful in obtaining a small Elizabeth Taylor AIDS Foundation/Macy's Passport Fund Grant for Prevention Programs and a Hawaii Women's Legal Foundation Grant to fund a multi-generational Ohana SISTA Program. Even though CDC states that"...even though abstinence from risky behaviors is considered the most effective way to avoid HIV infection,that adolescents and young adults need accurate, age-appropriate information about HIV and AIDS including, how to reduce or eliminate risk factors, how to talk with a potential partner about risk factors and how to negotiate safer sex,where to get tested for HIV, and how to use a condom correctly",both CDC and the Department of Health and Human Services have deemphasized group intervention and education as viable HIV Risk Reduction methodologies, focusing on funding of specific intervention programs within high risk target groups, i.e. MSMs. Given recent political events in the US, such intervention and risk reduction/sex education modalities will continue to struggle with limited funding opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Continue to operate a HIV/STI prevention program in the County of Hawaii focusing on high risk young men and women utilizing the SISTA and BRADDA Programs. 2. Further develop and promote a Facebook Internet presence for SISTA and BRADDA as a social media vehicle to expend the reach of HIHAF's SISTA and BRADDA HIV Prevention Program. 3. Continue to evaluate the SISTA and BRADDA program success within the community. 4. Share and distribute SISTA and BRADDA materials to County organizations who deal with high risk, vulnerable youth. 5. Continue to modify the SISTA and BRADDA programs as needed to address the rapidly changing social and risk issues that continue to confront the young adults on the Big Island community. 6. Continue to provide forum for information, peer training, advocacy, and mentor-ship within the high risk young adults of the Big Island community through use of social media. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1. Conduct the SISTA Program in at least 10 groups of young women(5-7/group). Conduct 10 SISTA Programs in the County. 2. Conduct the revised BRADD Program in at least 10 groups. (5-7/group). Conduct 10 BRADDA Programs in the County. 3. Maintain an internet Face book page for SISTA and BRADDA. At least 50 page INTERNET hits/month. 4. Collect and maintain a file of evaluations from Program participants. At least 30 evaluations collected and evaluate Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $5,078 $15,000 $15,000 Professional Fees Operations $254 $2,500 $2,500 Supplies $352 $3,500 $3,500 Equipment $1,000 $1,000 Other: Staff Mileage $354 $1,000 $1,000 Other: Advertisement $587 $2,000 $2,000 Other: Other: Other: TOTAL $6,625 $25,000 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council n The Mayor ❑ The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Ti If no conflicts exist, check here. L'U < t / 3 / Signature of Authorized Person (specify title) � Q-c� Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's flltllrP funding reryuPct and may recult in nrtinns taken to rPrnupr thPSP funds.. By signing below, you are acknowledging that you have read and understood these requirements. 1/-311/ 7 Signature of Authorized Person (specify title) `d ec_f` Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: SISTA and BRADDA programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Conduct 10 SISTA Programs in the County Conduct 10 BRADDA Programs in the County At least 50 page INTERNET hit At least 30 evaluations collected and evaluate TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $15,000 Professional Fees Operations $2,500 Supplies $3,500 Equipment $1,000 Other: Staff Mileage $1,000 Other: Advertisement $2,000 Other: Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawai'i Island Home for Recovery, Inc. HIHR Food Pantry 70 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Food Pantry Agency Director: Rita Sandi Palma Phone No.: (808) 640 — 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 — 7852 Mailing Address: Address: 440 Kapiolani St. Address: City,ST,Zip Hilo, HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 — 7894 Accountant/CPA: Alex J. Smith Phone No.: (808 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ✓❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑Youth ✓❑Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ✓Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017- 2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Food Pantry 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 N/A N/A N/A 2. Agency Mission Statement: HIHR Mission is to Serve the Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical, health and other disabilities, prioritizing the Chronically Homeless. HIHR programs help focus homeless population to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing, improving their life's and general skills, increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System(VI-SPDAT)and the Housing First Model Approached wish are the new trends in Homelessness care,that are strongly advocated and enforced by the Federal and State Agencies upon to those providers that targeted to assist homeless throughout Hawaii County and the State of Hawaii. 3. Program Description: Hawaii Island Home for Recovery Inc. (HIHR)has been providing Homeless Shelter Services since 2002,adding a Food Pantry Service will increase the well-being of all residents in an independent healthier living residency facility at HIHR that serves the Single Adult Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical, health and other disabilities,prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking, which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers, including primarily mental illnesses,substance abuse disorders,dual diagnosis, physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals. HIHR asses and creates Individualized Service Plans including case management,job training,job placement,substance abuse/mental health treatment,healthcare, living skills,financial training, education, housing resources,entitlements,parenting,domestic violence services, recreational activities, holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility and with optional link to additional services and resources coordinate with multiple local community service providers,and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our chronically homeless population in the Big Island. HIHR provides an independent healthier living residency facility, a caring living environment that helps restores individuals to a sounder more balance mind, body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget& Position Count: Total Program Budget: 2,000.00 Total Program Position Count: 1 Total Agency Budget: 521,246.00 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Food Pantry 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate HIHR Outreach 2,000.00 • TOTAL: 2,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential and or possible sources of additional grants,funds and general resources available via like the Federal, State,County, Institutional,public and or Private Entities. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will work to achieve the overall program goals,as stated above in the Mission Statement and Program Description. Promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourage the restoring of adult individuals to a sound and unblemished mind, body and spirit.These program goals would greatly increase their success when complemented with the additional benefits of a Food Pantry Service at our facility of our residents. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR 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 clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide Hot serve meals to Programs Residents 100% Provide bag meals to Programs Residents 100% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 2,000.00 1,000.00 Professional Fees Operations 1,000.00 Supplies 8,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 2,000.00 10,000.00 *If applicable EXHIBIT A NflNPRfFIT GRANT APPI ICATICIN FY X117-2(11 R Paaa 4 of R County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Food Pantry 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. EXECUTIVE DIRECTOR �� '7 01 /31 /2017 Signature of Authorized Person specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Food Pantry 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Food Pantry ii. 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in artinnc taken to recover theca flinr/c, By signing below, you are acknowledging that you have read and understood these requirements. .d EXECUTIVE DIRECTOR a144... 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Food Pantr 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide Hot serve meals to Programs Residents 100% Provide bag meals to Programs Residents 100% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 1,000.00 Professional Fees Operations 1,000.00 Supplies 8,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Supportive Housing Program #1 71 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su•portive Housing Program #1 Agency Director: Rita Sandi Palma Phone No.: (808) 640 — 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 — 7852 Mailing Address: Address: 440 Kapiolani St. Address: City,ST,Zip Hilo, HI. 96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 — 7894 Accountant/CPA: Alex J. Smith Phone No.: (808 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $49,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna Hamakua ❑✓ North Kona ['South Hilo ✓❑ North Kohala ❑✓ South Kona ✓❑ North Hilo ✓❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑Youth ❑✓ Victims of Crimes [' Culture and the arts ❑✓ Aged ✓❑Victims of Health or Social Crises ✓❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #1 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 10,000.00 5,000.00 14,500.00 2.Agency Mission Statement: HIHR Programs to Serves the Single Adult Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals.The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing, improving their life's and general skills,increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Permanent Supportive Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached wish are the new trends in Homelessness care,that's strongly advocated and enforced by the Federal and State Agencies upon to those providers that targeted to assist homeless throughout Hawaii County and the state of Hawaii. 3. Program Description: Hawaii Island Home for Recovery Inc. (HIHR)has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,and Permanent Supportive Housing Services since 2011, in an independent healthier living residency facility that serves the Single Adult Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical, health and other disabilities,prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers, including primarily mental illnesses,substance abuse disorders,dual diagnosis,physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals. HIHR asses and creates Individualized Service Plans including case management,job training,job placement,substance abuse/mental health treatment,healthcare, living skills,financial training,education, housing resources,entitlements,parenting,domestic violence services, recreational activities, holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment, services at HIHR main facility and with optional link to additional services and resources coordinate with multiple local community service providers,and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our chronically homeless population in the Big Island. HIHR provides an independent healthier living residency facility for chronically homeless,a caring living environment that helps restores individuals to a sounder more balance mind, body and spirit,to live independently becoming contributing members to their communities. 4. Total Budget& Position Count: Total Program Budget: 180,925.00 Total Program Position Count: 3 Total Agency Budget: 521,246.00 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #1 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State Of Hawaii Grant 124,111.00 Program Fees 50,014.00 Hawaii Island United Way 4,800.00 Other Funds 2,000.00 TOTAL: 180,925.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential and or possible sources of additional grants,funds and general resources available via like the Federal, State,County, Institutional,public and or Private Entities.As is reflected by the history,development and expansion of our agency programs into Permanent Supportive Housing which was made possible in part with Federal Grants via HUD and its program initiative Continuum of Care(CoC),administrated by DHS of the State of Hawaii. HUD-CoC funding was afforded for the period Nov 2011-Oct 2015, and lately for the current fiscal period of Nov 2015-Oct 2020 with an annual contract renewal agreement. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will work to achieve the overall program goals,as stated above in the Mission Statement and Program Description. Promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourage the restoring of adult individuals to a sound and unblemished mind, body and spirit. After the participant is assessed,the Case Manager will coordinate HIHR and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager will promote participation in a variety of programs that improve housing stability. HIHR Case Manager/Care Coordinator will maintain bi-weekly meetings to process and follow up activities with residents.They will also conduct team meetings with providers including Probation Officers,mental health, substance abuse and medical Case Managers as part of the support system to follow up with the goals and objectives of the Individualized Service Plan to enhance the well-being of all the program residents. By experience,the chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment. HIHR will make referrals to the job development agencies as well as General Assistance, Social Security benefits,or other mainstream services to increase income. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Sup•ortive Housin. Pro.ram #1 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90% At Exit to Obtain/Maintain Permanent Housing. 80% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 63,732.00 61,232.00 30,000.00 Professional Fees 11,000.00 14,600.00 Operations 78,664.00 82,164.00 10,000.00 Supplies 27,984.00 22,929.00 9,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 181,380.00 180,925.00 49,000.00 *If applicable EXHIBIT A NfNPR(1FIT GRANT APPI IC'ATIC)N FY 9n17-1n1R Papa A of R County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #1 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. EXECUTIVE DIRECTOR d 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housin• Pros ram #1 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su. gortive Housing Program #1 ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.Rov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiitiirP funding rPrgiuect nnol mny rPcnit in nrtinnc tnken to rProvPr theca funrlc. By signing below, you are acknowledging that you have read and understood these requirements. EXECUTIVE DIRECTOR v/L., 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Pro•ram #1 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90% At Exit to Obtain/Maintain Permanent Housing. 80% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 30,000.00 Professional Fees Operations 10,000.00 Supplies 9,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 49,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawai'i Island Home for Recovery, Inc. HIHR Supportive Housing Program #2 72 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #2 Agency Director: Rita Sandi Palma Phone No.: (808) 640 — 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 — 7852 Mailing Address: Address: 440 Kapiolani St. Address: City,ST,Zip Hilo, HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 — 7894 Accountant/CPA: Alex J. Smith Phone No.: (808 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) ✓Q Puna n Hamakua 0 North Kona ✓0 South Hilo Q✓ North Kohala n South Kona ✓Q North Hilo n South Kohala Q✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth 0 Victims of Crimes ❑Culture and the arts Q Aged ❑Victims of Health or Social Crises n Needs of the poor ✓Q Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #2 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 N/A N/A N/A 2. Agency Mission Statement: HIHR Programs to Serves the Single Adult Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical, health and other disabilities, prioritizing the Chronically Homeless Individuals.The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing, improving their life's and general skills,increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Permanent Supportive Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached wish are the new trends in Homelessness care,that's strongly advocated and enforced by the Federal and State Agencies upon to those providers that targeted to assist homeless throughout Hawaii County and the state of Hawaii. 3. Program Description: Hawaii Island Home for Recovery Inc. (HIHR)has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,and Permanent Supportive Housing Services since 2011, in an independent healthier living residency facility that serves the Single Adult Homeless population with mental illnesses, substance abuse disorders,dual diagnosis and with physical, health and other disabilities,prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers, including primarily mental illnesses,substance abuse disorders,dual diagnosis,physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency.HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals. HIHR asses and creates Individualized Service Plans including case management,job training,job placement,substance abuse/mental health treatment, healthcare, living skills,financial training,education,housing resources,entitlements, parenting,domestic violence services, recreational activities, holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility and with optional link to additional services and resources coordinate with multiple local community service providers,and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our chronically homeless population in the Big Island. HIHR provides an independent healthier living residency facility for chronically homeless,a caring living environment that helps restores individuals to a sounder more balance mind, body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget& Position Count: Total Program Budget: 46,140.00 Total Program Position Count: 1 Total Agency Budget: 521,246.00 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su• .ortive Housin• Pro.ram #2 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State Of Hawaii Grant 37,040.00 Program Fees 9,100.00 TOTAL: 46,140.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential and or possible sources of additional grants,funds and general resources available via like the Federal,State,County, Institutional,public and or Private Entities.As is reflected by the history,development and expansion of our agency programs into Permanent Supportive Housing which was made possible in part with Federal Grants via HUD and its program initiative Continuum of Care(CoC),administrated by DHS of the State of Hawaii. HUD-CoC funding was afforded for the current fiscal period of Nov 2015-Oct 2020 with an annual contract renewal agreement. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will work to achieve the overall program goals,as stated above in the Mission Statement and Program Description. Promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourage the restoring of adult individuals to a sound and unblemished mind,body and spirit. After the participant is assessed,the Case Manager will coordinate HIHR and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager will promote participation in a variety of programs that improve housing stability. HIHR Case Manager/Care Coordinator will maintain bi-weekly meetings to process and follow up activities with residents.They will also conduct team meetings with providers including Probation Officers, mental health, substance abuse and medical Case Managers as part of the support system to follow up with the goals and objectives of the Individualized Service Plan to enhance the well-being of all the program residents. By experience,the chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment. HIHR will make referrals to the job development agencies as well as General Assistance, Social Security benefits,or other mainstream services to increase income. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su. •ortive Housin. Prof ram #2 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90% At Exit to Obtain/Maintain Permanent Housing. 80% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 16,508.00 16,508.00 8,000.00 Professional Fees 2,900.00 2,900.00 Operations 21,188.00 21,188.00 3,000.00 Supplies 5,544.00 5,544.00 1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 46,140.00 46,140.00 12,000.00 *If applicable EXHIBIT A NONPROFIT( RANT APPI !CATION FY ?f117-7f11R Paap d of R County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su. •ortive Housin. Pro.ram #2 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council n The Mayor n The Managing Director The Director of Finance • The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. EXECUTIVE DIRECTOR //� 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su• •ortive Housin. Prof ram #2 ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su• •ortive Housin. Pros ram #2 ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 rerluact and may racult in nrtinnc tnkan to rarnvar theta funds. By signing below, you are acknowledging that you have read and understood these requirements. EXECUTIVE DIRECTOR7/I 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su• •ortive Housin• Pro.ram #2 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90% At Exit to Obtain/Maintain Permanent Housing. aor TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 8,000.00 Professional Fees Operations 3,000.00 Supplies 1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 12,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Supportive Housing Program #3 73 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #3 Agency Director: Rita Sandi Palma Phone No.: (808) 640 — 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 — 7852 Mailing Address: Address: 440 Kapiolani St. Address: City,ST,Zip Hilo, HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111 @yahoo.com Fax No.: (808 ) 935 — 7894 Accountant/CPA: Alex J.Smith Phone No.: (808 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna Q✓ Hamakua ✓Q North Kona ✓0 South Hilo 0 North Kohala South Kona ✓0 North Hilo 2 South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓0 Educational concerns ❑Youth ✓❑Victims of Crimes Culture and the arts ✓Q Aged 0 Victims of Health or Social Crises ✓Q Needs of the poor 171 Physical/Emotional Disabilities ✓Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #3 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 N/A N/A N/A 2.Agency Mission Statement: HIHR Programs to Serves the Single Adult Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical, health and other disabilities,prioritizing the Chronically Homeless Individuals.The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing, improving their life's and general skills, increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Permanent Supportive Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached wish are the new trends in Homelessness care,that's strongly advocated and enforced by the Federal and State Agencies upon to those providers that targeted to assist homeless throughout Hawaii County and the state of Hawaii. 3. Program Description: Hawaii Island Home for Recovery Inc. (HIHR)has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,and Permanent Supportive Housing Services since 2011, in an independent healthier living residency facility that serves the Single Adult Homeless population with mental illnesses, substance abuse disorders,dual diagnosis and with physical,health and other disabilities, prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers, including primarily mental illnesses,substance abuse disorders,dual diagnosis, physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals. HIHR asses and creates Individualized Service Plans including case management,job training,job placement,substance abuse/mental health treatment, healthcare, living skills,financial training,education, housing resources,entitlements, parenting,domestic violence services, recreational activities,holistic, spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility and with optional link to additional services and resources coordinate with multiple local community service providers,and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our chronically homeless population in the Big Island. HIHR provides an independent healthier living residency facility for chronically homeless,a caring living environment that helps restores individuals to a sounder more balance mind,body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget& Position Count: Total Program Budget: 46,140.00 Total Program Position Count: 1 Total Agency Budget: 521,246.00 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su sportive Housin. Prof ram #3 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State Of Hawaii Grant 37,040.00 Program Fees 9,100.00 TOTAL: 46,140.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential and or possible sources of additional grants,funds and general resources available via like the Federal, State,County, Institutional,public and or Private Entities.As is reflected by the history,development and expansion of our agency programs into Permanent Supportive Housing which was made possible in part with Federal Grants via HUD and its program initiative Continuum of Care(CoC),administrated by DHS of the State of Hawaii. HUD-CoC funding was afforded for the current fiscal period of Nov 2015-Oct 2020 with an annual contract renewal agreement. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will work to achieve the overall program goals,as stated above in the Mission Statement and Program Description. Promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourage the restoring of adult individuals to a sound and unblemished mind, body and spirit. After the participant is assessed,the Case Manager will coordinate HIHR and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager will promote participation in a variety of programs that improve housing stability. HIHR Case Manager/Care Coordinator will maintain bi-weekly meetings to process and follow up activities with residents.They will also conduct team meetings with providers including Probation Officers,mental health,substance abuse and medical Case Managers as part of the support system to follow up with the goals and objectives of the Individualized Service Plan to enhance the well-being of all the program residents. By experience,the chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment. HIHR will make referrals to the job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #3 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90% At Exit to Obtain/Maintain Permanent Housing. 80% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Rey Salary and Wages N/A 16,508.00 8,000.00 Professional Fees N/A 2,900.00 Operations N/A 21,188.00 3,000.00 Supplies N/A 5,544.00 1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL N/A 46,140.00 12,000.00 *If applicable EXHIBIT A NONPROFIT(;RANT APPI ICATION FY 7(117-7n1 R Paap d of R County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #3 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council f Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director H The Director of Finance • The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. EXECUTIVE DIRECTOR 4 i2a/7724___ 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #3 ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program #3 ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding request rind mny rPcult in nrtinns tnkPn to rPrnvPr thPcP funrlc, By signing below, you are acknowledging that you have read and understood these requirements. EXECUTIVE DIRECTOR �'cG ����ryJ 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Su.•ortive Housin• Program #3 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90% At Exit to Obtain/Maintain Permanent Housing. 80% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 8,000.00 Professional Fees Operations 3,000.00 Supplies 1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 12,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Transitional Housing Program 74 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program Agency Director: Rita Sandi Palma Phone No.: (808) 640 — 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 — 7852 Mailing Address: Address: 440 Kapiolani St. Address: City,ST,Zip Hilo, HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 — 7894 Accountant/CPA: Alex J. Smith Phone No.: (80 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $49,000 Geographical Areas To Be Served: (One or more can be checked) ✓Q Puna n Hamakua 2 North Kona n South Hilo ✓❑ North Kohala C South Kona ✓❑ North Hilo n South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓D Educational concerns n Youth Victims of Crimes ❑Culture and the arts 171 Aged Victims of Health or Social Crises 2 Needs of the poor n Physical/Emotional Disabilities ✓Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housin• Pro.ram 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 10,000.00 5,000.00 13,750.00 2.Agency Mission Statement: HIHR Mission is to Serve the Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical, health and other disabilities,prioritizing the Chronically Homeless. HIHR programs help focus homeless population to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing, improving their life's and general skills, increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System(VI-SPDAT)and the Housing First Model Approached wish are the new trends in Homelessness care,that are strongly advocated and enforced by the Federal and State Agencies upon to those providers that targeted to assist homeless throughout Hawaii County and the State of Hawaii. 3. Program Description: Hawaii Island Home for Recovery Inc. (HIHR) has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,and Permanent Supportive Housing Services since 2011, in an independent healthier living residency facility that serves the Single Adult Homeless population with mental illnesses,substance abuse disorders,dual diagnosis and with physical, health and other disabilities,prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers, including primarily mental illnesses,substance abuse disorders,dual diagnosis,physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals. HIHR asses and creates Individualized Service Plans including case management,job training,job placement,substance abuse/mental health treatment, healthcare, living skills,financial training,education, housing resources,entitlements, parenting,domestic violence services, recreational activities,holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment, services at HIHR main facility and with optional link to additional services and resources coordinate with multiple local community service providers,and in some instances with Island wide, State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our chronically homeless population in the Big Island. HIHR provides an independent healthier living residency facility for chronically homeless,a caring living environment that helps restores individuals to a sounder more balance mind, body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget& Position Count: Total Program Budget: 212,351.00 Total Program Position Count: 4 Total Agency Budget: 521,246.00 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State Of Hawaii Grant 157,251.00 Program Fees 37,300.00 Hawaii Island United Way 10,800.00 Other Funds 7,000.00 TOTAL: 212,351.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential and or possible sources of additional grants,funds and general resources available via like the Federal,State,County, Institutional,public and or Private Entities.As is reflected by the history,development and expansion of our agency programs into Transitional Housing Services which was supported in part,with funding from DHS-HPO of the State of Hawaii from Aug 2007-July 2011,with renewal funding from Aug 2011-July 2015 and with annual contract agreement renewals, including additional supplemental extensions up to the early 2017. Lately for the current fiscal period of Feb 2017-July 2021 with an annual contract renewal agreement. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will work to achieve the overall program goals,as stated above in the Mission Statement and Program Description. Promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourage the restoring of adult individuals to a sound and unblemished mind,body and spirit. After the participant is assessed,the Case Manager will coordinate HIHR and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager will promote participation in a variety of programs that improve housing stability. HIHR Case Manager/Care Coordinator will maintain bi-weekly meetings to process and follow up activities with residents.They will also conduct team meetings with providers including Probation Officers,mental health,substance abuse and medical Case Managers as part of the support system to follow up with the goals and objectives of the Individualized Service Plan to enhance the well-being of all the program residents. By experience,the chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment. HIHR will make referrals to the job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housin. Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90% At Exit to Obtain/Maintain Permanent Housing. 80% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 108,078.00 134,172.00 30,000.00 Professional Fees 17,120.00 14,580.00 Operations 88,700.00 52,687.00 10,000.00 Supplies 15,000.00 10,912.00 9,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 228,898.00 212,351.00 49,000.00 *If applicable EXHIBIT A NONPROFIT( RANT APPI !CATION FY 7(117-701 R PAPP 4 of County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housin. Pro.ram 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. EXECUTIVE DIRECTOR d 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program i1. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, 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, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Hous Pro.ram ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding requect and may result in artinns taken to rernver these fundc, By signing below, you are acknowledging that you have read and understood these requirements. EXECUTIVE DIRECTOR ?id. 01 /31 /2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housin. Pro.ram 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Comprehensive Assessment/Individual Service Plan/Case Manager. 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Training in Program/Other Community Providers. 90 At Exit to Obtain I Maintain Permanent Housing. 80% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 30,000.00 Professional Fees Operations 10,000.00 Supplies 9,000.00 Equipment Other: Other: Other: Other: Other: TOTAL 49,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawai'i Montessori Schools Financial Aid Program 75 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program Agency Director: Angeline Geldhof Phone No.: (808) 329 — 0700 Contact Person: Angeline Geldhof or Maya Wheaton Phone No.: (808) 329 — 0700 Mailing Address: Address: 74-978 Manawale'a Streeet Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Facility Address: Address: same Address: City,ST,Zip Email Address: angeline@hawaiimontessori.org Fax No.: (808 ) 334 — 0327 Accountant/CPA: Rozanne Connell Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPA's and Associates Mailing Address: Address: P.O. Box 4372 Address: 136 Kino'ole Street City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ✓❑ Hamakua ❑✓ North Kona ❑South Hilo ✓❑ North Kohala ❑✓ South Kona ❑ North Hilo ✓0 South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $5,000 $5,000 $3,750 2.Agency Mission Statement: Our mission at Hawai'i Montessori Schools is education 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 2016-2017 school year,we have 119 students enrolled,of which 25 are receiving some kind of financial aid from us. To date,we have provided a total of$35,021 in financial aid for the 2016-17 school year. 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 the 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: $45,000 Total Program Position Count: 35 Total Agency Budget: $1,087,636 Total Agency Position Count: 125 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii Non-Profit Grant in Aid $10,000 G. N.Wilcox Trust 5,000 Mclnerny Foundation 15,000 Samuela N.and Mary Castle Foundation 15,000 TOTAL: $45,000 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 tour 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 is funded in part through the school's operating budget. 7. Program Objectives Using County Nonprofit Grant Program Funds: We feel it is important for children to have an excellent start to their educational career. Over the years we have noticed many children are unprepared for Kindergarten.This in some part is due to the"push down"of the elementary curriculum. Young children are asked to do things that are at times developmentally inappropriate and impractical.When we look at the Hawaii State School Readiness Assessment results in West Hawai'i,which includes the Honoka'a and Kealakehe Complexes,49%of the students entering Kindergarten have never been in an early learning setting. Now that the Common Core Curriculum Standards has been fully implemented,there will be more pressure for these young children to succeed in school,and if they have not had the opportunity to attend and early learning environment they will start elementary school at a disadvantage. The Financial Aid Program allows us to assist needy families who are seeking to enroll their children in a quality preschool program, thereby increasing their chance for success in their future educational career. We hope to give tuition assistance to 35 students in the 2017-2018 school year. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Students who will receive financial aid so may attend a high-quality early learning 35 center Amount of Financial aid distributed to 40 students for the 2017-2018 school year. $45,000 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Financial Aid Program $35,021 $45,000 $10,000 Other: Other: Other: Other: TOTAL $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. no AL-.A. 111111 (a/Li1 /27/2017 Signature/of Authorized Person (s ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express,and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futures funding rerputct nnri mny recult in nrtinnc tnken to rarnvPr thece funric. By signing below,you are acknowledging that you have read and understood these requirements. , . . k 1/27/2017 Signature of Authorized Person (speci title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Students who will receive financial aid so may attend a high-quality early learning ss center. Amount of Financial aid distributed to 35 students for the 2017-2018 school year. $45,000 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Financial Aid Program $10,000 Other: Other: Other: Other: TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaii Oil Seed Producers (HOSPRO) LLC Training Oil Palm Mill Operators for Vegetable Oil Production 76 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production Agency Director: William W.M. Steiner Phone No.: (808) 294 — 0750 Contact Person: Same Phone No.: (808) 982 — 7943 Mailing Address: Address: 200 Kanoelehua Ave Address: Number 205 City,ST,Zip Hilo,HI 96720 Facility Address: Address: 200 Kanoelehua Ave Address: Number 205 City,ST,Zip Hilo,HI 96720 Email Address: wwmsteiner@gmail.com Fax No.: ( ) — Accountant/CPA: Ina Wolfe Phone No.: (916) 813 — 8661 Firm (if applicable): Taketa, Iwata,Hara&Assoc Mailing Address: Address: POB 2126 Address: City,ST,Zip Volcano, HI 96785 YOU ARE RESPONSIBLE TO KEEP THE 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 0 North Kona 0 South Hilo ❑ North Kohala ❑South Kona ❑North Hilo 0 South Kohala ❑Ka'O Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0.00 0.00 0.00 2.Agency Mission Statement: As a 501 C5 nonprofit agricultural cooperative,the purpose of HOSPRO shall be to provide farmers and agriculturalists growing oil seed crops a way to share relevant agricultural information between themselves and with others;provide for purchase,siting and upkeep of commonly owned machinery useful to production and extraction of oil from their crops;provide a service to participating farmers for locating markets;manage profits and losses arising from the marketing of products produced by processing oil seed nuts;provide for research into common growing or processing problems experienced by HOSPRO members;and generally provide benefit to oil seed growers on Hawaii Island and the broader State while simultaneously demonstrating how integrated approaches can lead to energy and food security setting a prime example for such in the State of Hawaii and beyond. 3. Program Description: Hawaii Oil Seed Producers(HOSPRO)has established 80 acres of producing American x African Oil Palm hybrids with 8 cooperating landowners for production of vegetable oil for biofuel,edible oil,compost and animal feed.They are now in the process of obtaining larger acreages to expand production.The project grew out of a proof of concept study by UHH Dean of the College of Agriculture, Forestry and Natural Resource Management(CAFNRM)who imported 10,000 USDA approved phytosanitized seeds of hybrid oil palms from Costa Rica to determine if the trees would survive insects,fungi and climatic events in Hawaii,produce vegetable oil for multiple uses,and do well on the different soil regimes of the Big Island. Upon retiring in 2012,Dr.Steiner was asked to form the HOSPRO Cooperative and obtain an oil extraction mill to process nuts from the ripening fruit of the palm trees.Upon completion of the formation of the 501 C5,a USDA grant was obtained which enabled HOSPRO to purchase the mill.An estimate of production based on weight and numbers of fruit bunches indicates that 12-18 bunches/tree are possible with weight of young tree fruit bunches averaging 5#each for a total production estimated at 500 gallons/acre.A promise of purchase from Pacific Biodiesel places the value of the nut/fruit crop at$3/gallon.Estimates for the value of dry waste for compost and wet waste for animal feed is about$1,260/acre. HOSPRO is now ready to set the extraction mill up to begin producing oil and byproducts,and would like to obtain 2 UHH CAFNRM students to aid in setting up and processing fruit/nuts into marketable products.HOSPRO is especially interested in supporting student interns who would qualify as STEM students,who are seeking engineering degrees in the agricultural field of choice,and who could work for 20 hours/week for at least 9 months each. 4.Total Budget&Position Count: Total Program Budget: $15,000 Total Program Position Count: 2 partime Total Agency Budget: $18,000 Total Agency Position Count: 1 fulltime EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate SB 1268, introduced 2017,will request$1,600,000 for expansion of the industry FY 18$800,000 Fliowing grants in aid have been requested for yr 2017-18 by HOSPRO Legislative Grant-in-Aid Capital purchase of nursery and warehouse site,tractor,soil fumigator $312,000 Legislative Grant-in-Aid Operations for renovations of shadehouses, salaries $268,340 TOTAL: $1,380,340 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We plan to have an income based on a conservative estimate of 20#of fruit/tree at$3/gallon(per Pacific Biodiesel);we have 80 acres currently planted*.This after costs will yeild$1,309/ac including income from dry compost and wet animal feed,but without including estimated income from intercropping cacao and/or coffee.We are planning expansion of the number of trees planted onto a minimum of 2,000 acres currently offered us. ANTICIPATED PRODUCTION ANTICIPATED INCOME SIZE OF Yr NUMBER OF WEIGHT OF 0.13 CONVER $3/gal $3/g Income/acre ACREAGE FRUIT TREES FRUIT BUNCHES SION FACTOR less cost adjustment (20#/TREE) 10 1 1,000 20,000# 2,600 gal $7,800 $4,290 = $427/ac 80 1 8,000 160,000# 20,800 gal $62,400 $34,320= $427/ac 120 1 12,000 240,000# 31,200 gal $93,600 $51,480= $427/ac 2,000 4 200,000 4,000,000# 520,000 gal $1,560,000 $706,000= $427/ac plus income/acre from compost figured at 30%of dry weight divided by 100 x$11 = $660/ac plus income/acre from animal feed figured at 20%of fruit bunch weight divided by 100 x$15=$600/ac conservative income estimate for spin off byproducts of $1260/ac *Thus minimum income$1,260/ac plus$427/ac x 80 acres=$134,960/80 acres presently planted increasing to$3,226,000 by year 4 after expansion to 2,000 acres. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objectives are to provide training and part time jobs to two University of Hawaii agricultural students from UHH.This will benefit us two ways;first in having"hands"to help us build out the small extraction mill,and second to begin building the expert manpower we will need to operate the mill and service the farms that are planned.We wish to hire the students for 8 months each,to include one semester and one summer of employment.These would be classified as at STEM(science,technology, engineering and math)positions. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1. 2 weeks of training on operation,construction and results of milling oil palm fruit Students gain a basic knowledge of mill (Performance measure:tests to a minimum of 80%knowledge on the material presented) construction and operation 2. 3 months of assembly of mill including adjusting mill for maximum output of oil Students gain practical mechanical experience (Performance measure:tests to a minimum of 80%of knowledge on assembly challenge) and practical experience in mill opreation • 3.6.5 months of oil extraction(Performance measure:becomes proficient in operations Student now can hire as operater at$22-25/hr Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $14,336 $14,336 $14,336 Professional Fees Operations Supplies 600 600 14,936 Equipment Other: Other: Other: Other: Other- TOTAL $14,936 $14,936 $14,936 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: NO CONFLICT OF INTERESTS ARE KNOWN OR ANTICIPATED. ✓❑ If no conflicts exist, check here. ,! - - 't Ci Glyr- 1 /30/2017 Or Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production si. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, 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.ehawaii.gov,complete the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to.and accepted by,the council. I(we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2018 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 fiitura funding rprpunct rind mny rpcuit in nrtinnc tnkan to rarnvvr thaca fiinrlc, By signing below,you are acknowledging that you have read and understood these requirements. /10I; "� Ga, 1 /30/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Oil Seed Producers (HOSPRO) LLC Program Name: Training Oil Palm Mill Operators For Vegetable Oil Production 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Students gain a basic knowledge of mit construction and operation Students gain practical mechanical experience and practical experience in mill opreation Student now can hire as operater at$22-25/hr TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $14,336 Professional Fees Operations Supplies 14,936 Equipment Other: Other: Other: Other: Other: TOTAL $14,936 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawai'i Tropical Fruit Growers Rainwater Catchment Video Project 77 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers Program Name: Rainwater Catchment Video Pro'ect Agency Director: Ken Love, Executive Director Phone No.: (808) 323 — 2417 Contact Person: Chantal Chung Phone No.: (808) 937 — 9800 Mailing Address: Address: P.O. Box 1162 Address: City,ST,Zip Captain Cook, HI 96704 Facility Address: Address: P.O.Box 1162 Address: 81-6393 Mamalahoa City,ST,Zip Captain Cook, HI 96704 Email Address: ken@mycoffee.net Fax No.: ( ) — Accountant/CPA: Paul DeFaliipi (Treasurer) Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: PO Box 1162 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: $44,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑✓ North Kona ✓❑South Hilo ❑✓ North Kohala ❑✓ South Kona ✓❑ North Hilo ✓0 South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers Program Name: Rainwater Catchment Video Pro'ect 1. Prior Year Award of County Nonprofit Grant Program Funds: • FY 14-15 FY 15-16 FY 16-17 None None None 2.Agency Mission Statement: Mission Statement: We are dedicated to the Hawaii-grown tropical fruit community through promotion, research,education and collaboration. Vision Statement: Expanding and perpetuating the diversity, production and legacy of Hawaii grown tropical fruit to its full potential. Our Purpose: Hawaii Tropical Fruit Growers is a nonprofit organization, incorporated in 1989,with the primary purpose of promoting the interests of any and all aspects of tropical fruit in the State of Hawaii. 3. Program Description: This project will produce 6 video segments on the best practices for safe rainwater catchment for the estimated 60,000 agricultural and household users in Hawaii County.Segments will be 4-5 minutes in length to be posted online and also combined to form a 30 minute show on public access television.Agricultural producers would be informed about what steps they need to take in order to safely produce value-added products from their land if they are on catchment water.With no governmental oversight of rainwater catchment systems in Hawaii,it is the responsibility of the farmers and residents to know how to maintain their systems to avoid the potential negative impacts on human health. Hawaii Tropical Fruit Growers proposes to partner with the University of Hawaii Sea Grant Program(UH)to address the need for accessible,science-based knowledge and education.Videos will highlight rainwater catchment system components(including proper filtration and disinfection)and best maintenance practices. UH Sea Grant will provide technical assistance to this project through their extension staff. Funding is needed to hire assistance with production,videography,editing, and posting.A portion of the funding will go to UH for technical assistance. UH will provide staff time as an in-kind match. Hawaii Tropical Fruit Growers will hire necessary assistance with production. 4.Total Budget&Position Count: Total Program Budget: 44000.00 Total Program Position Count: 0 Total Agency Budget: Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers Program Name: Rainwater Catchment Video Pro'ect 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Visionary Videos, ( Inkind) $5000. HTFG-Web, Information distribution via monthly and annual meetings and Internet(Inkind) $1500. TOTAL: Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: No further revenues will be needed to support this project. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1) Enable Hawaii County communities who are reliant on rainwater catchment systems for their water supply to make informed decisions related to their rainwater catchment practices that directly impact health. This would also enable producers to develop value added products. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers Program Name: Rainwater Catchment Video Pro'ect 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Research and gathering of information on top quality catchment systems. Month 1-3 Meeting of extension staff and other interested agencies,institutions and stakeholders Month 4-5 Produce and film six(6)informational videos Month 6-8 Review videos and begin online distribution. Month 9 Continue distribution and community communication through project partners Month 10 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Contract: Videographer 15000.00 15000.00 Other: Contract: Hawaii Sea Grant-Extension staff-Technical assistance 25000.00 25000.00 Other: Administrative and Overhead 10% 4000.00 4000.00 Other: Other: TOTAL 44000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers Program Name: Rainwater Catchment Video Pro'ect 10, ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exi t, check here. , _ 3 ( ---- 1 7 Signature f A nor ed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers Program Name: Rainwater Catchment Video Pro'ect 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 Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, 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 2017-2018 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers Program Name: Rainwater Catchment Video Pro'ect 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 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 fi�nn'inr�requect rind mny recult in nrtinnc tnken to rernver theca funrls, By signing below, you are acknowledging that you have read and understood these requirements. 3 ( ( Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaii Tropical Fruit Growers • Program Name: Rainwater Catchment Video Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Research and gathering of information on top quality catchment systems Month 1-3 Meeting of extension staff and other interested agencies, institutions and stakeholders Month 4-5 Produce and film six(6)informational videos Month 6-8 Review videos and begin online distribution Month s Continue distribution and community communication through project partners Month 10 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Contract: Videographer 15000.00 Other: Contract: Hawaii Sea Grant-Extension staff-Technical assistance 25000.00 Other: Administrative and Overhead 10% 4000.00 Other: Other: TOTAL 44000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hawaiian Habitats Foundation, Inc. County of Hawai'i Nonprofit Grants Program 78 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program Agency Director: Margot Robinson Phone No.: (sos) 345 — 3084 Contact Person: Margot Robinson Phone No.: (sob) 345 — 3084 Mailing Address: Address: P.O.Box 1245 Address: City,ST,Zip Hilo,HI 96721 Facility Address: Address: 60 Waianuenue Ave. Address: City,ST,Zip Hilo,HI Email Address: Iifeinvolcano@gmail.com Fax No.: ( ) — Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna (7 Hamakua ❑North Kona El South Hilo ❑✓ North Kohala Q South Kona I ]North Hilo ❑South Kohala ®Ka'u Services or Activities To Be Provided: (One or more can be checked) CI✓ Educational concerns ❑Youth 0 Victims of Crimes 0 Culture and the arts Q Aged 0 Victims of Health or Social Crises Q✓ Needs of the poor []Physical/Emotional Disabilities 2 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 14-)S FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: The mission of Hawaiian Habitats Foundation Inc.is to create a much needed affordable housing platform through innovative construction,sustainability,agriculture,blue zones,community outreach,legislation,and non-qualified applicant education.By keeping dwellings at the minimum of county standards,even low-income families and individuals can achieve the dream of homeownership in Hawaii County and abroad. 3.Program Description: Hawaiian Habitats Foundation Inc.was founded on the need to help and educate low-income,working lass individuals and families achieve the dream of homeownership.This demographic includes but is not limited to low-income recent college graduates,service workers,millennia's,single parent families,and retirees that work full-time but still cannot afford to purchase conventional homes.With a median home value of$589,800 in the state and$333,200 in Hawaii County,most housing is simply not affordable for our demographic.Our affordable housing program will build smaller dwellings in affordable subdivisions at the minimum required size of the county guidelines.This allows our organization to keep costs as low as possible which ensures a much larger pool of buyers and a greater impact on or community. Our program's goal this year is to construct twelve,single family homes that will meet all county and lender's standards and requirements.This particular design has 2bedrooms/1 bathroom with a size of 800 square feet with 600 square feet of living space with a single carport and all the appliances included.Through our strategic partners and consultants,we can build these dwellings at a complete cost of$83,485 per unit These can be purchased by individuals and families that earn less than 520,000 per year with no down payment through our lenders.This program wiN provide a platform to build equity and a future for those whom thought homeownership was not possible for their families. 4.Total Budget&Position Count Total Program Budget $1,055,820 Total Program Position Count 8 Total Agency Budget: $1,077,820 Total Agency Position Count EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program 5.Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii Nonprofit Grant Program $627,395 Private Investment $417,425 Online Crowdfunding $10,000 Direct Website Donations $3,000 Fundraising Events $20,000 AL: ` $1,077,820 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: -We plan on bringing on several private investors this year.We have already sparked plenty of interest in the private and public sector.We offer and attractive investment package that starts between$75.000-$85,000.This will yield a return of 10%after six months.We offer longer terms at 22%plus points. -We will also utilize online crowd-funding platforms as well.Specifically Causes.com,JustGMng.com,Indigogo.com,and Crowdraise.com. -Our website will also utilize direct website donations.One of our strategic partners has donated topnotch web-design and search engine optimization through his tech team in Silicon Valley,California.All donations will be tax deductible. -We will also host various fundraising events,dinners,and galas open to both the public and to private organization.This will result in donations,additional investors,and additional strategic partners. -Hawaiian Habitats Foundation Inc.will also host a series of non-qualified applicant assistance workshops.The workshops will be free and will not generate income themselves.However,they will help put low-income individuals and families in a position to purchase our homes by improving their credit and structure their finances. 7.Program Objectives Usin County Nonprofit Grant Program Funds: -Build seven affordable houses improving the future and quality of life for seven low-income families or individuals. -Provide 7 construction projects for local general contractors and his/her apprentices and laborers. -Provide seven contracts for local plumbinglelectricaUsurveyor contractors and his/her apprentices and laborers. -Provide seven projects for local architects and engineers -Hire a part-time director of operations for Hawaiian Habitats Foundation Inc. -Hire a part-time secretary for the director of operations for Hawaiian Habitats Foundation Inc. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific) Building Affordable Homes 12 New Homes For Low-Income Families Provide Contracts for Local General Contractors 12 New Projects for Gen.Contractors Provide Contracts for Local Electrical/Plumbing/Sureyor Contractors 12 New Contracts for Electricians/Plumbers Provide Work for Local Architects/Engineers 12 New Projects for Hire a Part Time Operations Director for Hawaiian Habitats Foundation Inc. New Operations Job Created Locally Hire a Part-Time Secretary for a Operations Director of Hawaiian Habitats Foundation Inc. New Seaeta iy Job Created Locally Attach additional pages as necessary. 9.TABLE H: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actuate Total Budget Grant Req Salary and Wages $50,000 $40,000 Professional Fps $98,220 $57,295 Operations $195,600 1114,100 Supplies $547,200 $319,200 Equipment $83,400 $48,650 Other: Insurance $4,000 $3,000 Other: $77,400 $45,150 Other: Other: Other: TOTAL $1,055,820 $627,395 elf applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program i0. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose 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 illtefeSt 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: Q If no conflicts exist,check here. tiL Signature of uthorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program 11.Certification of Understanding (Page 1 of 2) i (we)have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I(we)hereby certify that information supplied herein,including all supporting documents,is correct and that I(we) have the authority and ability to fully administer the program(s) pursuant to law. I(we)understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we)understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I(we)understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document.Unsigned documents will be disqualified.Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, i (we) understand and will comply with the requirement to enroll with fiawai'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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of 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 shag result In loss of all grant funds received during the grant period(must be 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.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in q timely manner will impact the evaluation of your agency's futura funding rPrgrrpst and rnny rpcirlt in nrtinnc Minn.(to rprnupr thacp funds. By signing below,you are acknowledging that you have read and understood these requirements. A ../1 4te.. 0 - ravwcr) /Aq-11 Signature Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hawaiian Habitats Foundation Inc. Program Name: County of Hawaii Nonprofit Grants Program 12.COUNCIL AWARD WORKSHEET TABLE I: Applica PROGRAM PERFORMANCE MEASURES Council Proposed Projected Results Projected Result 12 New times For Low-Income FamNies 12 New Projects for Gen. Contractors 12 New Contracts for 12 New Projects for New Operations Job Created Latey New Secretary Job Crested Locally TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $40,000 Professional Fees $57,295 Operations $114,100 Supplies $319,200 Equipment $48,650 Other: Insurance $3,000 Other: Furnishings/Appliances , $45,150 Other: Other: Other: TOTAL $627,395 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPUCATION FY 2017-2018 Page 8 of 8 Heart Ranch Heart Ranch 79 County of Hawai`i Nonprofit Grant Application FY2017-18 Name:N �- ►� ©7©�Y Agency a Program Name: u.a Agency Director: Anthony Harris Phone No.: (808) 640 — 2232 Contact Person: Fronda Harris Phone No.: (808) 937 — 9717 Mailing Address: Address: 380 Akolea Rd. Address: City,ST,Zip Hilo, Hi 96720 Facility Address: Address: 380 Akolea Rd. Address: City,ST,Zip Hilo, HI 96720 Email Address: Fax No.: (sob ) 969 — 7409 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Puna ❑✓ 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 Q 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: tkecktr4 Rah�^ Program Name: { 'int.,\ 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $4,500 2. Agency Mission Statement: The Heart Ranch Mission is: "To Build Confidence, Develop Leadership,and Encourage Personal Growth in children and families." The goals are measured by: 1)Build Confidence demonstration of each participants body posture,open communication,and response to the animals. 2)Develop Leadership This is measurable in evidence of participants pro-active approach to the horse, in making decisions and not allowing the horse to dominate and lead them,in demonstration of building phases of pressure in order of need,with the concept as light as possible,as much as necessary. 3)Encouraging personal growth in families. This is demonstrated by family attendance to sessions,and events,demonstration of involvement in the child's experience by taking pictures,giving encouraging feedback,asking questions after and/or giving kudos at end of sessions. 3. Program Description: The program was born out of the Harris'personal faith and has adopted the basic tenants of love and care. Each child is paired with a horse where life lessons such as"do unto others"is taught first hand,where care and concern breeds mutual love and respect.Self-confidence and leadership are developed by mastering control of a 1,000 pound animal-the horse;which provides the ultimate test of both as the animal naturally seeks its own boundaries.Horses require and seek leadership in order to have a successful partnership with a human.The child is faced with the decision to take the lead. If they do not,the horse will.One-on-one mentorship guides the child through this process with positive reinforcement challenging and encouraging the child to take control. Mentors are one of a variety of the volunteers,and there are no paid employees to date. Responsibility,work ethic,and life skills are reinforced via the assignment of a chore.This is the time where many children start to build their relationship with their mentor;talking about life's challenges and observing their mentor as a positive role model, who interacts with children and animals in a positive way.In addition to the horses,goats,cows,dogs and a bunny are cared for.There are small garden projects and other self sustaining chores that children participate in. It is during this time that responsibility,work ethic,caring for the land,and daily life skills are learned. The session continues to the care of the horse. It is here that hygiene,animal stewardship,caring for others and animals,and safe boundaries flourish.Children learn the correct way to approach the horse,the cost of taking care of a horse,the anatomy of a horse,and the proper way to care for and handle the horse. (Continued on additional page) 4.Total Budget& Position Count: Total Program Budget: $50,000 Total Program Position Count: 27 Total Agency Budget: $50,000 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: 416.000 Program Name: W.6./} 96")A 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Private Donors $15,000 Potential for Repeat Award of The Harry &Jeanette Weinberg Foundation Employee Giving Pr $10,000 Fundraising Support from Auwana Hawaii-selling Big Island Candy Bars on Adventure X Tour $4,500 Hawaii County Grant $15,000 Fundraisers $3,500 TOTAL: $48,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Grant writing-specifically The Harry&Jeanette Weinberg Foundation Employee Giving Program,as well as others as we learn about them. Public Speaking-The founders have spoken to groups such as Rotary and Lions,as well as local churches. They will schedule additional speaking appointments with additional service clubs,and other groups. Private Donations-Various individual donations are received from donors in and out of the community. Fundraisers-Connections with other community members are being made to help formulate fundraising campaigns. We are planning a joint venture with Hawaii Horse Owners Association during the Panaewa Stampede Rodeo in February 2017. 7. Program Objectives Using County Nonprofit Grant Program Funds: Animal feed costs remains the biggest budgetary item each year. With the low quality of nutrients in the grass in our area,all our animals need to be subsidized daily with additional feed. This includes hay and some grain for our horses and goats. Along with feed costs,we purchase medicines,stall shavings and additional supplements for the animals used in the program. Volunteering is at the center of what makes Heart Ranch,and it is completely dependent on its gracious volunteers. Our volunteer team loves to be here and to provide a safe environment of encouragement and love. Our Youth Volunteer Program is one in which teens 14 through 18 years of age have an opportunity to give back. Youth volunteers are past participants of the program. Periodic retreats,camping,and activities in addition to their weekly service time,are scheduled to guide and nurture these youth with a special servant's heart,to a deeper and more consistent level. Financial costs to assist in supporting these activities is necessary to provide the mentorship. They are the future and worthy of our time and commitment. EXHIBIT A NONPROFIT GRANT APPLICATION P12017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: &AA SO.000 Program Name: kbA 1?Nijht h 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Heart Ranch has provided over 2,650 individual mentoring sessions since opening in 2012 Building of Self Confidence,Leadership and averaging 530 per year. We are also developing a new program to service local veterans Personal Growth;Self Image,Healthy Choices suffering from PTSD. There are an estimated 5,000 US military veterans suffering from and Boundaries;Family Unity,Love and post traumatic stress disorder(PTSD)on the Big Island of Hawaii,alone,according to the Sharing,Memory Making,Community, Health&Research Center(www.ptsdhealth.org). We are hosting an Equine Assisted Physical Activity,Work Ethic,Respect,Animal Psychotherapy seminar in May to provide additional educational resources to the Care,Environment Ethics and Therapists on the Big Island. Developing of a Servant's Heart Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req 0 0 0 Salary and Wages 0 $500 Professional Fees $567 $600 Operations $18,951 $22,300 $12,000 Supplies 0 0 Equipment Other: Veterinary $1,350 $1,800 Other: Insurance $2,384 $2,550 $1,500 Other: Conferences 0 $3,000 $1,500 Other: Maintenance Supplies for facility $3,325 $4,000 Other: Veterans PTSD Program 0 $2,500 TOTAL $26,577 $37,250 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: VA- Rani,^ Program Name: l4a14 RAvi n. 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council 0 The Mayor [l The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑,/ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: k-64 ( &'tc4 Program Name: Pali Rithdiv 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to :tttp://vendoL5.e:-.?` laiI,E.,ov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: 1.ktcwr4 Riot h Program Name: 1.64 ' on, 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information t ; i i,sionorabout and instructions are available at � .__ .�___.__ �_ —._. ___._--rL -----=� May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding raquPct nnrl mny reciilt in nrtinnc tnkan to rPr mrPr theca frinric. By signing below, you are acknowledging that you have read and understood these requirements. 3041")0A1A-""Thms , u I /30 /(-? Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Vwt Wvial Program Name: 1 o 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Building of Self Confidence, Leadership and Personal Growth;Self Image, Healthy Choices and Boundaries;Family Unit Sharing,Memory Making, Community, Physical Activity,Work Ethic, Respect,Animal Care,Environment Ethics and Developing of a Servant's Heart TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees Operations Supplies $12,000 Equipment Other: Veterinary Other: Insurance $1,500 Other: Conferences $1,500 Other: Maintenance Supplies for facility Other: Veterans PTSD Program TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Help the Poor F EADS 80 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS Agency Director: Sarker Sharmin Phone No.: (408) 401 — 7688 Contact Person: Sarker Sharmin Phone No.: (408) 401 — 7688 Mailing Address: Address: P.O. Box 10065 Address: City,ST,Zip Hilo 96721 Facility Address: Address: 440 Kapiolani street Address: City,ST,Zip Hilo, HI 96720 Email Address: HelpThePoorUSA.Hawaii©gmail.com Fax No.: ( ) — Accountant/CPA: Phone No.: ( ) _ Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 1Q Puna 0 Hamakua [] North Kona 0 South Hilo ❑ North Kohala ®South Kona 0 North Hilo ®South Kohala Ka'u KMY Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓CJ Youth ❑✓ Victims of Crimes ®Culture and the arts ✓l Aged ®Victims of Health or Social Crises ❑✓ Needs of the poor [2j Physical/Emotional Disabilities [✓] Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 N/A N/A $23,750.00 2.Agency Mission Statement: HelpThePoor(HIP)organization'•was established-in 201.3 in Hilo,Hawaii.The organization has been receiving its'funds from small private donations,fund raising endeavors,and the Hawaii County grant.In November 2014, HelpThePoor organization qualified for the IRS 501(c)3 tax exempt code for nonprofit organizations.The organization was established due to the increase in the rate of homeless in Hilo area which is well-documented in local and county reports.According to the Hawaii Tribune- Herald,there has been a dramatic increase in the homeless population showing a 4%increase statewide with the Big Island accounting for more than 50%of the Increase.On Hawaii's Big Island the number of homeless individuals increased from 1,241 in 2015 to 1,394 in 2016. Hawaii News Now discovered the amount of homeless is from locals with only 7%being outsiders. According to Big Island Now,the unemployment rate in December 2016 was at its lowest of 3%. Compounding the problem,as cited by a local agency,Community Alliance Partners,the$8 an hour minimum wage does not cover rent of an apartment. Likewise,the number of homeless has increase but the number of community support programs has not.Thus,this is implying the shortage of assistance helping the homeless and the needy people. HTP was estabished to fill in the gaps of programs and the need of the community justifies our programs.HTP's primary focus has been on the homeless and needy people and its mission statement is to"help to make a difference"by inspiring hope through providing support in the direst times.The main activities have been meal distributions,public awareness campaigns,conducting community health,kitchen training programs, food and safety education referral,outreach program with Bluejay to give free cell phones to homeless and needy. In 2016, HelpThePoor serviced,more than 2000 persons- providing distributing approximately 1551 meals as well as conducted 48 awareness campaigns and health checks with 20 parrticipan and formed alliance with other non profits such as"Hope services"and"Hawaiian ands Homens has uforzgRecovery"forctivities.volunteering,community 3. Program Description: Fostering Empowerment by Alleviating Dire Straits(FEADS)program will alleviate the dire needs for nutrition and improve their quality of health.by providingnutritional meal(in meal distribution,.food parcels,soup kitchens,etc.)to homeless and needy.The second,assistance them with obtaining documentation such identification cards,birth certificates,etc. because Its the major obstacle stopping many beneficiaries from getting services and benefits.The third step is to empower thm with training programs such as Kitchen tranining,tools program to loan them free tools,security guard or other vocational training programs,farm work training,yard work and fence building training and etc.The fourth step is to provide shelter for the people who are in need of a place to stay who are homeless,about to become homeless,and to provide a temporary section 8 housing place for people who have received section 8 housing vouchers and are in danger of losing their vouchers due to being unable to find a place that accepts section 8 since according to section 8 ruling if you cannot find a place withing a specified period of time they lose their section&voucher and have to go back to the bottom of the waiting list.Transitional housing is a place for people who have gone through different programs such as drug rehabilitation,domestic violence,and ssi candidates etc. 1.Written by Max Dible on 30th June 2016 titled, "Big Island Homeless Population Up", http://hawalitribune-heraid.com/news/local-news/big-island-homeless-population 2.Written by Mileka Lincoln Jun 18th 2015 titled"Homeless on Hawaii Island:Population Has More Than Doubled in 2 Year. 3.Big Island Now, December 16,2016, "Hawai'I Unemployment Rate 3%,Lowest Since 2007", http://bigislandnow.com/2016/12/16/hawal%CA%BBi-unemployment-rate-3-lowest-since-2007/ 4.Comments taken from Community Alliance Partners Big Island Chair, Rita Sandi-Palma in the 18th June 2015 article Hawaii 4.Total Budget& Position Count: Total Program Budget: $182,000 Total Program Position Count: 3 1 Total Agency Budget: $208,050 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source County of Hawaii Estimate USDA $182,000 Private Donations $25,000 $1050 TOTAL: $208,050 Attach additional.pages,..if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: FEADS program has expanded on grant applications and besides the Hawaii County grant,request was sent to USDA to establish a greenhouses to produce some of its own food for feeding,and to cut expenses on feedings. In addition,grant applications are sent to United Way as well.The local coordination mechanism with Food Basket has cut the cost for local food supplies used for meals,as well as coordination with the local people for donations. HTP has also leased a land to grow its own food and using the land as its own training facility to teach public farm works and methods of sustainable living and will be in alliance with the future programs.The food produced from the land will be used in some of the public feeding to homeless and needy for HTP. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1: Decrease in the amount of unfed homeless Activities to distribute meals and food parcels on gap days that local partners are not distributing(approximately 3 times a week). Objective 2: Assist in documenting POC so they can obtain services. Activities include assisting beneficiaries with obtaining identification cards and birth certificates.Then,after getting the identification cards,referring to register for programs both government and non-government programs such as LIFELINE. In addition,awareness campaigns of events and information pertinent to their health and life. Objective 3: Homeless and Needy families have gained skills and materials Activities include assisting in communityoutreachby refining individualsof concern.to:other agencies for development and: educational programs.The sponsorship of the training program is to cover some of the training expenses beyond tuition such as materials,transportation,etc.that the beneficiary may need.One of the main initiatives under the FEADS program is the Farm to Table Initiative.HelpThePoor organization would like to sponsor vocational training for needy individuals into various sectors such as Agriculture and Food Service/Hospitality(but not limited to).The training to be sponsored are inclusive but not limited to food preparation,food handling,food service,catering,farm work,selling and marketing produce etc.The idea is to not only provide training but provide an environment that the trainee can gain hands on experience.Some of the proposed programs(but not limited to)are landscaping and gardening,security training,food preparation courses,and computer software training in QuickBooks and MS Office. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (Le.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Applicant Projected Results #of beneficiaries to be assisted with obtaining ID,Birth certificates and etc. 20 #of meals/food parcels distributed 2000 #of beneficiaries participating in the FARM to Table training and tools program 35 #of Public awareness Campaigns and outreach programs 50 Overflow shelter for homeless,at risk homeless,transitional and temp.sec 8 housing 20 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 18,200 18,200-• Professional Fees 2375 3200 3200 Operations 5000 5000 5000 Supplies 2000 2000 2000 Equipment 2500 2500 2500 Other: Overflow shelter and expenses 0 129800 129800 Other: Activity costs 11000 45000 20000 Other: Michellaneous Costs 875 2350 1300 Other. Other: TOTAL $23,750 $208,050 $182,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council D The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurabledirect benefits accruing to the individual as opposed to benefits accruing in generalto 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. ak_kak, ft )3 ) ) 7 'Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s)pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Egress, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we)understand that failure to submit the final report within 60 days of 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 htti://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiit(rra funding ragtuest rind mny rim.*in nrtipnc tnkpn to rPrnvar thin',fiunrlc, By signing below,you are acknowledging that you have read and understood these requirements. l C... CLAVkC-.§....- S''':( _- 0 ) ) 2 I I 1 '71 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: HelpThePoor Program Name: FEADS 12. COUNCIL AWARD WORKSHEET TABLE is PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of beneficiaries being assisted with ID renewal and birthcertification and etc. 20 #of meals/food parcrcels distributed 2000 #of beneficiaries participated in Farm to Table/FEADS and Tools program 35 #of Public awareness campaigns 50 Overflow shelter for homeless,at risk homeless,transitional and temp.sec 8 housing 20 TABLE II: PROGRAM.EXPENDITURES FY 17-18 Council Grant Request . Award Salary and Wages 18,200 Professional Fees 3200 Operations 5000 Supplies 2000 Equipment 2500 Other: Overflow shelter and expenses 129800 Other: Activity costs 20000 Other: Michellaneous Costs 1300 Other: Other: TOTAL $182,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hilo Community Players Theatre to Inspire Our Community 81 County of Hawai`i Nonpro t Grant Application FY2017-18 Agency Name: Hilo Community Playe Program Name: Theatre to Inspire our community Agency Director: Catherine McPherson-Tampos Phone No.: (808) 934 — 7248 Contact Person: Dr. Rachel Klein Phone No.: (808) 959 — 4588 Mailing Address: Address: P.O.Box 46 Address: City,ST,Zip Hilo,HI 96720 Facility Address: Address: Address: City,ST,Zip Email Address: HiloCommunityPlayers©Gmail.com Fax No.: (808 ) 959 — 4580 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP T E ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCED: •ARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Gran Program Funds: Geographical Areas To Be •-rved: (One or more can be checked) Q Puna Q Karnak a ❑North Kona El South Hilo D North ohala ❑South Kona Q North Hilo ❑South ohala []Kalli Services or Activities To ; Provided: (One or more can be checked) 0 Educational concerns 0 Youth ❑Victims of Crimes �✓ Culture and the arts Q Aged 0 Victims of Health or Social Crises ❑ Needs of the poor ❑Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hilo Community Players Program Name: Theatre to Inspire our Community 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 6,000.00 6,000.00 0.00 2.Agency Mission Statement: The Mission of the 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: This program will include the production and performance of a full theatre season including 4-6 theatrical productions for community entertainment,enrichment and education.Members of the community will be welcomed to be involved in all aspects, having the option to participate in.production and performance,or as an audience member.All auditions and performances will be open to the public.The season shall include two"Shakespeare in the Park"productions,provided to the community at no cost.At least one production(Annual"Kid-Shakes"Production)will be directly designed for children's participation. 4.Total Budget&Position Count: Total Program Budget: Total Program Position Count: 10 Total Agency Budget: 122,100.00 26,000.00 Total Agency Position Count: 10 EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hilo Community Players Program Name: Theatre to Inspire our Community 5. Program Funding Sources(identify all sources of funding applied to this grogram): FY17-18 Revenue Source Estimate Grant Support 17,000.00 Public Donations 2,000.00 Fundraising Events 2,000.00 Existing Program Funds 1,100.00 TOTAL: 22,100.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The organization will host at least one fundraising event or performance during the year as well as accepting community donations throughout the year.Donations received through AmazonSmile and other charitable organizations will be used to directly fund this program.Though program will offer subsidized admission to productions,admission fees collected will help to support the program funding. 7. Program Objectives Using County Nonprofit Grant Program Funds: If awarded county nonprofit grant funding,the Hilo Community Players would be able to produce artistic and educational live programming for communities on the Big Island.With grant funding,we plan to expand our children's program to offer/subsidize performing Basses for children under 18 and provide at least one performance opportunity for those children.We intend to provide a rich program with ample performance opportunity and training to members of the community of all ages,including seniors and children.Additionally;our program would provide enrichment to the community by making theatre arts accessible to all members of the community.Our summer"Shakespeare in the Park"and"KidShakes"productions will continue to be offered to the community at no admission cost,and if grant money is awarded we could greatly reduce admission costs to all other portions of the program season.This program also provides ample volunteer work experience opportunities and the chance for volunteers to learn technical skills which could help them enter or develop their position in the workforce.Through our program we also offer scholarship opportunities to those in need of financial support to participate in the arts. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonpro "t Grant Application FY2017-18 Agency Name: Hilo Community Playe Program Name: Theatre to Inspire our ••mmunity 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE EASURES (i.e.:Number of clients served,workshops or events held,volun rhours,etc.Describe,be specifc-1 Applicant Projected Results Number of audience members served 3600 Number of performers participating 120 Number of technical skill volunteers participating 36 Number of workshops,Basses,perofrmances and events heldERMIIIMIIIIIIIME Volunteer hours available Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITU• FY 16-17 FY 17-18 FY 17-113 Actual* Total Bud:et Grant Re. • •• . • . 1,625.00 5,000.00 3,000.00 • - 1,631.00 3,000.00 3,000.00 • •' 1,153.28 1,800.00 1,500.00 MIIIIIIIIIIIIIIIIIIMIN • • 2,551.17 3,500.00 2,000.00 IIIIIIIIIIIIIIIIIIIIIIMIIII • • �� - 597.09 3,000.00 2,000.00 111 • • _ . Scholarships Awarded 200.00 1,000.00 700.00 • 1 _ , Equipment Storage 4,800.00 4,800.00 MIIIIIIIIIIIIIIIIIIIIIIIIIIII MMIIIIIIIIIIIIIIIIIIIIIIIIIIII TOT• 7,757.54 22,100.00 17,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hilo Community Players Program Name: Theatre to Inspire our Community 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures .o avoid, in fact or appearance,any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. 461 'f2.t:510 441 01/31/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hilo Community Players Program Name: Theatre to Inspire our Community 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/oversighagency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 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 indude an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonpro t Grant Application FY2017-18 Agency Name: Hilo Community Playe Program Name: Theatre to Inspire our 'ommunity 11. Certification o 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 occ rrence) must be provided to the County of Hawaii Finance Department,which specifically and ex•licitly indicates that the County of Hawai'i is an additional insured prior to receiving any paym-nt(s). I (we) understand that failure to submit the fin:I report within 60 days of June 30th shall result in loss of all grant funds received during the grant p,riod(must be refunded to County)and exclusion from future grant participation for a minimum of o e year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for fu • er notification to submit the final report. Information and instructions are available at http://www.h.waiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge t t any funds awarded will be restricted for the purposes stated in the application, except for a maximu ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 mus be returned to the County of Hawai'i with the final report. Failure to return these funds in a timet manner will impact the evaluation of your agency's futurr funding rPquPst and may rpgdt in artia c tnlrpn to rernuer thaw fiindc, By signing below,you are acknowledging that ou have read and understood these requirements. 002' pr201/31/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hilo Community Players Program Name: Theatre to Inspire our Community AIMMI 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of audience members served 3600 Number of performers participating 120 Number of technical skill volunteers participating 36 Number of workshops,classes,perofrmances and events held 6'10 Volunteer hours available 800 per volunteer TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages 3,000.00 Professional Fees 3,000.00 Operations 1,500 00 Supplies 2,000.00 Equipment 2,000.00 Other: Scholarships Awarded 700.00 Other: Equipment Storage 4,800.00 Other: Other: Other: TOTAL 17,000.00 Additional Council directives reardirret award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Honoka%a Hongwanji Mission Katsu Goto Memorial Committee 82 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee Agency Director: Miles Okumura Phone No.: (808 ) 640 — 4602 Contact Person: Patsy Iwasaki Phone No.: (808 ) 640 — 0683 Mailing Address: Address: 232 Edita Street Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Honokaa Hongwanji Mission Address: P.O. Box 1667 City,ST,Zip Honokaa, HI 96727 Email Address: piwasaki@hawaii.edu Fax No.: (808 ) 932 — 7214 Accountant/CPA: Maurice Kaneshiro(treasurer)/Clara C.S.Toma Phone No.: (808 ) 775 — 8006 Firm (if applicable): Mailing Address: Address: P.O. Box 1698 Address: City,ST,Zip Honokaa, HI 96727 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $32,000 Geographical Areas To Be Served: (One or more can be checked) ✓Puna ‘—'/Hamakua North Kona South Hilo I 'North Kohala 1-17--South Kona ✓North Hilo South Kohala F Ka`u Services or Activities To Be Provided: (One or more can be checked) Educational concerns Youth n Victims of Crimes ‘/Culture and the arts 'Aged n Victims of Health or Social Crises n Needs of the poor n Physical/Emotional Disabilities (Public Health and Welfare of the People and the Environment AMMINUMESIEffiffitHIMNIMMONAW EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 none none none 2. Agency Mission Statement: The Honokaa Hongwanji Mission is.a non profit organization that has been serving the Hamakua Coast of the Big Island for over 113 years. It is a subordinate temple of the Honpa Hongwanji Mission of Hawaii. Its mission is to: Respect the unique multicultural makeup of Hawaii, its history,and environment and give members and visitors alike a strong sense of this unique and diverse culture. Offer a range of religious opportunities for all members. To ensure a diverse membership mix,supporting our congregation's wide range of cultural and economic backgrounds. Challenge,develop and educate each member to move beyond his or her perceived level of potential. Nurture a strong sense of Sangha based on acceptance,respect, compassion and service to others. Strive to distinguish ourselves in our day to day activities. Produce creative leaders who are committed to family,community,environment and peace. Provide exceptional teaching and learning opportunities toward the understanding of Buddism,especially that of Jodo-Shinshu, and the development of a propagation program for a diverse congregation honoring that commitment. Honokaa Hongwanji has long been a leader in the community to honor and memorialize Katsu Goto, a labor martyr who defended immigrant and sugar plantation laborers'civil and democratic rights.Honokaa Hongwanji has been involved in numerous activities regarding Katsu Goto, including building the memorial located in Honokaa town next to the library in 1994 and presenting an annual memorial service.The board of directors has authorized the"Katsu Goto Memorial Committee"and Executive Producer Patsy Iwasaki to produce the film documentary video about Katsu Goto. 3. Program Description: This is a request for production funds for a one-hour film documentary called"Honokaa Hero:the Story of Katsu Goto/A Case for Democracy:the Story of Katsu Goto"(working titles)about the life and subsequent lynching of Katsu Goto, a Japanese sugar plantation contract laborer to Hawaii in 1885.We will explore the life of Goto,as a young man in Japan, influenced by the democratic, political reforms of the Meiji Restoration in Japan,including the Shonansha "People' s Rights Movement" a group of young democracy advocates; his active participation in civic life as a government worker and contributor to an economic journal; his emigration to the Hawaii Island as a sugar plantation laborer; his fulfillment of a 3-year sugar contract with Soper,Wright&Co; his emergence as a community leader after opening a general store in Honokaa; his promotion and defense of human rights and democracy as a community and labor leader in Honokaa; his work towards improved conditions for exploited immigrant workers; how the laws and court system of the Kingdom of Hawaii dealt with this seminal case; and the intimidation of a minority group via a lynching. Along with these significant themes,the team will also discuss the continuing humanitarian efforts being done in Goto's name, including the creation of the Goto Foundation by his adopted niece Dr.Fumiko Kaya and the importance of this case and application of his story relating to today's issues of democracy, racism,violence, immigration,social injustice and living and thriving in a multicultural world.We believe this film can impact and inspire diverse audiences to take initiatives to help promote peace and equity to a fragmented nation and a world that desperately needs it.The production team will combine interviews with academic scholars,historians,descendants, community members,dramatic reenactments,historical photos,original film and beautiful B-roll footage from Hawaii and Japan to bring this compelling and inspiring story,that is part of the dialogue and conflict that shaped our Hawaii island,our state,and our nation,to life.This is a true story that occurred in the Hawaii County locus of control that directly respects the aina/land and appreciates the many lessons it has to teach and will work in partnershi with the local community to study, protect, preserve and sustain the unique cultural and historical legacy of Hawaii Island. 4.Total Budget& Position Count: Total Program Budget: $32,000 Total Program Position Count: 3 Total Agency Budget: 1165,100 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii State Legislature Grant-in-Aid (to be released only when total funding reached) 36,000 In Kind Contributions by Program Positions of services 25,000 Atherton Family Foundation 20,000 YWCA of Oahu 5,000 Family of the late Dr. Fumiko Kaya 5,000 Honpa Hongwanji Mission of Hawaii 5,000 Big Island Candies (See also additional Revenue Source page) 5,000 TOTAL: 133,100 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: During the first phase of pre production, the team donated much of their time as in-kind services($25,000)to interview 12 community members to create two 4-minute short videos The Legacy and Bringing the Story to Life, about the legacy of Katsu Goto for the Bernice Pauahi Bishop Museum's Tradition and Transition: Stories of Hawaii's Immigrants (2011-2014)exhibit as well as preliminary interviews with Goto of Hiroshima Foundation members, descendants and a few scholars in Japan in 2014. The team has raised approximately$135,500 towards the development of this project which includes an award from the Hawaii State Legislature of$36,000; however, this$36,000 will only be released if the total budget of$165,100 is raised. The team has developed a website(http://katsugotomovie.org/)and materials to raise funds from public and private foundations as well as corporate funding.The website has a PayPal donation link which has generated donations online.The site has a list of donors or the name of someone they would like to honor with their contributions. Articles have been written, publicity generated and members of the team have been giving presentations throughout the community to raise awareness, interest and increase public engagement and raise funds. NGN TV aired a 25-minute special titled "Bringing the Legacy of Katsu Goto to Life" to generate interest, public engagement and fundraising in January 2016. The special had multiple showings during the month and was captioned in both English and Japanese for TV viewers at no cost to the project by NGN.The team received excellent feedback and interest along with people visiting the project' s website. Although this was an excellent and successful program to create interest and engage the public, it did not generate the much hoped for contributions.The team will continue to seek out foundation, corporate and individual donations to raise the funding necessary to complete the film documentary. 7. Program Objectives Using County Nonprofit Grant Program Funds: Production: Create accurate timeline of Goto events from Japan to Hawaii Confirm and meet with additional sources for interviews Transcription of interviews Development of treatment and script Determine and catalogue material collected Research collections, solidify list of material to be used Audio/Camera costs, Director/Editor costs, Producer/Writer Titles/Graphics, Music Composer, Narrator,Translation, Stock Footage/Stills, Recording Studio Time, Post Studio/Editing Equipment Rental, Music Rights, Color Correction/Online Picture, Mastering/Final Mix DISTRIBUTION: Film Festivals/Marketing, Press Kits/Postage Television and Digital Broadcast Ads, Festival Entry Fees, Final Website/Hosting DVD Authoring/Mastering, Printing Posters Design Blueray DVDs(1,000 Packaged/Shipped) E&O Insurance for PBS, Close Captioning/Sub Titles Online Digital Distribution EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 Revenue Source FY17-18 Estimate Ben Franklin Crafts/Ace Hardware Hawaii 5,000 Kosasa Family Fund 5,000 Island Insurance Foundation 5,000 University of Hawaii at Hilo Humanities Division 5,000 ILWU Memorial Association 2,500 Central Pacific Bank 2,000 KTA Superstore 1,000 _University of Hawaii Diversity and Equity Initiative 1,000 University of Hawaii Diversity Committee 1,000 East Hawaii Hiroshima Kenjinkai 1,000 Individual donations 3600 TOTAL(this page only) $32,100 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Presentations and viewing to community groups,organizations,etc. reaching over 5,000 Public viewing presentations on all islands reaching over 5,000 College/university libraries,faculty,staff,students access to free DVDs or streaming video Over 50 public library branches access to free DVDs or streaming video Over 200,000 Hawaii public/private students access to free DVD or streaming video Hawaii PBS, NGN TV Hawaii 200,000 viewers National PBS,with 350 members stations 95 million per month watch PBS programming Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages - in kind 73000 Professional Fees 14,000 14,000 Operations 8000 8000 10,000 10,000 10,000 Supplies 12,000 12,000 12,000 Equipment Other: Studio Rental 5,000 5,000 5,000 Other: Travel 8,000 5,000 5,000 Other: Outreach 3000 3100 Other: Distribution, including DVDs, live streaming to public/private schools 32,000 32,000 Other: Production materials and services 3000 3000 TOTAL 165,100 165,100 32,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council The Mayor n The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: V/ If no conflicts exist, check here. 1/31/16 Signature of AufWorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at - ., on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requect and may result in artianc taken to recnver these funds. By signing below, you are acknowledging that you have read and understood these requirements. h 1/31/16 �f Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Honokaa Hongwanji Mission Program Name: Katsu Goto Memorial Committee ti, 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result reaching over 5,000 Presentations and viewing to community groups,organizations,etc. reaching over 5,000 Public presentations and viewing on all islands College/university libraries,faculty,staff,students access to free DVDs or streamii access to free DVDs or Over 50 public library branches streaming video access to free DVD or Over 200,000 Hawaii public/private students streaming video 200,000 viewers Hawaii PBS, NGN TV Hawaii 95 million per month watch National PBS,with 350 members stations PBS programming TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies 10,000 Equipment 12,000 Other: Studio Rental 5,000 Other: Travel 5,000 Other: Outreach Other: Distribution, including DVDs, live streaming to public/private schools Other: Production materials and services TOTAL 32,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hope Services Hawaii, Inc. Continuum of Care Programs (CoC) 83 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Denise Oguma Phone No.: (808) 936 — 3995 Mailing Address: Address: 296 Kilauea Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 116 Kapiolani Street Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bmenino@hopeserviceshawaii.org Fax No.: (808 ) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: (808) 933 — 6008 Firm (if applicable): Mailing Address: Address: 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: $50,000 Geographical Areas To Be Served: (One or more can be checked) (✓� Puna n Hamakua C North Kona ✓ South Hilo n North Kohala n South Kona ✓ North Hilo n South Kohala ✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns Ill Youth Victims of Crimes ❑ Culture and the arts ✓❑Aged ✓ Victims of Health or Social Crises ✓❑ Needs of the poor I Physical/Emotional Disabilities • Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000.00 $15,000.00 $21,250.00 2. Agency Mission Statement: HOPE Services Hawaii, Inc.(HOPE), is a non-profit,faith-based organization based on Hawaii Island whose mission is to"Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." HOPE builds individual,family and community resiliency through direct service, community organizing, and intentional partnerships with public, private, and non-profit entities, including individual community citizens to work together to build strong families and healthy communities. HOPE is a long trusted and depended upon social service agency that responds to the most vulnerable populations on Hawaii Island, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth,elderly and justice involved individuals. 3. Program Description: Hawaii Island has the highest rate of chronic homelessness in the state.The Continuum of Care(CoC)programs provide permanent supportive housing for chronically homeless, high acuity individuals.To qualify for the program, individuals must have a documented disability in addition to either one(1)year of continuous homelessness or four(4)or more episodes of homelessness that equal 12-months within a three(3)year time period. In addition, preference is given to individuals that are of highest acuity using a common community assessment tool.To achieve the intended outcomes of the program,which include stable housing and independent living, Hope Services Hawaii works closely with other local social service agencies.This program is solely funded through federal grants that limits personnel and operational costs to no more than 7%of the grant. With 93%of the grant reserved for rental assistance it covers the cost of just half of one full time employee to implement the program. Its a constant challenge to secure matching funds to operate this program at its best to help those with the highest needs and most vulnerable in our community. In 2016, HOPE received funding for a second CoC program that has increased our capacity to house an additional twenty(20)chronically homeless individuals did not fund personnel costs. Providing Housing FIRST, is the first step in ending chronic homelessness in our community.The second highly critical component to this program is addressing the issues that led to their homelessness and rebuild independence and connection to family and community.This is the work of the Housing First Case Manager-a trained professional that acts as a positive change agent in holistically assisting 20 individuals/families most often living with issues such as severe and persistent mental health disorders, chronic illnesses, brain injury, and/or substance use disorders,to maintaining housing while concurrently promoting awareness and teaching strategies that reduce the likelihood of a return to homelessness in the future. 4.Total Budget& Position Count: Total Program Budget: $782,720.00 Total Program Position Count: 2 Total Agency Budget: $5,818,714.54 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii,County Council Non-Profit (unsecured, current ask) $50,000.00 Hawaii Island United Way(Unsecured, will apply, application due Feb 2017 for July 1, 2017) $21,000.00 Department of Human Services-CoC I (Secured) $564,600.00 Department of Human Services-CoC II (Secured) $147,120.00 TOTAL: $782,720.00 Attach additional pages, If needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This is an increased ask compared to previous years, as HOPE struggles each year to secure sufficient funding for two full-time case management positions and operational costs. This is the only program of its kind in Hawaii County due to the 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 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of persons served 100 Number of persons that will increase their income 30 Number of persons participating in an education or employment program 10 Number of persons who increased their knowledge of community resources 85 Number of persons who will complete a service plan 95 Number of persons accessing mental health services 80 Number of persons who will maintain their housing 85 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $14,466.10 $135,877.67 $20,000.00 Professional Fees $2,500.00 Operations $6,783.90 $25,000.00 $15,000.00 Supplies $8,000.00 $15,000.00 Equipment Other: Rent and Deposit Assistance $611,342.33 Other: Other: Other: Other: TOTAL $21,250.00 $782,720.00 $50,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: 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 I The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. 01/31/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fl/tl/rP fiinrling rPgIJPct nnrl mny result in nrtinnc tnkPn to rerrw r these funrlc, By signing below, you are acknowledging that you have read and understood these requirements. 01 /31/2017 Si nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Continuum of Care Programs (CoC) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of persons served 100 ' Number of persons that will increase their income 30 Number of persons participating in an education or employment program 10 Number of persons who increased their knowledge of community resources 85 Number of persons who will complete a service plan ss Number of persons accessing mental health services 80 Number of persons who will maintain their housing 85 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $20,000.00 Professional Fees Operations $15,000.00 Supplies $15,000.00 Equipment Other: Rent and Deposit Assistance Other: Other: Other: Other: TOTAL $50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hope Services Hawaii, Inc. Friendly Place Resource Center 84 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource Center Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Reinette Morgan Phone No.: (808) 937 — 8140 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: bmenino@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: $50,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo n North Kohala n South Kona ❑ North Hilo ✓ South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑Youth ❑✓ Victims of Crimes n Culture and the arts n Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor n Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 $15,000.00 0 2.Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), is a non-profit,faith-based organization based on Hawaii Island whose mission is to"Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." HOPE builds individual,family and community resiliency through direct service,community organizing,and intentional partnerships with public, private, and non-profit entities, including individual community citizens to work together to build strong families and healthy communities. HOPE is a long trusted and depended upon social service agency that responds to the most vulnerable populations on Hawaii Island, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities,youth,elderly and justice involved individuals. 3. Program Description: The Friendly Place Resource Center operates Monday through Friday,from 9:00am to 2:30pm. The Resource Center is staffed by one(1)full-time Housing Navigator-a trained professional that has extensive experience working with individuals and families that are homeless—including those that are or chronically homeless.The primary function of the Housing Navigator is to: 1. Certify individuals/households as homeless in accordance with the US Department of Housing and Urban Development Standards;2. Prioritize services based on the VI-SPDAT assessment(a triage tool that assesses depth of need); 3.Assist individuals/households in becoming Document Ready;4. Participate in the warm hand off to the Housing Team.As a secondary function,the Housing Navigator also provides client advocacy, case management, benefit establishment, linkage to mental health and substance use services, and all other supportive services as needed.The Housing Navigator provides individualized client support by helping each client develop a plan to address their barriers including an honest budget.The Housing Navigator also plays a critical role in addressing the neighboring community's concerns of safety, security, and neighborly conduct of program participants.The Housing Navigator also coordinates and oversees all aspects of the Resource Center including daily meals provided in partnership with local faith groups, access to restroom, showers, laundry facilities,clothing, personal hygiene, lockers, and mail service.The Housing Navigator facilitates the weekly Akamai Circle or site-based life skills training, links to substance abuse treatment, nutrition programs,veterans services,conflict resolution and mediation,and workshops on budgeting,financial literacy and tenant rights and responsibilities. This resource center is an access point to services in Kailua-Kona. 4.Total Budget& Position Count: Total Program Budget: $489,045.89 Total Program Position Count: 7 Total Agency Budget: $5,818,714.54 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County(unsecured, current ask) $50,000.00 State/Dept of Human Services, Homeless Program Office $340,560.00 State/Dept of Health, Adult Mental Health Division $32,673.50 Fundraising $65,812.39 TOTAL: $489,045.89 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE Services Hawaii will continue to search and apply for government and private grants through foundations and other charitable organizations to help sustain our program.We are also working on fund-raising opportunities to enrich services and and developing a donor base. HOPE will also continue to leverage our community-based partnerships and over 75 registered volunteers to help offset service costs, consumable goods and support staffing. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from this grant will cover personnel costs(salary and benefits)needed to operate the Resource Center.This position is critical to the realizing the intended outcome of the project-to provide resources and services to the homeless individuals and families of West Hawaii and support in becoming document ready as the first step to obtaining permanent housing. In previous years,this position was funded by a grant through the State of Hawaii Department of Human Services. In the most recent award which executes February 1, 2017,this position is no longer funded based on the State's definition of outreach. Each day,the Friendly Place serves an average of 50 individuals.The Friendly Place allows these individuals a place to have a hot meal, a warm shower,a safe refuge,and most importantly, access to the services and support they need to get out of homelessness and into housing. The Friendly Place Resource Center is an access point to shelter and housing services. Through the work of the Friendly Place team(outreach, shelter, and housing),we were able to place 112 homeless individuals into emergency shelter of which 22%of the individuals were chronically homeless,and 25%were elderly.And where 48%of the individuals who exited from the emergency shelter moved into permanent housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource Center 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of persons served 1000 Number whose vulnerability will be assessed using the VI-SPDAT prioritization tool 80% Number of persons who increase life skills due to participation in the Akamai Circle 20% Number of persons who will become Document Ready for housing placement 60% Number of persons who will access meals,showers, laundry facilities or lockers 100% Number of persons who will receive mail at the Friendly Place 50% Number of persons who will receive clothing, health, or hygiene supplies 70% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 $417,457.40 $50,000.00 Professional Fees $5,000.00 Operations $56,588.49 Supplies $10,000.00 Equipment Other: Other: Other: Other: Other TOTAL 0 $489,045.89 $50,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource Center 1.0. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: 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 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. /1/4144.1- 01 /31/2017 S gnature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource 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 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funning rPrluPct and may rPcult in artinnc taken to rernver thPCP fundc. By signing below, you are acknowledging that you have read and understood these requirements. a° 01 /31/2017 Si nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Friendly Place Resource Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of persons served 1000 Number whose vulnerability will be assessed using the VI-SPDAT prioritization tool 80°' Number of persons who increase life skills due to participation in the Akamai Circle 20% Number of persons who will become Document Ready for housing placement 60% Number of persons who will access meals, showers, laundry facilities or lockers 100% Number of persons who will receive mail at the Friendly Place 50% Number of persons who will receive clothing, health, or hygiene supplies 70' TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $50,000.00 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hope Services Hawaii, Inc. Hale Kikaha 85 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Reinette Morgan Phone No.: (808) 937 — 8140 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: bmenino@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: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua North Kona ❑South Hilo North Kohala n South Kona North Hilo I ] South Kohala l I Ka'u Services or Activities To Be Provided: (One or more can be checked) l✓l Educational concerns Youth n Victims of Crimes n Culture and the arts ✓❑Aged n Victims of Health or Social Crises ✓❑ Needs of the poor (✓I Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: HOPE Services Hawaii, Inc.(HOPE), is a non-profit,faith-based organization based on Hawaii Island whose mission is to"Bring to life gospel values of justice, love,compassion and hope through service, empowerment and advocacy." HOPE builds individual,family and community resiliency through direct service, community organizing, and intentional partnerships with public, private, and non-profit entities, including individual community citizens to work together to build strong families and healthy communities. HOPE is a long trusted and depended upon social service agency that responds to the most vulnerable populations on Hawaii Island, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities,youth,elderly and justice involved individuals. 3. Program Description: In December of 2016, HOPE transitioned three(3)homeless veterans and twenty(20)chronically homeless, high acuity individuals out of homelessness and into permanent supportive housing, quickly filling 23-units at Hale Kikaha(located within the Friendly Place Campus)to full capacity.To facilitate a successful transition out of homelessness, and to address the vulnerabilities that led to their homelessness,tenants of Hale Kikaha receive support from a full-time Housing First Case Manager.A Housing First Case Manager is a trained professional that acts as a positive change agent in holistically assisting individuals most often living with issues such as severe and persistent mental health disorders, chronic illness, brain injury, and/or substance use disorders,to maintain housing while concurrently promoting awareness and teaching strategies that reduce the likelihood of a return to homelessness in the future. Housing First Case Management is defined as: structured and active professional care that facilitates access to resources to improve housing and life stability through brokering and advocacy for services, based upon an assessment of needs.The case management services are intended to provide the direct, hands-on assistance that service users require to achieve greater independence in their life, as case managers work with service users on their journey. Case management services are provided to the tenants at Hale Kikaha.The Housing First Case Manager also plays a critical role in addressing the neighboring community's concerns of safety,security, and neighborly conduct among the tenants of Hale Kikaha.The Case Manager will also assist in communication with the County of Hawaii Office of Housing and Community Development to report any issues with facilities or equipment currently under warranty. This is our first time ask to support this program in Kailua-Kona. 4.Total Budget& Position Count: Total Program Budget: $191,096.80 Total Program Position Count: 1 Total Agency Budget: $5,818,714.54 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County(unsecured, current ask) $25,000.00 Rental Revenue $166,096.80 TOTAL: $191,096.80 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE Services Hawaii will continue to search and apply for government and private grants through foundations and other charitable organizations to help sustain our program.We are also working on fund-raising opportunities to enrich services and and developing a donor base. HOPE will also continue to leverage our community-based partnerships and over 75 registered volunteers to help offset service costs, consumable goods and support staffing. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from this grant will cover personnel costs(salary and benefits)needed to operate the 23 units at Hale Kikaha.This position is critical to realizing the intended outcomes of the project-to house high acuity, chronically homeless individuals, and to provide the necessary wrap-around services and supports to address the vulnerabilities that contributed to their homelessness. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of persons served 23 Number of persons that will increase their income 20 Number of persons participating in an education or employment program 5 Number of persons accessing mental health services 20 Number of persons who complete a service plan 20 Number of persons who maintain their housing 20 Number of persons who are linked to community resources 20 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $22,500.00 $112,228.73 $25,000.00 Professional Fees $20,000.00 Operations $48,368.07 Supplies $8,000.00 Equipment $2,500.00 Other: Other: Other: Other: Other: TOTAL $191,096.8 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: 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 I ( 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. /{t L 01/31 /2017 Si ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funning rPgiIPct and may reciilt in nrtianc taken to rernver theca funrdc. By signing below, you are acknowledging that you have read and understood these requirements. 01/31/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Hale Kikaha 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of persons served 23 Number of persons that will increase their income 20 Number of persons participating in an education or employment program 5 Number of persons accessing mental health services 20 Number of persons who complete a service plan 20 Number of persons who maintain their housing 20 Number of persons who are linked to community resources 20 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $25,000.00 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hope Services Hawaii, Inc. HOPE Resource Center 86 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource Center Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Denise Oguma Phone No.: (808) 936 — 3995 Mailing Address: Address: 296 Kilauea Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 110 Ululani Street Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bmenino@hopeserviceshawaii.org Fax No.: (808 ) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: (808 ) 933 — 6008 Firm (if applicable): Mailing Address: Address: 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: $50,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna [ Hamakua ❑✓ North Kona ✓❑South Hilo ❑✓ North Kohala ✓❑South Kona ❑✓ North Hilo H South Kohala ✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns ❑Youth ✓ Victims of Crimes ❑ Culture and the arts ✓❑Aged n Victims of Health or Social Crises H Needs of the poor H Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $15,000 $22,500.00 2.Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), is a non-profit,faith-based organization based on Hawaii Island whose mission is to"Bring to life gospel values of justice, love,compassion and hope through service,empowerment and advocacy." HOPE builds individual,family and community resiliency through direct service,community organizing,and intentional partnerships with public, private, and non-profit entities, including individual community citizens to work together to build strong families and healthy communities. HOPE is a long trusted and depended upon social service agency that responds to the most vulnerable populations on Hawaii Island, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities,youth,elderly and justice involved individuals. 3. Program Description: The location is new, but the intent of the program will remain the same. Our new state contract to provide emergency shelter services begins February 1,2017 with an implementation ramp up timetable of April 1, 2017. We will be moving our men's shelter operations from 116 Kapiolani Street to 110 Ululani Street, Hilo by April 1, 2017. This move will allow us to meet the new shelter rules defined by the State Department of Human Services including private space, partitions, shower/toilet/basin ratio per resident. We will offer thirty-two(32)bed spaces for single men in six(6)leased apartment units we currently manage from the Roman Catholic Church in the State of Hawaii.Through our outreach and engagement efforts on the streets, bushes, camp sites, parks, beaches and cars,once a person agrees to shelter, it is critical to have a shelter bed ready for them. Having a short stay residence to rest their head at night allows the Housing Navigator the ability to follow up with the individual on site on a consistent basis. The target goal of 60 days will be their length of stay at the shelter.The goal is to rapidly rehouse these men 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; prioritizing those with the highest acuity first, and allocating the services accordingly. Along with teaching and modeling skills and strategies for increased interdependence,this may include but not limited to:setting up appointments; attending appointments; budgeting and money management; payment of rent; shopping;food preparation;cleaning; laundry; using the transportation systems. 4.Total Budget& Position Count: Total Program Budget: $557,081.78 Total Program Position Count: 11 Total Agency Budget: $5,818,714.54 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County(unsecured, current ask) $50,000.00 Department of Human Services (Secured) $296,070.00 Program Fees (Secured) $46,720.00 Fundraising (Unsecured) $164,291.78 TOTAL: $557,081.78 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE Services Hawaii will continue to search and apply for government and private grants through foundations and other charitable organizations to help sustain the Representative Payee program.We are also working on fund-raising opportunities to enrich services and and developing a donor base. HOPE will also continue to leverage our community-based partnerships and over 75 registered volunteers to help offset service costs,consumable goods and support staffing. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover operational and supply cost to maintain the day-to-day operations of HOPE Resource Center. We previously called this program the East Hawaii Emergency Housing Program. Decreasing chronic homelessness in East Hawaii by providing emergency shelter to those most vulnerable in our community; improve residential stability to men experiencing homelessness; improve the health outcomes and quality of life to men experiencing homelessness and decrease victimization on the streets.The HOPE Resource Center is designed to make emergency shelter accessible for men experiencing homelessness and take initial steps to secure and maintain jobs--often the first step towards getting out of the homeless shelter system and into housing as quickly as possible. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource Center 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of persons served 140 Number of residents who exited into permanent housing 70 Number of occupied bed nights 9,000 Number of residents who exited to other temporary housing 25 Number of residents who accessed health care services(physical health, mental, Sub Ab) 100 Number of residents who obtained new or maintained current employment 50 Number of residents who increased their income or skills 50 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $22,500.00 $381,721.94 Professional Fees $5,000.00 Operations $145,000.00 $40,000.00 Supplies $20,000.00 $10,000.00 Equipment $5,359.84 Other: Other: Other: Other: Other: TOTAL $22,500.00 $557,081.78 $50,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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): n Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. /11Q4w`. , a- 01/31 /2017 Si nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource Center ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource 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 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aciency's future funding rerpiect and mny recult in ortinnc token to rernver theca funds. By signing below, you are acknowledging that you have read and understood these requirements. /L( A) M4W My 01 /31/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: HOPE Resource Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of clients served 140 Number of clients who receive budgeting counsel 70 Number of clients who participate in life skills, financial literacy and budgeting education 9.000 Number of clients who transition off services 25 Number of clients linked to mental health 100 Number of checks processed 50 Number of clients who participate in a treatment plan 50 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations $40,000.00 Supplies $10,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hope Services Hawaii, Inc. Representative Payee Services 87 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Denise Oguma Phone No.: (808) 936 — 3995 Mailing Address: Address: 296 Kilauea Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 116 Kapiolani Street Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bmenino@hopeserviceshawaii.org Fax No.: (808 ) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: (808 ) 933 — 6008 Firm (if applicable): Mailing Address: Address: 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: $17,500 Geographical Areas To Be Served: (One or more can be checked) ✓ Puna ✓ Hamakua n North Kona n South Hilo n North Kohala n South Kona • North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) • Educational concerns ❑Youth n Victims of Crimes n Culture and the arts n Aged ✓ Victims of Health or Social Crises ✓Q Needs of the poor n Physical/Emotional Disabilities ✓0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 $17,500 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), is a non-profit,faith-based organization based on Hawaii Island whose mission is to"Bring to life gospel values of justice, love,compassion and hope through service, empowerment and advocacy." HOPE builds individual,family and community resiliency through direct service,community organizing, and intentional partnerships with public, private, and non-profit entities, including individual community citizens to work together to build strong families and healthy communities. HOPE is a long trusted and depended upon social service agency that responds to the most vulnerable populations on Hawaii Island, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities,youth, elderly and justice involved individuals. 3. Program Description: The Representative Payee program is designed to assist individuals with severe and persistent mental illnesses who have Supplemental Security Income(SSI)benefits and are unable to independently manage their finances. Referrals are received from the Social Security Administration, Department of Health Adult Mental Health Division or community mental health case managers. Clients may be victims of financial abuse from family members or peers who take advantage of them and take their money, leaving the individual vulnerable.The Representative Payee(staff), in partnership with the client,develops a monthly budget to ensure their basic needs of food,clothing, housing, and medical care are met. Rent payments are made directly to the landlord or property manager, ensuring rent is paid in full and on time,thus decreasing their risk to homelessness.After all expenses are paid,the program staff work closely with the client to assist in saving a portion of their discretionary funds, preferably in an interest-bearing bank account,for future emergencies and/or purchases of bigger ticket items.All remaining funds are then distributed to the client as an allowance on a daily,weekly or monthly basis,depending on the client's functioning level.At program capacity of two-hundred(200)clients,the Representative Payee staff distribute nearly 1,200 checks and provide over 80 hours of financial and money management counsel each month. Representative Payee staff complete accounting reports that show how each individual's income is spent and saved and report changes in client circumstances that could affect benefit eligibility, including income, resources, change of address, living arrangements, return to work, etc.to the Social Security Administration,further decreasing the vulnerability of mentally ill individuals at-risk of homelessness. 4. Total Budget& Position Count: Total Program Budget: $118,238.81 Total Program Position Count: 2 Total Agency Budget: $5,818,714.54 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County(unsecured, current ask) $50,000.00 Adult Mental Health Division (Secured) $68,238.81 TOTAL: $118,238.81 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE Services Hawaii will continue to search and apply for government and private grants through foundations and other charitable organizations to help sustain the Representative Payee program.We are also working on fund-raising opportunities to enrich services and and developing a donor base. HOPE will also continue to leverage our community-based partnerships and over 75 registered volunteers to help offset service costs,consumable goods and support staffing. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover personnel costs(salary&benefits)to maintain the capacity of our Representative Payee team. The County's contribution is critical and timely,given the decrease in the total of reimbursement cost by half threatening our current staff capacity by one(1). Our representative payee who receives Social Security or SSI payments(or both)for someone who cannot manage his or her benefit payments.County funding will be used for our staff to maintain the responsibilities as a payee: 1)Use benefit payments received to pay for the current and foreseeable needs of the each consumer; 2)Create a budget with consumer to save any benefit payments not needed to meet current needs; 3)Keep accurate records of how all funds are distributed providing receipts for all special request; 4)Report changes that may affect benefit payments directly to Social Security Administration. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of clients served 200 Number of clients who receive budgeting counsel 200 Number of clients who participate in life skills,financial literacy and budgeting education 200 Number of clients who transition off services 12 Number of clients linked to mental health 170 Number of checks processed 14,400 Number of clients who participate in a treatment plan 160 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $17,500.00 $112,358.99 $10,500.00 Professional Fees Operations $5,879.82 $7,000.00 Supplies Equipment Other: Other: Other: Other: Other TOTAL $17,500.00 $118,238.81 $17,500.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: 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): I I Member or members of the Council Staff appointed by a member of the Council I I The Mayor I 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. , Cep 01/31/2017 Sign ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerquPct and mny rPcult in nrtinnc taken to rarnvPr thecP funds. By signing below, you are acknowledging that you have read and understood these requirements. / 01/31/2017 Signat re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: Representative Payee Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of clients served 200 Number of clients who receive budgeting counsel 200 Number of clients who participate in life skills,financial literacy and budgeting education zoo Number of clients who transition off services 12 Number of clients linked to mental health 170 Number of checks processed 14,400 Number of clients who participate in a treatment plan 160 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $10,500.00 Professional Fees Operations $7,000.00 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $17,500.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hope Services Hawaii, Inc. West Hawaii Emergency Housing Program 88 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program Agency Director: Brandee Menino Phone No.: (808) 933 — 6013 Contact Person: Reinette Ipo Morgan Phone No.: (808) 936 — 3995 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, HI 96740 Email Address: bmenino@hopeserviceshawaii.org Fax No.: (808 ) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: (808 ) 933 — 6008 Firm (if applicable): Mailing Address: Address: 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: $30,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua n North Kona South Hilo n North Kohala ❑✓ South Kona n North Hilo H South Kohala C Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns Youth H Victims of Crimes n Culture and the arts ✓ Aged n Victims of Health or Social Crises ✓❑ Needs of the poor ✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $15,000 $20,000.00 2.Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), is a non-profit,faith-based organization based on Hawaii Island whose mission is to"Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." HOPE builds individual,family and community resiliency through direct service,community organizing,and intentional partnerships with public, private,and non-profit entities, including individual community citizens to work together to build strong families and healthy communities. HOPE is a long trusted and depended upon social service agency that responds to the most vulnerable populations on Hawaii Island, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities,youth,elderly and justice involved individuals. 3. Program Description: The West Hawaii Emergency Housing Program(WHEHP)offers short-term temporary housing for men and women who are experiencing homelessness in West Hawaii. In January 2016,we expanded shelter hours from 15 hours per day to 24 hours a day, seven days a week.At initial intake, an individualized housing plan is developed with the individual.An assessment is conducted to determine current housing and employment challenges,from which goals are then established to promote and strengthen housing and financial sustainability. Residents are provided with life skills trainings, including basic budgeting and tenant readiness, housing search, placement and rent assistance. Staff also connect residents to other community resources including Supplemental Nutrition Assistance Program(SNAP)and health insurance enrollment, healthcare, mental health services,substance abuse treatment, and employment readiness and training.With a targeted stay of 60 days, service plans and goals are reviewed frequently,and individuals are encouraged to be diligent in pursuing their goals.The goal is to move from the emergency shelter and into housing in the private rental market as quickly as possible. The program leverages civic, academic and community groups to facilitate academic, enrichment and socialization opportunities for both adults. It is also not uncommon for our shelter staff to see,engage or be confronted with violence and threats of violence; profane, racist and/or sexist language conflict;and interactions with First Responders.Shelter staff or Housing Navigators, are trained in CPR/First Aid and non-violent crisis interventions to maintain resident and staff safety.The Shelter offers the first step to feeling safe and stable enough to obtain and maintain employment. Securing employment and increasing their income is often the first step towards moving out of the shelter and into their own homes. 4.Total Budget& Position Count: Total Program Budget: $441,968.17 Total Program Position Count: 9 Total Agency Budget: $5,818,714.54 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County(unsecured, current ask) $30,000.00 Department of Human Services (Secured) $322,477.30 Program Fees (Secured) $33,201.00 Foundation (Unsecured) $30,000.00 Emergency Solutions Grant-State of Hawaii (Secured) $26,289.84 TOTAL: $441,968.17 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 to a desired 24 hours/7 day a week program as encouraged by the previous County administration. Mayor Kim has also made ending homelessness a priority.There is great need by the community to have this program open throughout the day to meet the needs 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 Services Hawaii will continue to search and apply for government and private grants through foundations and other charitable organizations to help sustain our homeless outreach program.We are also working on fund-raising opportunities to enrich services and and developing a donor base. HOPE has secured funds for a position to help increase our fundraising efforts to meet increasing need and to maintain new funding sources through new government grants,foundational giving opportunities, and individual contributions from the community. HOPE will also continue to leverage our community-based partnerships and over 75 registered volunteers to help offset service costs, consumable goods and support staffing. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover personnel costs(salary&benefits)to maintain current 24/7 staff coverage at this facility.With your continued support and funding level, it is our intention to maintain the operation of the shelter 24 hours a day/7days a week. 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 the lessee and contractor with no dedicated County revenue to support operations, HOPE is responsible to seek operational funds and to meet the demands of our vulnerable community. The ask of the County's contribution,which is less then 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(University of Hawaii, Center on the Family, Homeless Service Utilization Report 2014). In 2015, over half of the persons served were new persons,first time accessing the homeless service system. HOPE needs the resources to be able to upkeep this County-owned facility from wear and tear by the new,transient population. HOPE is the lifeline and safety net to the most vulnerable persons in our community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of persons served 120 Number of residents who exited into permanent housing 60 Number of occupied bed nights 9,500 Number of residents who exited to other temporary housing 20 Number of residents who accessed health care services(physical health, mental, Sub Ab) 95 Number of residents who obtained new or maintained current employment 50 Number of residents who increased their income or skills 50 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $18,338.31 $323,417.75 $30,000.00 Professional Fees $5,000.00 Operations $1,661.69 $76,550.42 Supplies $30,000.00 Equipment $7,000.00 Other: Other: Other: Other: Other TOTAL $20,000.00 $441,968.17 $30,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency 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 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): I 1 Member or members of the Council n Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by 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: n If no conflicts exist, check here. 4 01/31/2017 Signature of Authi1/4.-41-4..-1143orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futiire funding rPgiiPct and may recult in nrtinnc taken to rernvpr thece funds, By signing below, you are acknowledging that you have read and understood these requirements. „o 01 /31/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hope Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of clients served 120 Number of clients who receive budgeting counsel 60 Number of clients who participate in life skills, financial literacy and budgeting education 9,500 Number of clients who transition off services 20 Number of clients linked to mental health 95 Number of checks processed 50 Number of clients who participate in a treatment plan 50 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $30,000.00 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 2017-2018 Page 8 of 8 Hospice of Hilo Technology for Improved Health Care Access 89 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technolo• for Im•roved Health Care Access Agency Director: Brenda S. Ho, MS, RN Phone No.: (808) 969 — 1733 Contact Person: Lisa Kwee Phone No.: (808) 969 — 1733 Mailing Address: Address: 1011 Waianuenue Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1011 Waianuenue Ave. Address: City,ST,Zip Hilo, HI 96720 Email Address: lisak@hospiceofhilo.org Fax No.: (808 ) 961 — 7397 Accountant/CPA: loana Agasa, CPA Phone No.: (808 ) 981 — 2405 Firm (if applicable): Mailing Address: Address: 280 Kapualani Street Address: City,ST,Zip Hilo, HI 86720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona ❑✓ North Hilo ❑ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technolo• for Im•roved Health Care Access 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $45,000 $7,500 $11,750 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: Hospice of Hilo(HOH), a private, non-profit 501(c)3 agency has compassionately served the end-of-life and bereavement needs of the east and south portions of Hawaii County since 1983(Laupahoehoe to South Point, Ka'u), a geographic area of over 2000 square miles. In 2016, HOH served 521 patients and their loved ones. In addition to the patients and families receiving hospice support, an additional 350 adults and children received free grief counseling from Hospice of Hilo's bereavement support team. The hospice model of service focuses on alleviating the pain and symptoms of patients facing a life-limiting or serious illness in their place of residence.The hospice benefit also provides the equipment and medication necessary to alleviate patients' pain and symptoms. The rural nature of Hospice of Hilo's service area, coupled with its high poverty rate and seniors over the age of 65, creates special challenges for its residents. Geographic distance to services and topographic challenges due to lack of safe roads,or infrastructure, create circumstances that make receiving consistent or urgent heath care especially problematic. Patients and families residing in rural areas deserve the same level of care and support as those living in easily reachable locations. For this reason, HOH seeks to add vital computer upgrades to the program and a much needed Telemedicine component,thus increasing health care access to residents of Hawaii County. 4. Total Budget & Position Count: Total Program Budget: $96,904 Total Program Position Count: 70 Total Agency Budget: $8,057,379 Total Agency Position Count: 80 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technology for Improved Health Care Access 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Foundations $10,000 Individual Donors/Fundraisers $15,000 Government-State Grant in Aid (2017-2018) $26,440 Government-County Non-Profit(2017-2018) $50,000 TOTAL: $101,440 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The flat rate paid to HOH from insurers is$160/day, regardless of the intensity of care delivered. The Average Per Day Cost of Care for a patient in rural and complex circumstances is 30%above Medicaid/Private Insurer reimbursement. HOH never passes uncovered care costs on to surviving family members. When the challenges of caring for complex rural patients are added to an already difficult disease process,the cost of providing care far exceeds the allocated$160/day. Hospice of Hilo believes quality health care should never be dependent on whether a patient can afford it. With this philosophy in mind, HOH will always strive to meet the needs of every person requesting its services, regardless of ability to pay. It is for this reason that HOH will continue to cultivate and be grateful for the support of County, State and private donors. The only way Hospice of Hilo will be able to increase its revenue is to serve more patients in our region. Hospice of Hilo continues to educate the community so that consumers clearly understand the benefits of accessing hospice and palliative care. There are also many initiatives being launched by Hospice of Hilo(ie. Kupu Care-Community Based Palliative Care Program) to ensure we are well-positioned to support patients and community health care providers, so that when the time is appropriate for a patient to choose hospice care or palliative care,we can reach them in an expedited manner and bring comfort and relief as quickly and as efficiently as possible. 7. Program Objectives Using County Nonprofit Grant Program Funds: County Nonprofit funds will be used to improve access to health care through the use of technology. The proposed project will have two goals: ONE- Replace aging laptops, purchase ipads for increased capacity and mobility, and upgrade outdated software vital to HOH's home care program, and TWO—implement a telemedicine component to HOH's Community Based Palliative Care Program, Kupu Care. (1)— Home Care Computer Support: On-site tracking and reporting of sensitive health information is vital to providing the best health care to the community. Efficient off-site reporting and compliance with the ever-changing regulations in the medical field make replacement of computers that are no longer serviceable, and updates to software,vital for proper logging of patient's protected health information, as well as electronic transmission of such records. In addition, bedside care in ever-changing home environments requires flexibility and mobility, both possible with the purchase of ipads for field use. (2)—Telemedicine(TM) is the use of telecommunication and information technology to provide clinical health care from a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. Real-time monitoring of patient health fluctuations that might indicate an impending health crisis will help the HOH team more effectively care for our rural community. The initial telemedicine launch will be in HOH's Community Based Palliative Care Program, Kupu Care, studies have show TM to be especially successful for patients with chronic conditions,while reducing the overall cost of care. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technolo• for Im•roved Health Care Access 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) See Attached Document Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: (pads with accessories (25 units) $17,500 $17,500 Other: Laptops (15 units) $15,000 $15,000 Other: Jet Packs (15 units) $600.00 $600.00 Other: Telemedicine(30 units) $63,804 $16,900 Other: TOTAL $96,904 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technolo• for Im•roved Health Care Access 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. SInri S, January 30, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technolo. for Im•roved Health Care Access 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technolo. for Im•roved Health Care Access ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fin-lire funding rPrquPct nnnl mny rPcult in nrtinnc tnkan to rarnver theca fiinrIc, By signing below, you are acknowledging that you have read and understood these requirements. 61.Pind01/4- . —}-f January 30, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hospice of Hilo Program Name: Technolo. for Im.roved Health Care Access 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result See Attached Document TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: 1pads with accessories (25 units) $17,500 Other: Laptops (15 units) $15,000 Other: Jet Packs (15 units) $600.00 Other: Telemedicine (30 units) $16,900 Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hospice of Hilo 8. Table 1: Attachment: What are the intended measurable outputs or outcomes that would be achieved with this funding? County Funding will be dedicated to improving access to health care through the use of technology-with two goals:(1) the replacement of aging laptops and outdated software vital to HOH's home care program, and purchase of ipads to increase flexibility and mobility for home-based bedside care, and (2) the implementation of a TELEMEDICINE component piloted in HOH's Community Based Palliative Care Program, Kupu Care. Pro,ram Performance Measures A• •licant Pro'ected Results Purchase New Ipads for bedside care Increases: patient engagement,mobility at bedside,ease of use,and flexibili . Purchase New Laptop Computers to Use of properly working computers in the field allow nurses to document ensure speed and data efficiency, observations,access medical terminology libraries to answer patient compliance with latest operating systems questions,transfer sensitive medical information for prescriptions or consultations and schedule a••oints;all while in the •atient's home. Upgrade Software with current industry Maintains patient EMR(electronic medical records) confidentiality,HIPPA standards compliance and federal Medicaid/Medicare documentation and billing ca•abilities. "Telemedicine has great potential to address some of the challenges faced by rural underserved communities in providing accessible,cost-effective, high-quality health care services. Telemedicine can overcome geographical barriers, and greatly increase access to health care services." -World Health Organization Many patients in the East Hawai'i service area,a driving distance of 97.6 miles,are challenged with: -Long travel distances from their place of residence to reach a health care provider -Lack of reliable vehicle for transportation, and/or a caregiver who is able to provide transportation -Chronic conditions which make travel painful,and sometimes dangerous Pro:ram Performance Measures A• •licant Pro'ected Results Install technology(computer Overall-Increases patient care and comfort tablets/laptops)in patient homes and Decreases patient stress,need for outpatient visits and cost to health system conduct patient trainings Provide patients with biometric Allows for real-time monitoring of various patient health triggers/biometrics equipment(blood pressure machines, to ensure patient is stable,and if not,allows team to dramatically increase scales,oxygen readers,sugar monitors response time etc.)and instruct patients on device usage Implement remote Monitoring of patients' -Establishes daily care connection between regularly scheduled care visits, health (through biometric equipment and allowing for health practitioner to intervene in real time when measurements skype)-maintain connection between in- go in a negative direction person visits,to be initiated by either side -Enables remote prescription verification and drug administration oversight, ensuring proper use of pharmaceuticals Collect data per patient -Automatically store patients' measurements and allow for remote care team access to information -Provide ongoing health update to Primary Care Provider(PCP) or specialist, allowing for improved communication between entire care team,as well as provide invaluable information for PCP to create Plan of Care Setup of Skype for as needed patient/care Intervene in real time when patient health declines to avoid ER visits and team check ins,to be initiated by either side Hospitalizations Telemedicine (TM)can be especially beneficial to patients suffering with chronic, life-limiting conditions. HOH would partner with Ho'okele Health Navigators LLC, a private duty home health company located on O'ahu, who completed a successful telemedicine pilot project under the Beacon Grant using their computer program and software design named, iHealthHome. HOH will pilot its TM component through its Community Based Palliative Care Program-Kupu Care. Hui Malama Ola Na Oiwi Cancer Program - Malama Ka Pili Pa'a Expansion 90 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion Agency Director: Mabel De Silva, HMONO Board of Directors, Chair Phone No.: (808) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: (808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (808 ) 531 — 1040 Firm (if applicable): CW Associates. CPAs Mailing Address: Address: 700 Bishop Street, Suite 1040 Address: City,ST,Zip Honolulu, 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: $20,000 Geographical Areas To Be Served: (One or more can be checked) WI Puna Ii Hamakua ✓❑ North Kona South Hilo ✓ North Kohala ✓❑ South Kona RI North Hilo i✓i South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns n Youth ri Victims of Crimes H Culture and the arts I✓I Aged Victims of Health or Social Crises Li Needs of the poor v Physical/Emotional Disabilities H Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $10,000 $7,500 2. Agency Mission Statement: Misssion Statement: '0 Hui Malama Ola Na 'Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho`oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawaii Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical. spiritual,and mental body, Malama i na mea Hawaii-and Hawaiian culture and practices. E ho`oikaika a ola ka lahui Hawaii-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na 'Oiwi, its Board of Directors, Administration, and Staff are guided and directed by Na Kupuna (our elders) with wisdom and skill received from our ancestors. We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power • Lokahi: Harmony, parity and balance • 'Ohana: Family-core, intermediate, extended •Po`okela: Excellence • Ho'omau: Life-long learning with guaranteed life for generations to come •Koho`ia:To be chosen; a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: The Hui Malama Ola Na'Oiwi (HMONO)Cancer Program Manager(CPM)is responsible for the success of the HMONO Cancer Program.The CPM provides cancer patient navigation for the HMONO cancer clients, facilitation of the existing island-wide Malama Ka Pili Pa'a(MKPP)Cancer Support Group based in Hilo, and the formation of four smaller, cancer support groups, based in the HMONO service areas of North Hawaii, Kona, Puna, and Ka`u. The cancer patient navigation process includes patient advocacy,assistance with health insurance marketplace policy changes and coverage, completion of insurance forms and application,facilitating communications between the cancer patient and his or her family, and assisting with the placement of cancer patients in off-island life-saving cancer treatments. In support of the latter responsibility,the CPM visits facilities to ensure appropriate placement and treatment. The island-wide MKPP cancer support group is an active group of cancer patients, patient caregivers,and cancer patient supporters with more than 30 active participants at any given time.The average attendance of the twice-a-month group meetings is 18 participants per meeting. Each summer the MKPP runs a fundraising softball tournament and every November MKPP hosts their annual Caregiver Appreciation dinner to give back to their care-giving community. Forty-six clients and caregivers attended this event.The MKPP also has,on average three group activities a month that are open to cancer patients. cancer patient supporter, and caregivers, with attendance ranging from five to 30 participants. The CPM facilitates the MKPP in-person meetings and events.The smaller support groups are mainly communicating electronically with occasional informal gatherings and these unofficial activities are not facilitated by the CPM. The CPM would like to continue to develop these smaller gatherings into reliable group support meetings and facilitate the meetings as well as any regional group outings. 4. Total Budget& Position Count: Total Program Budget: $ 80,200 Total Program Position Count: 1 Total Agency Budget: $ 2,727,000 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Health Resources Services Administration (HRSA) $55,500.00 MKPP Softball Tournament and related donations $ 4,700.00 County of Hawaii $20,000.00 TOTAL: $80,200.00 I 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 Cancer Program is mostly funded by the U.S. Department of Health and Human Services, Health Resources Services Administration (HRSA)and only supports a single position to coordinate our Cancer Program. HMONO utilizes its Health Resource Specialists as navigators whom work with the State of Hawaii's(Centers for Disease Control)Breast &Cervical Cancer Control Program(BCCCP)via the local community health centers, and assist cancer clients with screening. diagnostics, and treatment.The BCCCP provides breast and cervical cancer screening services to medically under-served women and appropriate referrals,when necessary: diagnostic follow-up, case management and assurances for medical treatment. This limited funding for cancer-related programs, which is currently not mandated or supported by HRSA,coupled with BCCCP clinical services, are supplemented by funds raised by our community cancer support group, Malama Ka Pili Pa'a (MKPP).Their most recent softball tournament and small-scale fundraisers provided us with$5,718 for the Cancer Program. MKPP's vision to share their journey with the communities around the island and to welcome other cancer survivors into their support group(s)will be supplemented by continued fundraising activities on a larger scale as awareness of our services increases. • 7. Program Objectives Using County Nonprofit Grant Program Funds: County of Hawaii funding will secure the establishment of the Cancer Program's vision of five place-based Malama Ka Pili Pa'a(MKPP)Cancer Support Groups,distributed in geographically and culturally unique areas across the island. Given the amount of time that cancer patients spend isolated indoors at home,treatment centers, or a doctor's office, it is important for those battling cancer to be able to gather, in support of each other and with cancer survivors, at outdoor locations to partake in conversation, art creation,and cultural activities.The funding will also be used for incentives(food,art materials,educational materials,etc.)to increase attendance of the start-up groups in Ka'u, Kona, and North Hawai'i.These nascent regional groups exist but the participants mainly communicate with each other electronically with occasional informal in-person gatherings. Each year MKPP is invited to attend the annual State of Hawai'i cancer survivorship conference(usually hosted on O'ahu) and the Cancer Patient Navigation(CPN)conference hosted by Queens and other state stakeholders. Funding would be used to send MKPP participants to these events.The past attendance of MKPP members has resulted in breakout sessions focused on their successes and challenges in dealing with cancer. The County of Hawai'i funding would also be used to train a secondary Cancer Program Manager(CPM)to advocate for, provide patient navigation services to, and support those battling cancer, and their caregivers, in the West Hawai'i areas.This CPM will also be a Certified Nursing Assistant and experienced in Case management.The West Hawai'i CPM will also receive additional training similar to'Imi Hale Native Hawaiian Cancer Network's 48-hr training program which includes 14 competencies utilizing 30+faculty from Hawaii cancer care hospitals and programs and exposure to culturally tailored and clinically relevant breast cancer information. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of meetings and outings for the Kona cancer support group network 4 Number of meetings and outings for the Ka'u cancer support group network 4 Number of meetings and outings for the North Hawaii cancer support group network 4 Number of meetings and outings for the Puna cancer support group network 4 _Number of trained Cancer Program Managers dedicated to West Hawaii areas 1 Number of cancer survivorship-related conferences attended by MKPP participants 2 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wars 50,409 55,870 $ 10,000 ProfessiaLEees 1,059 500 5,950 3,430 Operations 10,250 10,700 $ 5,000 Supplies Equipment 2,000 I Other: Off island travel (Survivorship Conf., CPM Navigation Training) 7,000 6,500 $ 4,400 Other: Vehicle rent for travel to island sites for support group expansion 1,000 1,200 $ 600 Other: Other: Other: TOTAL I $75,668 i $80,200 $ 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Mama Ka Pili Pa'a Expansion 'a. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists, NAME:Mabel W. De Silva POSITION: Chair, 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): j j Member or members of the Council Staff appointed by a member of the Council I The Mayor The Managing Director The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantia probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry, Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X If no conflicts exist, check here. / �`,,�7 � air /13'c' 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na `Oiwi Program Name:Cancer Program - Mama Ka Pili Pa'a Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Louis Hao POSITION: Vice Chair, 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): 7 Member or members of the Council 7 Staff appointed by a member of the Council H The Mayor The Managing Director u The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interests defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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. //aK/C----e--t-D 1/1-1,--.0 ( ‘b o& (^)(ou r) C)/'56 — / 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLiCATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na 'Oiwi Program Name: Cancer Program - Mama Ka Pili Pa'a Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Robert M. Yamada II POSITION: Secretary/Treasurer, 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): X 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 s defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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 served on the election campaign for Councilwoman Sue Lee Loy. Conflict of interest will be avoided by not discussing this grant application with Councilwoman Sue Lee Loy. j1 If no conflicts exist, check here. it(4/641 it t (7 Signature of Authorized erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na 'Oiwi Program Name: Cancer Program - Mama Ka Pili Pa'a Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: David J. Lovell POSITION: Director, 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): I Member or members of the Council I I Staff appointed by a member of the Council I �i The Mayor 7 The Managing Director j The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I X! If no conflicts exist, check here. �'` D i revfrk Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na `Oiwi Program Name: Cancer Program - lama Ka Pili Pa'a Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i, Only those listed below need to be disclosed. One form per person with a conflict is needed, If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Noelani Puniwai POSITION: Director, 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): 7 Member or members of the Council I Staff appointed by a member of the Council j The Mayor 7 The Managing Director 1 The Director of Finance F-1 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: �J If no conflicts exist, check here. fc*vj )( -27 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Leona K. Seto-Mook POSITION: Director, 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): H I Member or members of the Council I I Staff appointed by a member of the Council j j The Mayor The Managing Director I I The Director of Finance H The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Xi If no conflicts exist, check here. (Th (11C; r-evtoff. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017- 18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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:Sandra Lehua Andrade POSITION: Interim Executive Director May have a conflict or potential conflict of interest, including any familiarelationship, with any of the following (check all that apply): u Member or members of the Council j^{ Staff appointed by a member of the Council The Mayor j The Managing Director ni The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is hefired as a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: XI If no conflicts exist, check here. 44,145,et C hGt-it/ CIVAatit, ' Trifiert kYeaffi ')z e i)22o) 17 Signature of Authorized Person ((specil'i title; Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. Al"disclosure forms must be signed, regardless of whether a conflict exists. NAME:Cori Lin Wehrsig POSITION: Director of Community Relations and Special Projects May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 1 Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director j The Director of Finance H The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry Please specify any and ail mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. • Yy1 NiMIty Date Signature of Authorized Person ((specify title) ►CL-��_?I-0Ns Sp-7,c►,,-i--- , 72 j EXHIBIT NONPROFIT GRANT APPLICATION FY 2017-201S Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a 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, 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 , complete the 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 a_gency's_future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant_period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's ffiture funding requect and may recult in nrtinns taken to rernver these funds. By signing below, you are acknowledging that you have read and understood these requirements. ct,t.car.:,/ 400, //Ph 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Cancer Program - Malama Ka Pili Pa'a Expansion 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 4 Number of meetings and outings for the Kona cancer support group network Number of meetings and outings for the Ka'u cancer support group network 4 Number of meetings and outings for the North Hawai'i cancer support group network 4 4 Number of meetings and outings for the Puna cancer support group network Number of trained Cancer Program Managers (CPM)dedicated to West Hawai'i areas Number of cancer survivorship-related conferences attended by MKPP participants 2 1 � TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $ 10,000 Professional Fees Operations Supplies $ 5,000 Equipment I i I Other: Off island travel (Survivorship Conf., CPM Navigation Training) } $ 4,400 Other: Vehicle rent for travel to island sites for support group expansion $ 600 I t Other: Other: Other: TOTAL $ 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hui Malama Ola Na Oiwi Community Relations Program - Ladies Night Out 2017 91 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 Agency Director: Mabel De Silva, HMONO Board of Directors, Chair Phone No.: ( 8os) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: ( 808 ) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (808 ) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street, Suite 1040 Address: City,ST,Zip Honolulu, 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: $6,000 Geographical Areas To Be Served: (One or more can be checked) H Puna Hamakua .] North Kona ✓ South Hilo ✓0 North Kohala Q South Kona ✓Q North Hilo 16/1 South Kohala 1171 Ka'u Services or Activities To Be Provided: (One or more can be checked) [1 Educational concerns ri Youth ❑Victims of Crimes n Culture and the arts U Aged ❑Victims of Health or Social Crises Q✓ Needs of the poor Physical/Emotional Disabilities F.71 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $5,000 $3,000 $2,250 2. Agency Mission Statement: Misssion Statement: '0 Hui Malama Ola Na'Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho'oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawaii Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical, spiritual, and mental body, Malama i na mea Hawaii-and Hawaiian culture and practices. E ho'oikaika a ola ka lahui Hawaii-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na'Oiwi, its Board of Directors,Administration, and Staff are guided and directed by Na Kupuna(our elders) with wisdom and skill received from our ancestors. We are Hawaiian. We embrace the following basic values: •Ke Akua Mana: Existence of a higher power • Lokahi: Harmony, parity and balance •'Ohana: Family-core, intermediate, extended •Po`okela: Excellence •Ho'omau: Life-long learning with guaranteed life for generations to come •Koho'ia:To be chosen;a responsibility given to one to carry forward the wisdom, skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: The Hui Malama Ola Na'Oiwi(HMONO)Ladies Night Out(LNO)is an annual wellness event for Hawaii Island women in need. This flagship community event promoting self-care and positive self-esteem, occurs annually because more than 300 compassionate community volunteers and service provider professionals come together to contribute to an evening of hope and healing for women in need. For the 2016 LNO celebration, Hui Malama Ola Na'Oiwi along with nineteen community agencies servicing underprivileged women were allocated 650 guest tickets and asked to distribute the them to female clients, 18-years of age or older,who would not normally afford to partake in self-care or"pampering"activities and might benefit from an evening of health and wellness attention. From the 650 distributed tickets,49%of the identified women attended the 4-hour event.Greeted by a cheerfully decorated and welcoming venue containing an assortment of art and craft activities, health and wellness care stations,and a buffet of soup,sandwiches,fruits,vegetables,cookies, coffee, tea, and water,the 317 honored guests quickly indulged themselves in their choice of whole-person services. The LNO offerings ranged from arts and crafts fun;vision, blood pressure, glucose, health screenings and bone health education;foot, hand,chair,or table massage; Reiki, acupuncture, and chiropractic care; haircuts, nail painting,facials, spiritual Tarot card readings:to new and gently used clothing and footwear.The assortment of art-and-crafting fun . Door prizes,the table centerpieces,and gift bags containing wellness information and a few goodies were also given to the guests. Of the 317 attendees, 234 were registered or renewed as HMONO clients to avail themselves to the HMONO health and wellness advocacy services for diabetes, heart disease,cancer navigation and support, health-related non-emergency transportation, health education, and Traditional Hawaiian healing. Connecting with this vulnerable population is a critical goal of HMONO. 4.Total Budget & Position Count: Total Program Budget: $ 35,000 Total Program Position Count: 28 Total Agency Budget: $ 2,727,000 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Health Resources Services Administration (HRSA) $26,300 County of Hawaii $6,000 T-shirt sales $ 1,200 Restricted donation for the event $ 1,500 TOTAL: I $35,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Mama Ola Na'Oiwi(HMONO)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 HMONO's Ladies Night Out(LNO)wellness 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 to identify and submit applications for small event based grant opportunities. Much of the success for completing this event is attributable to in-kind services, in-kind materials, and volunteerism.The planning committee is committed year after year to increase in-kind services and goods to bring down cost to implement the event. This past year, HMONO established a Community Relations and Special Projects department to exponentially expand community awareness of the HMONO services.Through Radio,Television, Internet, Social,and Print-Media, HMONO's capacity to help the public become aware of the Ladies Night Out event will greatly increase. HMONO will invite interested community citizens to join our client'ohana and the support network vital to their journey back to health. 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 funding request supports the values instilled in our island community of"giving" and providing opportunity for the less fortunate women. Attendees will be registered or be renewed as HMONO clients to avail themselves to the HMONO health and wellness advocacy services for diabetes, heart disease, cancer navigation and support, health-related non-emergency transportation, health education, and Traditional Hawaiian healing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of women provided with health and wellness pampering activities. 500 Number of community providers and volunteers who will provide specific pampering services and behind the scenes tasks for the event. 250 Number of tickets that will be distributed to women in need. 700 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $ 9,260 $21,000 ProfesqqaciLEpPS 1,406 2,000 $ 1,500 16,091 1,500 Operations Supplies 5,094 $ 4,500 Equipment Other: Advertising 677 700 Other: Other: Other: Other. TOTAL $ 33,320 $ 35,000 $ 6,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 'a. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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:Mabel W. De Silva POSITION: Chair,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: YI If no conflicts exist, check here. si (01/101.i Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 cf 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Materna Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Louis Hao POSITION: Vice Chair, 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): I Member or members of the Council Staff appointed by a member of the Council The Mayor i I The Managing Director The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X If no conflicts exist, check here. "Ze..e.17 (v((re &hots r) / — /7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Robert M. Yamada II POSITION: Secretary/Treasurer, 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): X( 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 served on the election campaign for Councilwoman Sue Lee Loy. Conflict of interest will be avoided by not discussing this grant application with Councilwoman Sue Lee Loy. I If no conflicts exist, check here. r"" 1/;' 1((7 Sign lure of Aut o ized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:David J. Lovell POSITION: Director, 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): n Member or members of the Council ( Staff appointed by a member of the Council ( The Mayor The Managing Director ( ! The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest s defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-1.8 Agency Name: Hui Materna Ola Na 'Oiwi Program Name „vur,',ee/q10r* Ladies Night Out 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Noelani Puniwai POSITION: Director, 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): I Member or members of the Council Staff appointed by a member of the Council I The Mayor The Managing Director I The Director of Finance I I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest s defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X; If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure_forms must be signed, regardless of whether a conflict exists. NAME:Leona K. Seto-Mook POSITION: Director, 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): 1 Member or members of the Council I Staff appointed by a member of the Council j The Mayor The Managing Director 7 The Director of Finance I_; The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as. a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ITO If no conflicts exist, check here. (pifecto- iff)(1/ --7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Sandra Lehua Andrade POSITION: Interim Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I Member or members of the Council j ! Staff appointed by a member of the Council I ; The Mayor The Managing Director ( The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial Probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X If no conflicts exist, check here. IVAUd 100(11/1/1 Lvothve Dyer)/ t \ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Cori Lin Wehrsig POSITION: Director of Community Relations and Special Projects May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council I The Mayor I I The Managing Director j The Director of Finance { I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantia'`probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and ail mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X If no conflicts exist, check here. /<-'21Ar U 1 ev-t cat f; covyl►vi � - V.)— 17 Signature of Authorized Person (specify title) R 11 S Ions, x Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 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 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's f;iture funding reqUest and mny result in nrtinrc taken to rcrnver these fnncic. By signing below, you are acknowledging that you have read and understood these requirements. /41‘11 (/ //.3 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out 2017 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of women provided with health and wellness pampering activities. soo Number of community providers and volunteers who will provide specific pampering services and behind the scenes tasks for the event. 250 700 Number of tickets that will be distributed to women in need. TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $ 1,500 Operations Supplies $ 4,500 Equipment Other: Advertising Other: Other: Other: Other: TOTAL $ 6,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hui Malama Ola Na Oiwi Diabetes Program - Lets Talk Story with Aunty 92 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty Agency Director: Mabel De Silva, HMONO Board of Directors, Chair Phone No.: ( 808) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: ( 808 ) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, Hawai'i 96720 Email Address: Lisa@hmono.org Fax No.: (s0s ) 961 — 4794 Accountant/CPA: Phone No.: (808 ) 531 — 1040 Firm (if applicable): Cw Associates, CPAs Mailing Address: Address: 700 Bishop Street, Suite 1040 Address: City,ST,Zip Honolulu, Hawai'i 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $18,000 Geographical Areas To Be Served: (One or more can be checked) H Puna (i Hamakua n North Kona ✓ South Hilo ✓ North Kohala 1 South Kona WI North Hilo ✓❑ South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) H Educational concerns n Youth n Victims of Crimes tE Culture and the arts Aged Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities H Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 01 0 $ 5,500.00 2. Agency Mission Statement: Misssion Statement: '0 Hui Malama Ola Na 'Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho'oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawaii Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical, spiritual. and mental body, Malama i na mea Hawaii-and Hawaiian culture and practices. E ho'oikaika a ola ka lahui Hawaii-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na'Oiwi, its Board of Directors,Administration, and Staff are guided and directed by Na Kupuna (our elders) with wisdom and skill received from our ancestors. We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power • Lokahi: Harmony, parity and balance •'Ohana: Family-core, intermediate, extended • Po'okela: Excellence • Ho'omau: Life-long learning with guaranteed life for generations to come • Koho'ia:To be chosen; a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: This past fiscal year Hui Malama Ola Na'Oiwi (HMONO)Diabetes Program offerings ranged from a ten-session group education and awareness program to one-on-one sessions with a HMONO Registered Nurse(RN)Community Health Educator; from clinical screening at health fairs to individual case management for on-going agency support with clinical data and anecdotal information provided to the client's Primary Care Provider; and from"Let's Talk Story" engagements to the reinstatement, in December,of the Hilo-based Diabetes Support Group's bi-monthly meetings. Both the HMONO diabetes support group gatherings and the community group"Let's Talk Story"(LTS)sessions with Aunty have received the greatest amount of positive feedback from the diabetes populous, and both approaches embody HMONO's motto"Live Longer& Feel Better,Together." Expanding the reach of these two entities is of utmost importance for sharing HMONO Diabetes Program's 'ike kuhohonu (deep knowledge). Through the ongoing support of the County of Hawaii, a broader base of residents in need of diabetes awareness,education, and management knowledge will be reached.The"Let's Talk Story"community sessions with HMONO living treasure, kupuna Aunty Edna Baldado RN, her kako`o(apprentice), also a dedicated community health worker, and as needed, HMONO Interim Manager of Health Education &Case Management,Wanda Louis RN, will be held at the HMONO offices in Captain Cook, Hilo, Na`alehu. and Waimea.The HMONO Diabetes Program will also seek LTS with Aunty speaking engagements at not-for-profit human services agencies;civic,social, and fraternal organizations; and small businesses and corporations across Hawa`i Island. HMONO will organize and coordinate a minimum of 44 LTS with Aunty community sessions, throughout the funding year, ensuring that the talks are offered at various times and at locations across our island. Moreover, at each the LTS gathering,the participants will be encouraged to loin the nascent Diabetes Support group in the particular area. 4.Total Budget& Position Count: Total Program Budget: $ 185,750 Total Program Position Count: 5 Total Agency Budget: I$ 2,717,000 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Health Resources Services Administration (HRSA) $167,750 County of Hawaii $ 18,000 TOTAL: I $185,750 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The primary means of funding for Hui Malama Ola Na Oiwi (HMONO)is from the U.S. Department of Health and Human Services. Health Resources Services Administration(HRSA).This funding supports several positions to coordinate our diabetes program which consists of screening, health education materials and workshops, classes, speakers. and wellness events outreach. Community partners continue to support our Diabetes Program efforts.The University of Hawai'i at Hilo Daniel K Inouye College of Pharmacy outreach screening team provides clinical blood glucose and HbA1 c screening. Additionally,the School of Nursing provides our clients with health education classes through their Community Health Practicum. To address funding shortfalls,this past June HMONO established a Community Relations and Special Projects department to exponentially expand community awareness of HMONO services.Through Radio,Television, Internet, Social,and Print-Media, HMONO has increased its capacity to help the public become aware of the Diabetes Program's education classes,workshops, events, and associate services.The HMONO Community Relations team will also invite interested community citizens to join the HMONO client'ohana and the support network vital to their journey back to health. In addition, HMONO will continue to build collaborations and partnerships that bring our communities together through volunteerism and cohort support groups,thus increasing community impact and resulting in stronger applications for larger federal awards in the area of diabetes support and education.The HMONO board has directed that a concerted effort be made to develop a robust grant and donor program to include developing a diabetes signature event. 7. Program Objectives Using County Nonprofit Grant Program Funds: Hui Malama Ola Na'Oiwi (HMONO)will organize and coordinate a minimum of 44 LTS with Aunty community sessions, throughout the funding year, ensuring that the talks are offered at various times and at locations across our island. Moreover, at each the LTS gathering, the participants will be encouraged to join the nascent Diabetes Support group in the particular area. Each quarter, at least two(2)LTS with Aunty community sessions will occur at each of HMONO's four site locations: Captain Cook, Hilo, Na`alehu, and Waimea.The HMONO Diabetes Program will also work with civic, social, and fraternal organizations as well as not-for-profit agencies that offer human services,and small businesses and corporations concerned with their employees'wellness to offer LTS with Aunty community sessions at their locations with a goal of at least one session per month. If attendance for these 44 sessions. is at least 22 citizens, then HMONO projects that almost 1,000 Hawaii Islanders will receive Diabetes awareness, education, and management knowledge and be invited to join their local HMONO Diabetes Support Group. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) • Number of participants in LTS with Aunty community sessions at HMONO Captain Cook 176 Number of participants in LTS with Aunty community sessions at HMONO Hilo 176 Number of participants in LTS with Aunty community sessions at HMONO Na'alehu 176 Number of participants in LTS with Aunty community sessions at HMONO Waimea 176 Number of LTS with Aunty community sessions at HMONO sites 32 Number of LTS with Aunty community sessions at non-HMONO facilities 12 Number of participants in LTS with Aunty community sessions at non-HMONO facilities 264 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wags $ 79,663 $ 137,455 $ 12,000 Professional Fees 1,095 1,500 Operations 6,135 24,795 Supplies 3,230 17,000 $ 5,000 Equipment 0 2,000 Other: Lodging for LTS with Aunty speakers-sessions outside of Hilo 2,875 3,000 $ 1,000 Other: i Other: Other: Other. TOTAL $ 92,998 $ 185,750 $ 18,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017- 18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Mabel W. De Silva POSITION: Chair,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): I I Member or members of the Council ❑ Staff appointed by a member of the Council 1 The Mayor I The Managing Director The Director of Finance I I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interests defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: (XI if no conflicts exist, check here. ( r) /1/42 Signature of Authorized Person (specify title) /17 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Louis Hao POSITION: Vice Chair, 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 j ( 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: XI If no conflicts exist, check here. 74710 ) (v(C.6 01 01 r) 0j — �� — /7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Robert M. Yamada II POSITION: Secretary/Treasurer, 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): X Member or members of the Council I Staff appointed by a member of the Council ( I The Mayor I The Managing Director I The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as. a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I served on the election campaign for Councilwoman Sue Lee Loy. Conflict of interest will be avoided by not discussing this grant application with Councilwoman Sue Lee Loy. Vt46 If no conflicts exist, check here. P � a ,.. i, tif ii '---)- Vie,471 I(1)( 11.7 Sinature of Au harized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 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: David J. Lovell POSITION: Director, 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): f j Member or members of the Council Staff appointed by a member of the Council !fl The Mayor The Managing Director ; The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest s defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in genera!to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest [j If no conflicts exist, check here. D i reef 1 5 i Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Materna Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Noelani Puniwai POSITION: Director, 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: XI If no conflicts exist, check here. yy(S, O.tet D reOrrr) I ( Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na `Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Leona K. Seto-Mook POSITION: Director, 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): I I Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance j The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual wit'result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X If no conflicts exist, check here, (Pirec-1--0-r 1 7 li 7 1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 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:Sandra Lehua Andrade POSITION: Interim 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 I Staff appointed by a member of the Council H lI The Mayor The Managing Director I The Director of Finance 7 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual wt'r result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X; If no conflicts exist, check here, shtubwdezhawmufg_iTvoemyyl ben dive, D'veofw I 9.)ol Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2013 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists, NAME:Cori Lin Wehrsig POSITION. Director of Community Relations and Special Projects May have a conflict 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 1 The Managing Director 7' The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as: a substantia:probability that action taken by an individual viii!result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Xj if no conflicts exist, check here, 1Y rA r a� Date Signature of Authorized Person (specify title) -MIpy re EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant_period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requect nnrl mny result in artinnstnken torernver these funds.. By signing below, you are acknowledging that you have read and understood these requirements. 7eleti:v7, A 1 //3(///7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Let's Talk Story with Aunty 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of participants in LTS with Aunty community sessions at HMONO Captain Cook 176 Number of participants in LTS with Aunty community sessions at HMONO Hilo 176 Number of participants in LTS with Aunty community sessions at HMONO Na`alehu 176 176 Number of participants in LTS with Aunty community sessions at HMONO Waimea 32 Number of LTS with Aunty community sessions at HMONO sites 12 Number of LTS with Aunty community sessions at non-HMONO facilities Number of participants in LTS with Aunty community sessions at non-HMONO sites 264 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $ 12,000 Professional Fees Operations Supplies $ 5,000 Equipment Other: Lodging for LTS with Aunty speakers- sessions outside of Hilo $ 1,000 Other: Other: Other: Other: TOTAL $ 18,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hui Malama Ola Na Oiwi Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 93 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow Agency Director: Mabel De Silva, HMONO Board of Directors, Chair Phone No.: (808) 969 - 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: ( 808 ) 969 - 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, Hawai'i 96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 - 4794 Accountant/CPA: Phone No.: (808 ) 531 - 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street, Suite 1040 Address: City,ST,Zip Honolulu, Hawai'i 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $18,000 Geographical Areas To Be Served: (One or more can be checked) H Puna n Hamakua ✓ North Kona ✓ South Hilo Iv! North Kohala Q✓ South Kona 0✓ North Hilo i✓i South Kohala ✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓) Educational concerns n Youth ri Victims of Crimes (1 Culture and the arts H Aged i I Victims of Health or Social Crises Needs of the poor 7 Physical/Emotional Disabilities H Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 5,250 2. Agency Mission Statement: Misssion Statement: '0 Hui Malama Ola Na •Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho'oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawaii Island. Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical. spiritual, and mental body, Malama i na mea Hawaii-and Hawaiian culture and practices. E ho`oikaika a ola ka lahui Hawaii-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na 'Oiwi, its Board of Directors,Administration, and Staff are guided and directed by Na Kupuna(our elders) with wisdom and skill received from our ancestors. We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power •Lokahi: Harmony, parity and balance •`Ohana: Family-core, intermediate, extended •Po`okela: Excellence •Ho'omau: Life-long learning with guaranteed life for generations to come • Koho'ia:To be chosen; a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: Hui Malama Ola Na `Oiwi(HMONO)Nutrition Program engages learners of all ages and backgrounds to live a healthier life based on understanding nutrition, physical activity. and personal choices.The Nutrition Program staff offers essential strategies to fight the obesity epidemic through the proven curricula of"Hele Mai'Ai", "Eat Dis not Dat", and"Eat a Rainbow". Furthermore, to enhance the learning experience. the HMONO Nutrition Program staff has designed nutrition and hydration demonstrations, hands-on activities, and aerobic movement at five connection levels: preschool, elementary school, middle school, high school. and adult. In addition, during the 2017-2018 funding period, HMONO's registered dietitians will update the curricula to share relevant. leading-edge, scientifically sound research with the participants. Although the availability of healthier foods and beverages varies between communities with different income levels, ethnic compositionand other characteristics, and the limit of choices in under-served and rural communities constitute a substantial barrier to improving nutrition and preventing obesity, the Nutrition Program curricula offers do-able strategies for all walks of life. The State of Hawai'i Department of Health"Hele Mai'Ai" program consists of six modules while the"Eat Dis no Dat"and''Eat a Rainbow"are single module offerings. Every module taught is age-appropriate and presented by a trained, enthusiast professional.As part of the"Hele Mai'Ai"curriculum, and at many"Eat Dis not Dat"and"Eat a Rainbow"classes, screening assessments also occur. documenting blood pressure, height,weight,fruit and vegetable intake,and level of physical activity to serve as the baseline data for each participant. The Nutrition Program 2017-2018 goals include educating more youth participants and increasing its outreach efforts at community events and wellness fairs around the island. 4. Total Budget& Position Count: Total Program Budget: $ 65,800.00 Total Program Position Count: 12 Total Agency Budget: 1$ 2,727,000.00 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Health Resources Services Administration (HRSA) $47,800 1 County of Hawaii $ 18,000 TOTAL: $65,800 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The primary means of funding for Hui Malama Ola Na'Oiwi programs is from the U.S. Department of Health and Human Services, Health Resources Services Administration (HRSA). HRSA funding supports several positions to coordinate our nutrition program which consists of nutrition education workshops,classes, and outreach events. HRSA considers parts of Hawai'i Island to be a Health Professional Shortage Area(Pahoa, Ka`u), and the entire county to be a Medically Underserved Area since 2003.This same healthcare professional shortage affects other health care professionals,especially in the area of nutrition. Compounding this shortage, as the once largest segment of our population retires from the workforce and transitions to life on a fixed income, the demand for our services grows proportionately. To address the growth of clients and the associated funding shortfalls, HMONO has established a Community Relations and Special Projects department to exponentially expand community awareness of our services.Through Radio,Television, Internet, Social, and Print-Media, HMONO's capacity to help the public become aware of HMONO health education classes, workshops. events,and services. HMONO will invite interested community citizens to join our client'ohana and the support network vital to their journey back to health. In addition. we will continue to build collaborations and partnerships that bring our communities together through volunteerism and cohort support groups,thus increasing community impact and resulting in stronger applications for larger federal dollars in the area of nutrition support and education.The HMONO board has directed that a concerted effort be made to develop a robust grant and donor program to include developing a program signature event involving a healthy BBQ contest. 7. Program Objectives Using County Nonprofit Grant Program Funds: Obesity is linked to chronic health problems. Good nutrition combined with fitness activities is the proven strategy to combat obesity,achieve, and maintain a healthy weight. The objective of the HMONO Nutrition Program is to increase healthier eating practices amongst the youth and adult population throughout the island while also offering fitness opportunities through fun, age appropriate curricula. During the 2016-2017 funding period the Nutrition Program staff has collaborate with afterschool programs, County of Hawai'i Summer Fun programs, and schools reaching pre-K through high school students to pilot its nutrition workshops.This coming funding year,with the securing of key partners,the frequency of these youth outreach undertakings will growth enabling 400 students from across the island to gain nutrition and fitness knowledge, and learn how to apply it through personal choices.To reach targeted adult populations,the Nutrition Program will expand its work with community organizations, health care providers, and health based agencies to offer workshops and screening assessments documenting blood pressure. height,weight,fruit and vegetable intake, and level of physical activity to o serve as the baseline data for each participant.To reach Hawaii Island families,with a goal of speaking with 700 residents from under-served and rural communities,the Nutrition Program will be present at community events and wellness fairs to promote a cost-conscious healthy lifestyle of nutritious local foods, hydration, and exercise. With the assistance of the County of Hawaii,the HMONO Nutrition Program will achieve its goals: expanding its reach to school youth and multi-generational families; connecting, in a fun and powerful format,to all ages of learners; and teaching an adaptable, cost-conscience healthy lifestyle of local foods, hydration, and exercise through personal choice and empowerment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of youth from Captain Cook area to complete a Nutrition Program course 80 Number of youth from Hilo area to complete a Nutrition Program course 80 Number of youth from Na`alehu area to complete a Nutrition Program course 80 Number of youth from Pahoa area to complete a Nutrition Program course S0 Number of youth from Waimea area to complete a Nutrition Program course 80 Number of adults islandwide to complete a Nutrition Program course 250 Number of youth and adults reached at community events and wellness fairs 700 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wags $ 15,693 $ 48,692 $ 13,000 1,563 3,500 Professj.onal FfPS Operations 3,612 6,108 StliQs 5,325 5,500 $ 5,000 2,500 2,000 Equipment I Other Other: Other: Other: Other. TOTAL $ 28,693 I $ 65,800 $ 18,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Materna Ola Na 'Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Mabel W. De Silva POSITION: Chair,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): j Member or members of the Council I ( Staff appointed by a member of the Council 1 The Mayor 1 The Managing Director 1 I The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. f � �. __.. :rte% ; (alai / 2c;i j 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na 'Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Louis Hao POSITION: Vice Chair, 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 _I Staff appointed by a member of the Council 7 The Mayor I[ 1 The Managing Director ] The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 5Z1 If no conflicts exist, check here. U('CP, Chat( �� l T-3� Signature of Authorized Person (specify titre) Date EXHB1T A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Robert M. Yamada II POSITION: Secretary/Treasurer, 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): j )) Member or members of the Council I ( Staff appointed by a member of the Council The Mayor The Managing Director pi 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 served on the election campaign for Councilwoman Sue Lee Loy. Conflict of interest will be avoided by not discussing this grant application with Councilwoman Sue Lee Loy. I If no conflicts exist, check here. i4( Zjezezil(4,tt Signature of A orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: David J. Lovell POSITION: Director, 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 I j Staff appointed by a member of the Council I II The Mayor The Managing Director I The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: (X If no conflicts exist, check here, (DE(eC*V9 / 5 , ,y//Signature of Authorized Person (specify title) • Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose, All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Noelani Puniwai POSITION: Director, 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): I Member or members of the Council i Staff appointed by a member of the Council II The Mayor I I The Managing Director The Director of Finance I I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I X1 If no conflicts exist, check here, Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 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 Hiawai'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:Leona K. Seto-Mook POSITION: Director, 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 I The Mayor Ti The Managing Director j The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individualwill result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: IX': If no conflicts exist, check here. 1)1 r eg ''. 1 ?jc, i Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Sandra Lehua Andrade POSITION: Interim 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 I The Managing Director The Director of Finance jJ The Corporation Counsel, the Assistant Corporacion Counsel, or a Deputy Corporation Counsel Conflict of Interest's defined as: a substantial probability that act'an taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in genera:to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: if no conflicts exist, check here. vt'A.4Al Alk ( 41 - kcct 1 Diver 1-7 Signature of Authorized Person (specif`> title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2013 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:Cori Lin Wehrsig POSITION: Director of Community Relations and Special Projects May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check ail that apply): 'I Member or members of the Council H lI Staff appointed by a member of the Council �I The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and ail mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: X! If no conflicts exist, check here. • /fin DrP�7�Z DF""01hAun,f y ° —31)— ► 7 Signature of Authorized Person (sp cify titie)Ra1rltcr/S + SPwt3 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2013 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to 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 ofyouur program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 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 on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futures finding regnect rind may recult in nrtinoc tnkPn to rernvpr the cP funds. By signing below, you are acknowledging that you have read and understood these requirements. )Liz //I/A/7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Nutrition Program - Hele Mai 'Ai, Eat dis not dat, Eat a rainbow 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 80 Number of youth from Captain Cook area to complete a Nutrition Program course Number of youth from Hilo area to complete a Nutrition Program course 80 Number of youth from Na`alehu area to complete a Nutrition Program course 80 80 Number of youth from Pahoa area to complete a Nutrition Program course 80 Number of youth from Waimea area to complete a Nutrition Program course 250 Number of adults islandwide to complete a Nutrition Program course Number of youth and adults reached at community events and wellness fairs [700 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES I Grant Request Award Salary and Wages $ 13,000 Professional Fees Operations Supplies $ 5,000 Equipment Other: Other: I Other: Other: Other: TOTAL $ 18,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hui Malama Ola Na Oiwi Traditional Healing Program - La'au Project 94 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Maiama Ola Na- 'aiwi Program Name: Traditional Healing Program - lau Project iliiiirlaaVAUT611.VIX,C4t.t11218,440ifdaill.,W,..PLISRAICXWOMILY.133,- ..,1742MigflatalnaliA1124215%.M11.114211r07617.2.WMIZEDEMPENaM3632.,7111Eg? Agency Director: Mabel De Si!va: HMONO Board of Directors, Chai; Phone No.: ( 805) 969 — 9220 Contact Person: Lisa Canale, Project Anaiyst Phone No.: (808 ) 969 — 9220 Moing Address: Address: 1438 Kiiauee 4vnue Address: City, 5T,Zip Hilo HI 96720 Facility Address; Addcess: 1438 K3t.!=-,2 Avenue Address. City, Si,Zip Hilo, Hawa!'i 96720 Email Address: iisaifylmono.prg Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (sas ) 531 — 1040 Firm if applicable): OW Associates. CPAs Mailing Address; Address: 700 Si:shop SIred . Suite 1343 Address: (S.tv,Si,Lp Honoluk, Hiewe:': 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTL Y NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: S32.000 Geographical Areas To Sc Served: (Ore or more can be checked) !$,' Puna , rvi North Kona T471 South Hilo Ri North Kohaia South Kona FT:/i North Hilo H South Koh!3ia 1:11 Services or Activities To Be Provided: (One or more can be checked) Educatonal concerns ij Youth victims of Crimes Em i• aria he arts 6'- 1 \IICtIMS of Health or Social Crises Needs of the poor P Physical/Emctiona: Disacilities Health and ',Nei:Fare of th,.-3 People and the Environment NIH,131157119017/iTTERN-17.,--NOM/IMEUiingtiELAIIEL7,116aii7.27)iiZWIP7,,,TATS alli:nalo=i'r%7- 3034301VI,CWNIVir-WX.423%/FREISIWICANINEr:MOMPZ.V3ISTIMUMESAMERMWIIIIME199MOSSOISHIVER2IIIMETO EXHiBIT A NONPROFIT GRANT APPI ICATiON FY 2017 -2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY201 7-18 Agency dame: Hui Ma a na O a a `Oiwi Drogr"am Traditional Healing Program - La`au Project --- ---. c --- --- ----- :iam.. ..�^...x :^scmn nn.a�sar�.._.,tav^n0�a, r.max.:arxwar,:iut -..r±xa�s._'re1_�; .; amemxcaa; rsatrr:� +: caN �carr:.+se;,�swv-srra�.^e�.eacs +vn¢ ,m0 1, Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 15-16 ' FY 16-17 ;a0 v,u $9 000 2. Agency Mission Statement: Misssicn Statement: U HU, N_:ti^e ✓la Nb Qi'A,' makou-We are the croup that takes care of the health of Havitai an people, Eia ke kuleana: Ho'oulu ole o ika iah!ui Haviai i- Our mission is to uplift the health of the Hawaiian nation. iM•alanna is ivloku o K ewe_'„A c will take care of Hawaii Island Malama na kLa Bina-country and rural areas. �t3larra i kou oiakino -your physical, spiritual. and mental body, Malaria '+ iia mea Hewal`i -and Hawaiian culture and practices. E h.^, cit kai ka a ole 'r'a .ahui Hawal`i -We en envisicr,a Strong and healthy Hawaiian nation. Values. - ; wal�Y"a Ola Na `S Board of Directors,Administration, and Staff are guided and directed byNaaKuouno (our eiders) with wisdom ane skill received from our ancestors. '‘Ne are Hawaiian.We embrace the following basic values: Ne AKJa Mane- Existence of a higher power Losers: Harmony, parity and balance `O'r:ar:a: Family-core intermediate, extended 2o'ckela'. Excellence io`om li Life-long ;earning with guerar' d ife for generations to come K,aho.a. To be chosen; a responsibility' er to one to carry forward the wisdom skill and knowledge that guarantees 3. Program Description: .I ,lyeI 8iar a ula Na G �, - ti '? Traditional oi - ,! � Rrq ram encompasses 5es tne practices of Olehon (restoring) 1lest ring. the Hacu ati culture pau ( e i g) ,V U MQ aa ) that ase been passed down ^l,y from generation ration generauon cram k.apur ia: Malaria ipr. r o' the maul;o a (power of healing) and the like(knowledge of kUpuna; and Ho ci au (p pet,_T.e' )Native Hawaiian culture by providing the Hawaii. island community with traditional Native Hawaiian healing education, ' d encouragement of°sono (righteous)!lying throuah by mind, body, and spirit.The island-wide lata. <u -i,iicirksrioos, group oresentaiions. and classes focus on i a'au i apa'au (Using herbs to heal), Ho oponopono (mediation/to make things "ightj, Lomitomi Ha Ha (spiritual healing Kahea(faith healing). The skills`.nooro'or'ated in the learning process include Fe stn- ;observation), Hosolohe l listen r O), and -vtalama (presenretaking care). The Traditional i ani -!'s Lh au Project supports the effort of the Traditional Heaiing program through supplying lb'au Iapa'au (Jiang/herbs used to heal)used in the ikanaka macii lapa'au (Hey^ialian medicineN Ikshops and classes. Beyond growing plants for the iree',vc,rkshocs. L..Y'. Project plans to invites the community to the farm plots to educate Hawaii islanders an no'', to pronagat ,^,roe/, and care for traditional healing pants.The key components for the success of the La`au Project are the planting, propagating. .anr arc-wing of roc the learning.ring teaching, and sharing The importance anc,e of roth g iLr a.i food, herbs. and medicinal plants; and the ui taro l inty of the orc,jact efforts. The pilot project has thus far worked with individuals to propagate' i `ap a.+ Community it'y tvorkdays ler se,ediing propagation educational classes and workshops enabling ticipants to app; Native Hawaiian c cultural al cc?ic c to aloha ding incorporating components of K UrHina, Kane. Lone, and par 4analoa,aloi r side tofowint; the seasonal phases of the moon (makahiki/kb and ho'oiio kau)when considering specific farming tasks, are in development. Another strong, and ongoing,component of the La 3u Project ct is to research and test other says to propagate'variups, alir o .rants. 4. Total tai igen & Position Count:,. — — ---- -- — — — ---, Toa! ProPyarn $udget. +? 165,700 Tota? Program Position Count: 1--- — Total ,g:ncy 3udget: ti2,727,000 �Ua i .wiency Position Count: 128 — — — — -- E 5 T A i\j( N?R FST(::-PANT APPLICATION r'..,,2017-201R Page 2 of R ry ;H'i Nonprofitlr�.ppiic pion FY20 7-18 Agency Name: Hui Malarria O7 Na 6 iwi Program Name: Traditional Healing Program - La`eu Project ---- 5, Program Funding Sources (identify all sources of funding-applied to this program): FY17-18 :.1 Revenue Source , Estimate t I Health Resources Services Administration r'HRSA'i --- _ $ 63 700.00 Office of Hawaan Affair (OHA) — T $65,000.00 County of Hawa i $ 32;000.00------_—__-- — -- -- - -- -------------- ----- T{?TAL. $165,700.'=0 tt�ch odditiiori&;pages, if i7eeded. 6, Explain what plans your agency or program has to increase 9 evenues to support this program: As a population enters into retirement, they often seek alterncvive and complimentary J medicin i offerings. As more people r�, M Ol t ION! provides TraditionalHealing Program workshops and classes the demand for i S:; J that Hui , ,ala � Jr Na t,In C �- - ! .� this service has grown exponentially. The County of Havvaiiisupported te,initial community-based workshops in 2012 and this oroq am has excelled over the years. Both the Office of Hawaiian flair (OHA)and t to U.S. Department of Health and Human Services, Heat'. Resources Services Administration (HRSA) provide r nJ I g support for this program. The Traditional Healing Program sustainabilit is focused on growing g a variety of is eu (medicinal plants)and to develop brpigiais to 'grow-at-home.' rr rt. H. 1n[Irl the prnnensof l ✓e no'i g an ncome generating program ioy selling products via an interact store.The variety of d'au will be va fable from rne store and supplied by Inc HMDNC) farms and; in addition, Hk,10NC ''Alii! Kok for ways to purchase any extra, ia'au from our'grow-at-home"clients for the HMONO store thus creating and deo loping a fullysustainable harvesting practice. Ali of the Traditional ional Healing workshops and las >are free to the public,it „i support satt has established donation opportunities for participants. (i\'(ONO expects donations tO neip sustain the expansion of.he Traditional Healing program as well as establishing a schedule of classes offered each on around the entire island. HMONO uses the ,iakana Aloha"concept for donations s and contributions to all of the HMONO ANO progr "'s and tose'who have atended Traditional H; lin workshops, classes, and education consults sults hay.been particularly motivated to give. in addition, HJ)ONO will continue to build collaborations and p a-trcsr;s that or , r� > Island's communities together through volunteerism and cohort support groups tfLs increasing community impact and resulting in stronger aooiicm r s ol`larger awards in the area of alternative and complimentary medicine. 7. Program Obsectives Using County Nonprofit Grant Program Funds: The Traditional Healing Piccrarn s L afeu Project is seeking funding for consuitant services. labor, and materials to assist with all three of the project objectives: the cultivation oftraditional healing plants and food, community education of the cultivation techniques,and the sustainability of the Traditional e linU Program's I a a.. Project. The Ld`a a Pioject is activity.reclaiming two one-acre plots on two separate parcels on the Hamdkla coast. Soil remediation throughNatural(, Farming Techniques 5 also n _ne 'l preparation forimplementing the agriculture plan developed by HMONO agriculture consLiitant, Mr. Talon.. Materials ano labor are needed to complete the build-out and plant population of the agro-forestry terraces.Tnese en-aces will beinter-r pp around the sie entel flows and soil needs of the specific am a.This innovative approach is designed to address and improve initial, inermediate, and extended use impacts on ._rr•a. loaf and Kat. T learn 'r afrom. - e stepped process I pr,tn nr asustainabie forest e04'/4t 3Y' of foodtrees, and medicinal o assist with, crops, the community will be invited for handson experiential learning. The La—au Project farming techniques will demonstrate peirmac+ :tore, ocntemporany Hawaiian agroforestiy. traditional aloha ane practices, and the integration of microbiology divei'sification. The community and school-g t.,r wO rsr.ops will cc limited to to 12 participants for each session, ideally, the Pronate r Mar!ager will offer one workshop per moi-,t%achieving I2 for the fi.,nding period. in adds ion,thrlu,gr, a summer internship program. the Project Manager is seeking two agriculture undergraduates tO further the de';etop r nt of the sustainab lit+plan as well as to grow ri_Maki. 'Glena, kcko olau. :Caukama. and wanacine se filings used in the traditional healing practices. in addition the Project Manager is seeking the summer placement of two high school student for vocational training and empicyme'tt. EXHIBIT A Appi ATl(MI FY 2017-2018 Page 3 of S County of Hawai'i Nonprofit Grant Application FY2017-1 8 Agency Name: Hui Mama Ola Na '0- iwi Program Name: Traditional Healing Program - Lacau Project 8. TABLE What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES 1 , 11 Applicant Projected Results . ,.,,• ,,,b,of oienl,serv,d workshops or events held,volunteer hours,err:.Des:ribe.be spec:lfic.' LL____ ........._______. _ i Number of patcipants in 'aina based experiential learning sessions 190 Number of community'aina based experiential learning sessions i 12 , i Number of Hawaiian island c,ollege students in summer internship for la'au propagation i----- Numbe7 of Hawaiian Island high school students receiving summer vocational training ;2 Number of seedlings, cutting, and starter plants accessible to dontate to organizations andj individuals that ri,.otiici be i.Ased to further educational knowledge taught in workshops 500 : . Attach additional pages as necessary. 9. TABLE U: [---- , i I -7 PROGRAM EXPENDITURES FY 16-17 FY 17-18 : FY 1748 241tElL _____q_ Total Budget Grant Re — aayand \N age_i ---$ 122.618 1 S23.680.00 :! I , 24,265 12,500 1 $ 4,500.00 ! PrQfPasion.a.LEPes _ — _, 31,799 15,582 1 $ 1,820.00 ' raP_Eriarl5_____ 3,202 12,00,0 $ 2,000.00 _jiLlLPP Le.3 ---- 3_000 Equipment — Lac h_ l Ther, •__Cither; i • , • ntller, :1-- •--- 4 . r_, Lr_thell , 1 [ $154,800.00 $165,700.00 $ 32,000.00 L — TOTAL -!i:applicable EXHiBiT A \,;('-)NpROF:T GRANT APPLICATION FY 2017-2013 Page 4 of 3 (.7 0 Uilly 0 I Gu1E Appl*-.ation FY2UI 7i Agency ame Hui Mama Ola Na 'Olvvi progrm Name: Traditional Healing Program - La'au project O'RGANZATtOri CONRACT DiSC1 °SURE FORM Peas.-,,,-, 4.1i5C -..)SFj or t tz,arc memo c.ffcer, or acim:ri;s::•a tor oFvoor oTganza!-.. on ma ie vc`r, Haitia!',. need to be r.jsclose.-j., Ore f,orrn oar cemo ,Aqna cc t 1;' no 7.J:,,r.rcts axst, one form cor the orgar]zalion,, wrh tna cDr.TC'T.E. cotor creo.Kerj n.E.,LE:;:-7 ote sn-jtt'eo!. Pease duo!:catE as neet.ied fu! y d'ac .").i.-2. LE? C.4 cor-J'ict ANLL Mabel W. De Silva ,70SII0N Chair, Board of Directors (J;aC< or rnan'.T.a:ra or t- a St a27:‘,,ofn:.ec:i ov The cs' or Tne To.e or a ()'1 3,3r r ro tr? 57 Pease and a mog2o- .72-3 '9' E.:.7s3-as an, conFhots or -r, :"'`jr At,r111,Cr',7.eti EX ;3 -1 5 County fiicfit Grant z±q)plicatinn FY7)01 718 - Agency Name: Hui IVIalama Ola Na Oiwi PrOgrani "Nanle: Traditional Healing Program - La'au project ORGANFATION C0N1 DISCLO'CURF FORM ?;ease dl5CiOSE interes':,T_Hat ahy board n2emher, cfcr, dlrest.:dr, or administrator di- ccr cria:" i's 7:07 have witr the Crrc.ctv c"Hawal ;. On, / those ! .s.t.e.c,i below need TO be discioseci, One form per bei,:on ,,,Htrl fsc)flf!ist is r,ee.ded, lF ccr.,f!lc-ts exist, ore form far the organlzation, ith the cdn.f!ictc checkaci needs cc sccnctted. P,ease duplical:e as needed ic discl:ae, 4,1 c mrr7;/St NAME: Louis Hao POS :ON. Vice Chair, Board of Directors race a corrlsz dr ,a.sl-.ent. confiL:'.. of cr.:a-est, aim/ feme eatonst-,:r3, any of crov\ g ;,CP S..-..1K 0-7 a me' nerof the :cd dd. Tne „ , ry The .... ln,z 7L3:72.i rliT; 's • :r jer,21:ts ;:s Y'2 3,0c'3.5!Ed 70' C:C.Crijirg Pies sec;'y Cr cod al C01,-ftCTS 0' cor hotsRXjs.! re. V 1,Vti Vj4° 7 o Autr,dfiZEd P 7,:'721se NON P 7 ege5 of county of 7\:oriprofit Gran ppIicañon F 0 I 7- 1 8 .Agency Name: Hui Niralarna Ola N Oiwi Program Name: Traditional Healing Program - La'au project ORGANIZATION CONFLICT MSCLOSURE FORM iiteiest ariy board mernber, tri-S C'F!"--' ,4[=-1!.;, Orli:"chose listed bec need to be cils•close;-; One a con/ c: is :Theedeo, if no conflicts exist, one foi-m. fry Cra No C(.37M =:. cc j.Jc;J.c.;-31:.e !-H2clE..1 tOfoi./ 5sC• O ernyc Robert M. Yamada Il Secretary/Treasurer7 Board of Directors a ,30t.7,:r7t'a! :f .- ,57,E2, - A A h&: rzi ease soc "3 :r or I served on the electlon campaign for Councilwoman Sue Lee Loy. Conflict of interest will be avoided by not discussing this grant application with Councilwoman Sue Lee Loy. Ahied ;ac :401'2;4 I - -- .soe ci 5.1 7..!t.'&":; Dane App jc,27-jiki CV Pa,,.„:7i o7 CH-v,Antyof Hawai' i T rip;:o fit i",:-frarit Apolication FY7'01 7-18 Agency :\larne: Hui Malama Ola Piogram ane. Traditional Heeding Program - La'au project rewaliaramstunsefismaacrrimi 10. .0;,RGANiZATION DICCLOSURE FORM m : erC4HrEft0f, Or Vjthe Coizi1-4 Of ie ' : 0-2;0`.6' to be C.ne ci,:,,Hict :5 7: eaed. nr2 C07:f! CtS est, one form fo( the corfic:s optor, r..c, be 3ub7,.:tte, ?isa5e CCS s '3,'rose b,2.1-;:grECT; fOrTliOt N David J. Loveli P3Si'TiCY'i: Director, Board of Directors ai..' nave -a '1(hh 7ry fC)i0V4M;;.-3' re M2rr.oe,--Dr , e : recto rne of Fir,ance !-e speolf7 ec*:, 7E:nor OOnftCtS Of ,r.teres.:, 9. 7-e:s,n1 A County of Hawaii Non profit Grant A ppi icati Oil FY2017-1 8 Agency Name: Hui Mama (Dia PrOgraM 'Name: Tradjtional Healinci Program - La'au oroiect iD ORG,9:01i7A-TION CONFLICT DISCLOSURE FORM Please dLsc;ose am ch.-nfU!.2,:s sbnP;shs of;There's': tha-t.: ar:y board MeM12,e'„ officer, dcresto,-, oF hhat nave ',i'vfth tIne County of Ha'Aia OnL; those iisted ba!:),Aneec , tb 32 ;-.:1sCL"..'5E,. . One c'r - cc pe:sor'. ,,,vift) corrict 5 neecled. :f no confi;chs eyjst„ one form for of,c6hanzandr, tne est tO be s-,i5rnitted. as .7ea..tiked, tc 411 dishibsL-elor:ros cnist 5 w!-L?:.-.'72-o confifct Puniwai POST,07‘i Director, Board of Directors May re a z.c:'7f!is: H:iudingai faa ao1h an-, of :he (shvasK a!i t,ha: s:bh5„T VeTZ:e.' e -,• ar;a,g.Lic,,T, _ , ,e . • -2:vc an! ccrr.FTIci.i- conft.,.; - - - Pc Data EXH 5 CounJ7, ofHawaii Nonprofit Grant Application FY201 7-18 Agency Name: Hui Ma!ama Ole Na 'Oiwi Program Name: Traditional Healing Program - La'au project PIVS7056MCNNekOSONMEMMIIFINMMTIFIroit0EAWNINaiitiganiiiiVall7W.1047.iiiiTVArZWZIVINFFTBEIMSICSrAVOISINUISNIMAIRtliggancT3MMENSIVAM.AUZINANOMMIRMIONTATVALWWWWINUanAilliri ORGANZATOr'4 CONFLiCT ::D'ISCU1SURE FORM 0ie.7,se di3ciose am/ cCF :ts c' po ce :on of interest ;Ely hoeb rrember. oltcer, o: rad•rrin'sra=437 c.-?t ;7=3 C371-!awaV . Or!iy I:ROES listedCCV nee j to be o' :•_.-,c;osee::i ior7ce oercc e zonfliot is oeeied, fro confftts exist; one -form for the o3g,-.2,-.izat:or, tbe cb2cked noes to be nee Deo ‘:,.o 7,1H-/ L76, rE.-.1:7c.ifTie,5s of Leona K. Seto-Mook PO'S;-flCt Director. Board of Directors en-„,- 0.7 2:] e r•:.en e Lour a of FinaflCE CJDrpc cc 7.Th,:t -z L7'''rFCt "O' S •::; ;J'pg r:LS r.:2,:7f.35EFS: 2-2.-?..f.;-c.:3 00 i7c,s/51-3/ to .a ..":;i0; fl' ;nte.res:. Ai,recl,: riZed Persb --, 7j1:sre EX H 2017-2:)12 -.jS, Cony of iliay.;a1 -ri-r,1(.--,,1)1-, Grant FY20 .1 7- 8 me: Hui Marna Oa ograTn a In e: Traditional Hea!ing Program - La'au project IC, (.311.<;AT,,i1ZfiTr„,),IN CON!FLICT D1:5C;. °SURF FORM Ca Se W3cose rrie:'re , oificer, ry. of OrH,' those b c:cser.), L37E'. rloccr cs exEst, one form orgenht.:3: -., 'f.rp oLort-j:ir, 77ee-:s, cc bc zc.E ease as C:5,,f D3=2. :,,iirieZ,n2r-CI C.0:11:7;;;-_ Sandra Le'nua Andrade Interim Executive arector .7: • - '1.,f 7.7,E 7;1., rirat E: H oililt Ai of Grail Application FY7017- 1 8 ZA:;.-7,triCY Hui %Tama O!a Na PrOgraM Ufl e Traditional Healing Program - La'au project 13, 017-,G NZTON CO FLICT 1)15CLC)SURE FORM ir:te:ES':that :.71-',./ ...0card member, ofcer; Coiti those need to be dlsbloseb. One is needed. no confi•,:t.s exist OC form "No checved 77.s.,?..s;s to be s-...lbmittec! Piee.se OCSTS C.,L'A/12.7±er Cori Lin Viiiehrsig Director of Community Relations and Special Projects 37, o'te ;302', : 0.1 3: 7' SS C,r C,(:). - * r)1 — _ Pe.r,,stcn kEktitrg\IS Pr215-)i-e 7:7 7- If County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Traditional Healing Program - La'au Project ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Traditional Healing Program - La'au Project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period_(must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information - -� - � � and instructions are available at " = . - on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerpuect rind mny result in nrtinns taken to rerover theca funrlc. By signing below, you are acknowledging that you have read and understood these requirements. / J/ /7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Traditional Healing Program - La'au Project 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 120 Number of participants in'aina based experiential learning sessions Number of community'aina based experiential learning sessions 112 Number of Hawaiian Island college students in summer internship for la'au propagation 2 Number of Hawaiian Island high school students receiving summer vocational training Iz Number of seedlings, cutting, and starter plants accessible to dontate to organizations and individuals that would be used to further educational knowledge taught in workshops soo TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $23,680.00 Professional Fees $4,500.00 Operations , $ 1,820.00 Supplies $ 2,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $ 32,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hui Malama Ola Na Oiwi Transportation Program - Kokua Hali Specialty Transportation 95 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi (HMONO) Program Name: Transportation Program - KOkua Hall Specialty Transportation Agency Director: Mabel De Silva, HMONO Board of Directors, Chair Phone No.: (8os) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: (808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, Hawai'i 96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (808 ) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street, Suite 1040 Address: City,ST,Zip Honolulu, Hawai'i 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000 Geographical Areas To Be Served: (One or more can be checked) H Puna I✓l Hamakua (i North Kona ✓❑ South Hilo U North Kohala South Kona H North Hilo n South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns ri Youth ❑ Victims of Crimes �] Culture and the arts (✓d Aged ✓ Victims of Health or Social Crises ✓l Needs of the poor I✓) Physical/Emotional Disabilities H Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi (HMONO) Program Name: Transportation Program - KOkua Hali Specialty Transportation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $40,000 $35,000 $16,625 2. Agency Mission Statement: Misssion Statement: `O Hui Malama Ola Na Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho`oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawaii Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical, spiritual,and mental body, Malama i na mea Hawaii-and Hawaiian culture and practices. E ho`oikaika a ola ka lahui Hawaii-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na 'Oiwi, its Board of Directors, Administration, and Staff are guided and directed by Na Kupuna (our elders) with wisdom and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power •Lokahi: Harmony, parity and balance •`Ohana: Family-core, intermediate, extended • Po`okela: Excellence • Ho`omau: Life-long learning with guaranteed life for generations to come • Koho'ia:To be chosen;a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: Historically, HMONO's offering of Hawaii Island-wide transportation for health services to ambulatory and non-ambulatory clients via its trained drivers and receptionists.and the associated motor pool of one 4-wheel drive paratransit vehicle and five passenger vans has been very expensive to maintain, taking almost a quarter of the annual operating funds.While HMONO has cut back in other areas during the past years to continually provide this all-inclusive service, a change in the federal funding requirements alongside the reduction of grant awards, resulted in the acknowledgment that HMONO would need to restructure the Kokua Hali Health Transportation program to align with the 2016-2017 regulatory and fiscal reality. Owing to the 2016 donation of a gurney-capable van by Business Services Hawaii, the HMONO KOkua Hali Specialty Transportation Program began scheduling of two paratransit vehicles for transporting riders this past August.This streamlined, island-wide paratransit initiative helps Hawaii Islanders,who are unable to walk,get to health services.The Transportation Specialist,trained in First Aid and Standard CPR. schedules the transportation appointment, selects and drives the appropriate paratransit vehicle, accompanies and assists the client from time of pickup to drop-off to ensure safe and on time departure and arrival. The Transportation Specialist has a fleet of two wheel-chair accessible vehicles: one with gurney-capable lift and the other 4-wheel drive capability to pick up passengers in the most remote and rural areas. In the three months that the HMONO Kokua Hali Specialty Transportation Program has been operational,the sole driver has clocked, on the two paratransit vehicles, an aggregated 1,642 miles driven in the geographic areas of Hamakua, Hilo, Kohala, Kona, and Puna. Sixteen HMONO clients took 44 round-trips, from home and back, to 57 medical-related appointments,for an average of 1.38 clients per transport day. One client utilized the service on 12 separate occasions for 17 health-associated activities. 4. Total Budget& Position Count: Total Program Budget: $ 175,350.00 Total Program Position Count: 11 Total Agency Budget: $2,727,000.00 Total Agency Position Count: 128 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi (HMONO) Program Name: Transportation Program - KOkua Hali Specialty Transportation 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Health Resources Services Administration (HRSA) $115,350.00 County of Hawaii $ 60,000.00 TOTAL: $175,350.00 I 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 (HMONO)has relied on federal funding from Health Resources Services Administration(HRSA)to cover most of the costs associated with the Kokua Hali Specialty Transportation Program. HRSA funding provides personnel costs and most of the non-personnel costs. HMONO has registered to submit an application for a Public Utilities Commission (PUC)license which will allow billed revenue from Aloha Care. HMONO is also exploring the feasibility of developing its own tariff for specialty transportation services. HMONO is focused on developing a revenue stream by tapping into other insurance carriers such as HMSA, Medicaid/Medicare, and others. HMONO is also seeking opportunities to update our paratransit fleet with grant funding sources as well as to allocate transportation costs to other program funding. In addition, HMONO is looking into collecting passenger donations to support our program. Six months ago HMONO established a Community Relations and Special Projects department to exponentially expand community awareness of our services.Through Radio,Television, Internet, Social, and Print-Media, the Community Relations team will increase HMONO's capacity to help the public become aware of the Kokua Hali Specialty Transportation Program's paratransit services. HMONO will also invite interested community citizens to join the HMONO client'ohana and the support network vital to their journey back to health. 7. Program Objectives Using County Nonprofit Grant Program Funds: The island-wide HMONO KOkua Hali Specialty Transportation Program serves clients that are either in need of gurney-transport or are non-ambulatory(unable to walk)and,therefore,wheelchair bound. The paratransit service of these clients demands a longer loading and unloading time reducing the number of clients that can be transported in a given day. In addition, many of the paratransit clients have multiple health concerns resulting in a high frequency of trips per client served. Many of the clients are elderly and physically very fragile. Through funding from County of Hawaii, HMONO would expand the paratransit service and increase the safety of its ridership.The HMONO Kokua Hali Specialty Transportation Program would like to expand its ridership to walker-assisted clients. Currently,wheelchair-bound clients working to become ambulatory again through physical therapy visits and other health avenues, are dropped from the service as soon as the are able to walk with assistance,even though these clients are still in need of paratransit services to get to their health appointments. If funding levels increased to re-open the ridership to ambulatory with assistance clients, the Kokua Hali Specialty Transportation ridership could increase from an average of 1.38 to 7 clients per transport day. In recognition of the fragile state of the program's clients, HMONO wishes to increase the emergency medical training of its Transportation Specialist. Depending on the level of County of Hawaii support and funding,the Transportation Specialist would enroll, attend, and graduate from a one-week or a two-week emergency medical response training class.The curriculum meets and exceeds the requirements set by the National EMS Education Scope of Practice for an Emergency Medical Responder.With the County's assistance,the HMONO paratransit program can better serve more clients. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi (HMONO) Program Name: Transportation Program - KOkua Hali Specialty Transportation 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Hilo residents receiving paratransit for health service 75 Kona residents receiving paratransit for health service 30 Ka'u residents receiving paratransit for health service 25 North Hawaii residents receiving paratransit for health service 30 Puna residents receiving paratransit for health service 30 Emergency Response Training of the Transporation Specialist 1 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wars $ 38,338 $124,759 $ 32,689 Profes_sio siLEP.es Operations $ 28,892 $45,491 $ 25,311 $ 350 $ 5,000 $ 2,000 Supplies Equipment Other: Other: Other: +I Other: Other: TOTAL $67,580 $175,350 $60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na `Oiwi Program Name: Transportation Program - KOkua Hall Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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:Mabel W. De Silva POSITION: Chair, 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 I The Mayor I The Managing Director The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,, any conflicts or potential conflicts of interest: I XI If no conflicts exist, check here, 'AeL,te“/ 4. I°hot(r) /7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Transportation Program - Kokua Hali Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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:Louis Hao POSITION: Vice Chair, 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): rn Member or members of the Council fi Staff appointed by a member of the Council i j The Mayor The Managing Director The Director of Finance j The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as a substantial or:.abability 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: X If no conflicts exist, check here. 1� C� 1otiO O --/7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Transportation Program - KOkua Hali Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Robert M. Yamada II POSITION: Secretary/Treasurer, 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): I X Member or members of the Council I I Staff appointed by a member of the Council The Mayor The Managing Director I J The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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 served on the election campaign for Councilwoman Sue Lee Loy. Conflict of interest will be avoided by not discussing this grant application with Councilwoman Sue Lee Loy. 7 If no conflicts exist, check here. , ------,; ,T,-- - , -,, (7 ll� L ,, , _ ,,_,„7,,, , i_ / Signa ure of Author' e Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na 'Oiwi Program Name: Transportation Program - KOkua Hali Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME:David J. Lovell POSITION: Director, 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 7 Staff appointed by a member of the Council 7 The Mayor j The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: XI If no conflicts exist, check here. Dire c ) t /G / Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Transportation Program - Kokua Hali Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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:Noelani Puniwai POSITION: Director, 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: !X! If no conflicts exist, check here. / / (pir ) i/j)-- /' - �� / = it 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Transportation Program - Kokua Hall Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Leona K. Seto-Mook POSITION: Director, 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): 11_J Member or members of the Council Staff appointed by a member of the Council 1 The Mayor The Managing Director I The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I o If no conflicts exist, check here. //30 (7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Mama Ola Na `Oiwi Program Name: Transportation Program - KOkua Hali Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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::Sandra Lehua Andrade POSITION: Interim 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 asi a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and ail mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Xi If no conflicts exist, check here. jc • Nt lA Of/d/A- I0vI h Divt-cfvy 113 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017- 18 Agency Name: Hui Malama Ola Na `oiwi Program Name: Transportation Program - KOkua Hall Specialty Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Ha.wai'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:Cori Lin Wehrsig POSITION: Director of Community Relations and Special Projects May have a conflict 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 7 The Managing Director 7! The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial arobabiiity 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. ----Virr/WV>Yt Signature of Authorized Person (specify title)44 ' g 4 C- i'i-t.epoJL-c,-is Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2013 Page 5 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi (HMONO) Program Name: Transportation Program - KOkua Hall Specialty Transportation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 complete the 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi (HMONO) Program Name: Transportation Program - KOkua Hali Specialty Transportation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futurp funding rerquPct rind may rpciilt in nrtinnc tnkPn tri rprnvpr thpcp funrlc. By signing below, you are acknowledging that you have read and understood these requirements. / /3(//-7Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Malama Ola Na `Oiwi (HMONO) Program Name: Transportation Program - Kokua Hall Specialty Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result I'S Hilo residents receiving paratransit for health service I Kona residents receiving paratransit for health service 30 'I Ka'u residents receiving paratransit for health service 25 30 North Hawaii residents receiving paratransit for health service 30 Puna residents receiving paratransit for health service Emergency Response Training of the Transporation Specialist I I TABLE II: FY 17-18 Council PROGRAM EXPENDITURES I Grant Request Award i Salary and Wages $ 32,689 Professional Fees Operations I $ 25,311 Supplies $ 2,000 Equipment � I Other: I Other: Other: f I Other: I Other: TOTAL $ 60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hui Pono Holoholona Rehomed Lava Cats Continued Care 96 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care Agency Director: Frances P. Pueo Phone No.: (808) 968 — 8279 Contact Person: Frances P. Pueo Phone No.: (808) 345 — 2753 Mailing Address: Address: PO Box 943 Address: City,ST,Zip Mt.View HI 96771 Facility Address: Address: 11-3436 Hibiscus Street Address: City,ST,Zip Mt.View HI 96771 Email Address: paws@hphhawaii.org Fax No.: ( ) — Accountant/CPA: Vivian Toellner Phone No.: (808 ) 345 — 2753 Firm (if applicable): Mailing Address: Address: PO Box 6894 Address: City,ST,Zip Hilo HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth p 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 • Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: At the present time,more than 13,000 animals are euthanized on the island of Hawaii each year. Thousands more are abandoned and lost.The heart of HPH will respond with various programs for purposes of educating the general public on the need to humanely stop animal overpopulation through animal sterilization,furthering additional education on proper animal care,the importance of responsible companionship through kindness and respect. HPH will outreach to other organizations to encourage all to work cooperatively to sterilize all pets and feral cat colonies. HPH connects with individuals that are feeding and caring for cat colonies to be sterilized. Since 2007,volunteers have been caring for the cats at the Kea'au Transfer Station-KTS. Co-ordinated by HPH,the program uses principles of TNRM-Trap/Neuter/Return/Manage,a tested and a proven method worldwide to effectively and humanely manage cat colonies. In 2013,work began on a new Sanctuary: P.A.W.S-Pono Animal Way Sanctuary,bringing those abandon animals from KTS,Pahoa Lava Flow and other commercial areas to the sanctuary. Some were adopted out,while others remain on the 20 acres as their forever home. HPH strives to have animals live in a healthy,safe,caring environment. 3.Program Description: We provide medical care and food for the rescued animals from KTS,Pahoa Lava and commercial sites. These animals were first put into 10 x 30 foot kennels at PAWS to acclimate anywhere from one to three months,before release to various open covered feed stations within the 20 acres. The injured,old,handicapped are kept in the kennels for their well being and safety. Food,water,daily care and Veterinary services provided when necessary. The majority of the rescued animals are in good health,but if needing dental care,for example,that cost could be as much as$400 a cat. 4.Total Budget&Position Count: Total Program Budget 5,000.00 Total Program Position Count: 50 Total Agency Budget: 12,000.00 Total Agency Position Count: 200 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care S. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Yard Sales 6,000.00 Year End Newsletter Donations 3.200.00 Give Aloha Program 800.00 Donations 2,000.00 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: Continuation of donations and fundraising as we have been doing since our inception. Online sales of donated items. Asking for more financial support before accepting felines into PAWS-Pono Animal Way Sanctuary. 7.Program Objectives Using County Nonprofit Grant Program Funds: 1.Purchase medical supplies,food and services for the cats rehomed from Pahoa Lava and Keaau Transfer Station. 2.Hui Pono Holoholona/PAWS remains on standby to rescue more animals threatened by the lava. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Dr.Castro/Hilo Vet.Clinic 2 Dr.Seeske I Kilauea Vet.Services 10 Aloha Veterinary Center 8 Pet food-162 bags-22 pound bags @.70 cent a pound 162 Total 182 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 0 0 Supplies 12,000 2,500 Equipment 0 0 Other: Veterinary Services 5,000 2,500 Other: Other: Other: Other: TOTAL 0 17,000 5,000 if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Sign Lure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records,reporting, and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I(we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express,and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of alt grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by.the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future,funding rPrinPct and mny rPcult in nrtinnc tnkpn to rPrnvPr thacP funds. By signing below,you are acknowledging that you have read and understood these requirements. p � Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Rehomed Lava Cats Continued Care 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Dr.Castro/Hilo Vet.Clinic 2 Dr.Seeske/Kilauea Vet.Services 10 Aloha Veterinary Center 8 Pet food-162 bags-22 pound bags @.70 cent a pound 162 182 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 2,500 Equipment 0 Other: Veterinary Services 2,500 Other: Other: Other: Other: TOTAL 5,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Hui Pono Holoholona Subsidized Low Cost Spay/Neuter Clinics 97 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay / Neuter Clinics Agency Director: Frances P. Pueo Phone No.: (808) 968 — 8279 Contact Person: Frances P. Pueo Phone No.: (808) 345 — 2753 Mailing Address: Address: PO Box 943 Address: City,ST,Zip Mt.View HI 96771 Facility Address: Address: 11-3436 Hibiscus Street Address: City,ST,Zip Mt.View HI 96771 Email Address: paws@hphhawaii.org Fax No.: ( ) — Accountant/CPA: Vivian Toellner Phone No.: (808) 345 — 2753 Firm (if applicable): Mailing Address: Address: PO Box 6894 Address: City,ST,Zip Hilo HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna Hamakua ❑North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ❑Culture and the arts p 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 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay I Neuter Clinics 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000.00 $13,000.00 $18,875.00 2.Agency Mission Statement: Hui Pono Holoholona is an all volunteer,non profit 501 (c)(3)animal organization,dedicated to providing Low Cost Spay I Neuter for Cats&Dogs in the communities of East Hawaii Island. HPH found homes for over 1100 cats. We also trap, Spay/Neuter,Examine,Microchip,Vaccinate, Release&Manage(TNRM)feral and abandoned cats&kittens in various locations working with the caregivers to prevent uncontrolled breeding and overpopulation. Micro chipping helps insure the animal is returned thereby reducing euthanasia numbers at HIHS. Microchip records are given to the caregiver,HIHS and HPH also maintains this information. 3.Program Description: HPH advertises periodic Spay/Neuter clinics and works directly with the community to provide traps,transportation and assists individuals with trapping when necessary. We also have daily phone contact and maintain lists of people in need of our assistance. From 2007 until the end of 2016 we have spay/neutered over 3800 dogs and cats. We have spayed/neutered cats rescued from the 2015 Pahoa Lava and other areas threatened by the lava flow.We coordinated with the National Guard and Police Department to be to able rescue these animals with these areas. These grant funds we are requesting will be used to maintain and increase our operations which is exceeding our donations. 4.Total Budget&Position Count: Total Program Budget: $40,000 Total Program Position Count: 12 Total Agency Budget: $6969.98 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay / Neuter Clinics 5.Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Spay/Neuter Partipants 4,232.33 Mail Donations 1,578.22 Donation Boxes 1,157.17 Interest Earned 2.26 TOTAL: $6,969.98 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: Continuation of donations and fundraising as we have been doing since our inception. Increasing number of Donation boxes placed at various businesses in the community. Online sales of donated items. 7.Program Objectives Using County Nonprofit Grant Program Funds: 1-Sponsor monthly low cost Spay/Neuter clinics for the public. 2-Transport Animals to and from Spay/Neuter appointments. 3-Transport traps&bait food to and from homes of individuals borrowing our traps free of charge. 4-Purchase medical supplies for the Spay/Neuter clinic. 5-Coordmate with UHH Pre-Veterinary students and High School students interested in animal husbandry to attend our clinics. 6-Outreach through newspapers,Facebook,emails,County Fair booth,Volcano Parade&booth stressing the importance of dog and cat spay/neuter and pet care. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay / Neuter Clinics 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Dr.Castro/Hilo Vet.Clinic 18 Dr.Seeske/Kilauea Vet.Services 90 Aloha Veterinary Center 90 Dr.Bill San Filippo/Dr.Agnes Horvath-Clinic Veterinarians 402 Total 600 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 40,000 33,000 Supplies 6,000 4,000 Equipment 4,000 3,000 Other: Other: Other: Other: Other: TOTAL 0 50,000 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay / Neuter Clinics 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of 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): f l Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: El If no conflicts exist, check here. \--- ---) Sig ature of Authorized Person (s•-cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay / Neuter Clinics 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions;award procedures; and records,reporting,and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 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 2017-2018 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/ Neuter Clinics ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to.and accepted by.the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's futilrP funding rPq,uPct rind mny rPctilt in nrtinnc token to rernUPr thece firndc. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (speci title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay / Neuter Clinics 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Dr.Castro/Hilo Vet.Clinic 18 Dr.Seeske/Kilauea Vet.Services 9° Aloha Veterinary Center 90 Dr.Bill San Filippo/Dr.Agnes Horvath-Clinic Veterinarians 402 600 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 0 Operations 33,000 Supplies 4,000 Equipment 3,000 Other: Other: Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Island of Hawaii YMCA, The Family Visitation Center 99 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) Agency Director: Michael Morris Phone No.: ( 808 ) 242 - 9007 Contact Person: Michael Morris Phone No.: (808 ) 242 - 9007 Mailing Address: Address: The Island of Hawaii YMCA Address: 300 W. Lanikaula Street City,ST,Zip Hilo, HI 96720 Facility Address: Address: (same) Address: City,ST,Zip Email Address: mike@mauiymca.org mike@maul Fax No.: (808 ) 243 - 1622 Carbonaro CPAs& Management Group Accountant/CPA: Phone No.: (808 ) 930 - 6850 Firm (if applicable): Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $76,000 Geographical Areas To Be Served: (One or more can be checked) C Puna Q✓ Hamakua Q✓ North Kona WI South Hilo [ North Kohala F/1 South Kona (✓1 North Hilo n South Kohala V Ka`u Services or Activities To Be Provided: (One or more can be checked) I I Educational concerns 111 Youth III Victims of Crimes n 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 2017 -2018 Pau 1of8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 12,000 2. Agency Mission Statement: As described on the YMCA's national website, all YMCA's share three areas of focus: Our Areas of Focus The Y is a cause-driven organization that is for youth development, for healthy living and for social responsibility. That's because a strong community can only be achieved when we invest in our kids, our health and our neighbors. Defining our areas of focus: YOUTH DEVELOPMENT:Nurturing the potential of every child and teen. HEALTHY LIVING: Improving the nation's health and well-being. SOCIAL RESPONSIBILITY:Giving back and providing support to our neighbors. Opportunities for All The Y is for everyone. Our programs, services and initiatives enable kids to realize their potential, prepare teens for college, offer ways for families to have fun together, empower people to be healthier in spirit, mind and body; prepare people for employment, welcome and embrace newcomers and help foster a nationwide service ethic.And that's just the beginning. 3. Program Description: What is the Family Visitation Center? It is a safe, nurturing place within the YMCA facility where child visitations and exchanges can occur.The Center helps children and parents who are experiencing difficulties with domestic violence, divorce, separation or custody disputes. The Family Visitation Center can help when: Children need to go from one parent to another without their parents meeting each other. Children's visits with a parent are required to be supervised. Children's visits are court-ordered but their parents are not able to make the arrangements for visits. A parent is concerned about the safety of the children during visits with the other parent. Assistance is needed for children to visit with other adults and/or children. What services does the Family Visitation Center offer? SUPERVISED EXCHANGES-Children can go from one parent to the other without the parents meeting each other.The exchange of the children is supervised and occurs at the Center. SUPERVISED VISITATION - Center staff supervise visits between children and parents in a stable and supportive environment. Different levels of supervision are available, including full direct, intermittent, and beginning& ending supervision. SUPERVISED TELEPHONE VISITS -Center staff monitor telephone calls between children and parents.The children come to the Center with their custodial parent, and the"visiting parent"calls the center. To arrange visits at the Center, you need a court order or an agreement of all the adults involved. 4. Total Budget & Position Count: $76,000 Total Program Position Count: 4 _ Total Program Budget: Total Agency Budget: $332,000 _ Total Agency Position Count: 13 EXHIBIT A NONPROFIT GRANT APPLICATION FY 201.7-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County Council - Contingency Fund - 2017-18 Visitation fees paid by participants (usua y t e visiting parent 14,000 TOTAL: 14,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Applying to various grants; including an application to the Hawaii State Judiciary. 7. Program Objectives Using County Nonprofit Grant Program Funds: This application for County Nonprofit Grant Program Funds would be used to maintain approximately the current level of service at its Hilo facility. No long-term steady source of income is currently available. Continuation of the Family Visitation Center provides an invaluable resource for the judicial and social services systems in our community, significantly relieving pressures in society that could lead to further abuse, neglect, violence, and perhaps even deaths.To put it bluntly,the Center probably also reduces expenses that would have been spent on social work, police, court, prison, and other services if dysfunctions in the families instead continued and worsened. If sufficient long-term funds become available from whatever sources,the YMCA's Family Visitation Center would like to start a West Hawaii (Kona) branch center.This would involve additional salaries and wages of$58,000. Participants from the West Hawaii area and other areas outside Hilo have valued this program so much that they have travelled to Hilo to participate.This compounds the emotional and financial stresses they are under due to the travel time and travel expenses involved. Further, if sufficient long-term funds become available, additional days of service per week is desired, beyond the current weekend service. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) adults to be served at the Hilo facility 150 children and youth under 18 to be served at the Hilo facility 200 number of volunteers 20 number of volunteer hours 1,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req 65,000 76,000 76,000 Salary and Wages Professional Fees Operations Supplies Equipment Other: Othar: Other: Other: Other: TOTAL 65,000 76,000 76,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Belinda Hall POSITION: staff: Corporation Counsel May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance WI The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Not directly involved with Family Visitation Center. If no conflicts exist, check here. 44....; Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Lance Niimi POSITION: Assistant Housing Administrator May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council f] Staff appointed by a member of the Council n The Mayor ri The Managing Director The Director of Finance r1 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Not directly involved with Family Visitation Center. If no conflicts exist, check here. • Z:.• 11-?•r/ C'6,441/"- fAb/1-7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rarquect DnrJ mny recult in nctinnc taken to rernver theca funr�c, By signing below, you are acknowledging that you have read and understood these requirements. (6/10,-.3/).7. L l 00 Ai-a/ +v"' // 1/7/ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai i Nonprofit Grant Application FY2017-18 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 150 adults to be served at the Hilo facility 200 chldren and youth under 18 to be served at the Hilo facility number of volunteers 20 1,000 number of volunteer hours TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 76,000 Professional Fees Operations Supplies Equipment Other: Other. Other: Other: - Other: --- TOTAL 76,000 L - Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Ka'u Rural Health Community Association, Inc Ka`u Pilot Telehealth Outreach Project 100 'a County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Pro'ect Agency Director: Jessanie Marques Phone No.: (808) 928 — 0101 Contact Person: Jessanie Marques Phone No.: (808) 928 — 0101 Mailing Address: Address: P.O.Box 878 Address: City,ST,Zip Pahala, Hawaii 96777 Facility Address: Address: 96-3126 Puahala Street Address: City,ST,Zip Pahala,Hawaii 96777 Email Address: krhcai@yahoo.com Fax No.: (808) 928 — 0101 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑ Hamakua ❑North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑North Hilo ❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) p✓ Educational concerns p✓ Youth 0 Victims of Crimes ❑Culture and the arts p Aged Q✓ Victims of Health or Social Crises Q✓ Needs of the poor Physical/Emotional Disabilities p✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $25,000 2.Agency Mission Statement: Kau Rural Health Community Association, Inc.(KRHCAI)Mission"To Do What It Takes To Keep Kau Healthy",reflects the board of directors commitment to promote its Health&Wellness program that focus on health,education, research opportunities and economic sustainability 3. Program Description: KRHCAI is seeking County funding of$69,750 to implement and staff a one year FREE Pilot Telehealth Outreach Project" (KPTOP)to community members living in the District of Kau. In November 2016 American Well and HMSA established a landmark agreement providing equipment, IT connectivity and FREE access to primary care physicians/specialists via"HMSA Online Care". The Telehealth Kiosk is located at the Kau Resource&Distance Learning Center in Pahala and will be staffed by executive director,program coordinator,office manager, nursing students,certified nurse aides,and community health workers interns to enroll residents in Pahala and/or through home visits. KPTOP is anticipated to decrease emergency room visits and inpatient hospitalization especially those with chronic conditions i.e. diabetes,hypertension,asthma,kidney disease and behavioral health. Initially,the telehealth kiosk and outreach services will be available two days a week(9:00am-1:00pm)and is dependent on utilization and funding. KPTOP's "return on investment" is significant and meaningful because there are no other outreach programs with vested support from American Well and HMSA in Kau that offer FREE access to healthcare providers. KRHCAI's program budget request is minimal but,provides leverage with other funding resources. On behalf of KRHCAI board of directors, I thank you for this opportunity to participate in this Grant In Aide process and share our mana'o. We hope that you will agree to fully fund the Kau Pilot Telehealth Outreach Project($69,750),so Hawaii County can set a precedence in decreasing the high cost of healthcare; providing telehealth training to nursing students,community health workers and certified nurse aides; and supporting an innovative outreach telehealth project in our rural,underserved, geographically isolated and economically distressed community. 4.Total Budget&Position Count: Total Program Budget: $156,400 Total Program Position Count: 3 Total Agency Budget: $199,400 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Project 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate USDA Rural Development Community Facilities Infrastructure Grant FY2017-18 $49,500 KRHCAI Matching Funds $30,000 Atherton Family Foundation Grant Award FY2017-18 $20,000 In-Kind (American Well Telehealth Kiosk Equipment) $39,000 Donation/s $7,000 Membership Dues $2,000 TOTAL: $147,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1. Facility Useage for Medical Assist School Hawaii(1year). KRHCAI is in discussion to start a Medical Assistant course in June 2017-May 2018. 2.KRHCAI will submit an HMSA Foundation Grant FY2017-18 for$40K to support Executive Director(10hrs/week), Program Ccoordinator(20hrs/week),Office Manager(5hrs/week), Program Assistant (10hrs./week) 3.KRHCAI will submit a Hawaii Community Foundation FLEX proposal to support KPTOP maintenance and discretionary funding. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program objectives using Hawaii County Nonprofit grant program funds are to: 1) Decrease the emergency room visits and hospitalization by 10%based on 2016 hospital useage data.Timeline 2/2017-6/18. 2)Conduct 10 health,education/prevention workshops/webinars focusing on chronic disease self management,healthy relationships,injury prevention,Caregiving,tobacco/drug use,oral health survey,domestic/sexual violence prevention.Timeline 3/2017-6/18 3)Engage 5-10 staff,nursing students,community health workers and/or certified nurse aides to enroll 50+participants in HMSA Online Care.Timeline 2/2017-6/18. 4) Increase the number of HMSA Online enrollment, appointments,home visits, outreach,referrals and workshop/webinars to 50+. Timeline 2/2017-6/2018 5)Executive director will collect monthly data regarding enrollment,appointments,home visits,outreach,referrals, workshops/webinar attendance. Timeline 2/2017-6/2018. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Project 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Recruit student interns 5- 10 students Staff Development&Training 40- 80 hours Promote Health Education/Prevention Workshops 6-8 workshops Develop and establish Outreach protocol(individuals/home visits/referrals) 50 visits Develop and establish Telehealth weekly schedule Twice a week(initial time line) Develop and establish demographics,logistics database 50 Kau Residents Develop and establish program evaluation and community needs survey 50 community Satisfaction Survey Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages -0- 0- Professional Fees $121,000 $55,000 Operations $21,400 $7,500 Supplies $7,000 $3,250 Equipment -0- -0- Other: Staff Development&Training $3,000 $1,500 Other: Mileage Stipends $3,000 $1,500 Other: Marketing, Signage, Banners $1,000 $1,000 Other: Other: TOTAL $156,400 $69,750 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Pro'ect 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: 0 If no conflicts exist, check here. S)/lebL‘ 2e/WeZ9V Jan. 27, 2017 i nature of Authoriz Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Project i1.Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, 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 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 2017-2018 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future fiinding rPquact and mny result in nrtinnc tnkan to rvrnvar thecP fiindc. By signing below, you are acknowledging that you have read and understood these requirements. J Jan. 27, 2017 Signature of Authoriz dPerson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Pilot Telehealth Outreach Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Decrease emergency room visits and hospitalization by 10% 5-10 80 hours Promote Health Education/Prevention Workshops s-8 workshops Develop and establish Outreach Protocol(individuals,home visits,referrals) 50+visits Develop and establish Telehealth Schedule Twice a week(initial time line) Develop and establish demographics,logistics,intervention,database 50+Kau Residents Develop and establish program evaluation,community satisfaction survey 5o+c Satisfaction Surveyty Survey TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages -0- Professional Fees $55,000 Operations $7,500 Supplies $3,250 Equipment -0- Other: Staff Development&Training $1,500 Other: Mileage Stipends $1,500 Other: Marketing, Signage, Banners $1,000 Other: Other: TOTAL $69,750 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Keaukaha One Youth Development Hokualaka'i Restoration Project 101 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (808 ) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI, 96720 rzi COPY Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPAs&Management Group Phone No.: (808 ) 968 — 1002 Firm (if applicable): same as above Mailing Address: Address: 136 Kinoole Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ✓ Puna ✓ Hamakua Iv l North Kona ✓ South Hilo [ North Kohala n South Kona [' North Hilo E✓ South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns n Youth [Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged n Victims of Health or Social Crises ❑✓ Needs of the poor n Physical/Emotional Disabilities H Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0.00 0.00 0.00 2. Agency Mission Statement: The mission of the Keaukaha One Youth Development(KOYD) is to contribute toward developing the future leaders of Hawaii County by offering educational youth (ages 8-18) programs that fosters recognition of their strengths and passions and overall physical. mental and spiritual well-being grounded in cultural identity 3. Program Description: In November 2015. the Hokualaka'i double-hulled voyaging canoe owned and built by'Aha Punana Leo was graciously donated to KOYD and the community of Keaukaha. As the new caretakers, we decided to make Keaukaha its permanent home having been over-challenged with the restoration demands it requires. We envision this donation as another learning domain to further solidify our goals of creating cultural learning places for youth and their families to contribute their talents and learning engagements through our Polynesian voyaging heritage and to teach our youth to become qualified voyaging members of the Hokualaka'i. 4. Total Budget& Position Count: • Total Program Budget: $20,000.00 Total Program Position Count: 0 Total Agency Budget: $160,000.00 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii (reflects our current request) $20,000.00 TOTAL: $20,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hokualaka'i Restoration Project continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Hokualaka'i Restoration Project will strive to reach the following objectives: 1) Restore the HOkualaka i double-hulled voyaging canoe back to seaworthiness. 2) Teach the values of team work, goal setting. commitment, physical, mental, and spiritual well-being. and cultural identity through the restoration process and use of the voyaging canoe. 3) Create more cultural learning places for youth and their families to contribute their talents and learning engagements through our Polynesian voyaging heritage. 4)To inspire and teach our youth to become cultural practitioners in the arts of kalai wa'a(canoe restoration)and ho'okele wa'a (voyaging)through the use of Hokualaka'i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served 150 youth Volunteer hours of 12 people 5,760 hours Hokualaka i restoration Completed by June 2018 ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $12,000.00 $12,000.00 Equipment $5,000.00 $5,000.00 Other: Food $3,000.00 $3,000.00 Other: Other: Other: Other: TOTAL $0.00 $20,000.00 i $20,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. giEfitale p r 11241M -) Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerruect rind mny result in nrtinnc tnken to rernuer these finds. By signing below, you are acknowledging that you have read and understood these requirements. tKEWPVC o/gt /P naFavr l/2y l201 -7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 153 youth Volunteer hours of 12 people s;EC hours— HOkualaka i restoration completed by June 2013 "`See attachment TABLE II: FY 17-18 I Council PROGRAM EXPENDITURES Grant Request . Award Salary and Wages Professional Fees Operations Supplies $12,000.00 Equipment $5,000.00 Other: Food $3,000.00 Other: Other: Other. Other: TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2017-18 Keaukaha One Youth Development (KOYD) Hokualaka`i Restoration Project 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 I) Number of Hawaii County youth served Approximately 150 youth 2) Volunteer hours of 12 people: Executive Approximately 5.760 hours (see breakdown Director, Cultural Practitioner, and 10 below): Keaukaha Hawaiian Homestead kupuna40 hours per month x 12 months = 480 hours per person x 12 people = 5,760 hours 3) Hokualaka`i restoration Restoration completed by June 2018 Reference to Page 4, Question 9: Table II —Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Equipment Outdoor power 55,000.00 tools/equipment Supplies Misc. materials/supplies for S 12,000.00 Hokualaka`i reconstruction and site maintenance Food: Snacks/other food supplies for $3,000.00 volunteers/youth 1 Keaukaha One Youth Development RISE 21st Century After School Program 102 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program Agency Director: Shadd Keahi Warfield Phone No.: ( 808 ) 895 - 8666 Contact Person: Naomi Ahu Phone No.: (808 ) 756 - 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI 96720 rfJ COPY Facility Address: Address: same as above Address: City,ST, Zip Email Address: naomi koyd.rise©gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPAs& Management Group Phone No.: (808 ) 968 - 1002 Firm (if applicable): same as above Mailing Address: Address: 136 Kinoole Street Address: City, ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ✓� Puna ✓ Hamakua ( I North Kona III South Hilo I I North Kohala I I South Kona (✓� North Hilo I I South Kohala I I Ka'u Services or Activities To Be Provided: (One or more can be checked) III Educational concerns I Youth I I Victims of Crimes ✓ Culture and the arts I Aged n Victims of Health or Social Crises III Needs of the poor Physical/Emotional Disabilities VI Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 - 2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 14-15 FY 15-16 FY 16-17 0.00 6000.00 6750.00 2. Agency Mission Statement: The mission of the Keaukaha One Youth Development(KOYD) is to contribute toward developing the future leaders of Hawaii County by offering educational youth (ages 8-18)programs that fosters recognition of their strengths and passions and overall physical, mental, and spiritual well-being grounded in cultural identity. 3. Program Description: The RISE 21st Century After School Program was established in 2011 by Keahi Warfield and Naomi Ahu to serve as a community resource bank for underprivileged, Native Hawaiian youth ages 8-18 in the Hilo district. The main focus is to aid in revealing their individual strengths and passions for future career and academic success. A variety of mediums are used to build Individual Student Success Plans(ISSP)such as but not limited to: apprenticeships, Hawaiian cultural practice, internships, multimedia, performing arts, project exhibitions, student exchange, and work study initiatives.As youth discover their potential strengths and passions. RISE helps 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 also provides opportunities to support physical well-being, cultural identity, and leadership. By implementing this mission, RISE envisions that when the youth participants graduate from high school, they will have a clear and stronger idea of what their future career and academic pursuits will be. The relationships they have gained through our program will help motivate and encourage them to become valuable contributors to the well-being and sustainability of the Hilo community. 4. Total Budget & Position Count: Total Program Budget: $120,000.00 Total Program Position Count: 0 Total Agency Budget: $160,000.00 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii (reflects our current request) $20,000.00 Hawaii Community Foundation - STEM Learning (pending) $40,000.00 Hauoli Mau Loa Foundation - HOPE for Kids Elua (pending) $60,000.00 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 RISE 21st Century After School Program continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our key objectives for youth success are the following: 1)To reveal the strengths and passions of youth participants to contribute toward overall student engagement and confidence. 2)To help youth participants develop Individual Student Success Plans(ISSP)to track monthly goals and expectations and to contribute toward building responsible. respectful and reliable students. 3)To 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 hou (restoration discipline)and ho'okele/hoe wa`a(canoe voyaging/paddling)to teach values and encourage discipline, balance and leadership for physical, mental. and spiritual well-being. 5)To incorporate STEM (science, technology. engineering. and mathematics)principles in the cultural/place-based learning domains we have access to. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served 75 youth Volunteer hours of 13 people 2160 hours Implementation of Individual Student Success Plans(ISSP) Implement ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees $2,500.00 $1,500.00 Operations $3,250.00 $34,000.00 $4,000.00 Supplies $48,000.00 $8,000.00 Equipment $3,500.00 $3,500.00 $3,500.00 Other: Food/snacks for youth & volunteers $10,000.00 $3,000.00 Other: Travel $10,000.00 Other. Contract Services $5,000.00 Other; Gen'I Liability Insurance $7,000.00 Other: TOTAL $6,750.00 $120,000.00 $20,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council Staff appointed by a member of the Council I I The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. 1 l live-aii yr 2 &I� 1(1 �tzu ��taneIpft �j �� 7 Signature of Auth•rized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerluest nnrl mny result in nrtinnc token to rernver these funds. By signing below, you are acknowledging that you have read and understood these requirements. &XE-t tinvE--vigr agelPg63/05,yr 1124 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 75 youth Volunteer hours of 13 people 2160 hours Implementation of Individual Student Success Plans (ISSP) 'mpemeet "*See attachment TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $1,500.00 Operations $4,000.00 Supplies $8,000.00 Equipment $3,500.00 Other: Food/snacks for youth &volunteers $3,000.00 Other: Travel Other: Contract Services Other: Gen'I Liability Insurance Other: TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2017-18 Keaukaha One Youth Development (KOYD) Revealing Individual Strengths for Excellence (R.I.S.E.) Reference to Page 4, Question 8: Table I—What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I—Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 75 youth 2) Volunteer hours of three people: Executive Approximately 2160 hours (see breakdown Director, Executive Assistant, and below): Fiscal/Administrative Coordinator * 60 hours per month x 12 months = 720 hours per person x 3 people = 2160 hours 3) Number of volunteer mentors and hours 10 volunteers, 360 hours (see breakdown served below): 10 volunteers x 3 hours = 30 hours per month x 12 months = 360 hours 4) Implementation of Individual Student Evidence of beginning stages of Success Plans (ISSP) for youth participants implementation such as goal setting and recorded support from mentors and parents Reference to Page 4, Question 9: Table II—Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Administrative/Professional CPA—Year End Financial $1,500.00 Fees: Statement Generation Maintenance: Monthly Interior/Exterior $4,000.00 Grounds Maintenance Equipment *S.T.E.M. Project supplies $8,000.00 Monthly 4G data plan for (2) $1,000.00 RISE staff iPad's Xerox machine expenses $2,500.00 Food: Snacks/other food supplies $3,000.00 *Science, Technology, Engineering, and Mathematics 1 Keaukaha One Youth Development Youth Paddling Program 103 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program Agency Director: Shadd Keahi Warfield Phone No.: (808 ) 895 — 8666 Contact Person: Naomi Ahu Phone No.: ( 808 ) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, HI. 96720 Facility Address: Address: same as above p Address: City,ST, Zip Email Address: naomi.koyd rise@gmail com Fax No.: ( ) — Accountant/CPA: Carbonaro CPAs&Management Group Phone No.: (808 ) 968 — 1002 Firm (if applicable): same as above Mailing Address: Address: 136 Kinoole Street Address: City,ST,Zip Hilo. HI. 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) RI Puna I✓i Hamakua I I North Kona ✓ South Hilo I I North Kohala I I South Kona n North Hilo South Kohala I I Ka'u Services or Activities To Be Provided: (One or more can be checked) I Educational concerns III Youth Victims of Crimes III Culture and the arts Aged I I Victims of Health or Social Crises I✓) Needs of the poor n Physical/Emotional Disabilities ✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 - 2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0.00 6000.00 6750.00 2. Agency Mission Statement: The mission of the Keaukaha One Youth Development(KOYD) is to contribute toward developing the future leaders of Hawaii County by offering educational youth (ages 8-18) programs that fosters recognition of their strengths and passions and overall physical. mental and spiritual well-being grounded in 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: $20,000.00 Total Program Position Count: 0 Total Agency Budget: $160,000.00 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii (reflects our current request) $20,000.00 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 Youth Paddling Program continues to rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause 7. Program Objectives Using County Nonprofit Grant Program Funds: The Youth Paddling Program will strive to reach the following objectives: 1)Teach the values of team work, goal setting. commitment. physical, mental, and spiritual well-being, and cultural identity through the use of the Hawaiian Canoe. 2) Utilize the Hawaiian Canoe to present the metaphoric message of ones journey through life- "you steer your own waa(life), but not without the help of others(KOYD and our extended communities)." 3) Help offset the high risks of drug and alcohol exposure/abuse among our Hawaii County youth through fostering after school canoe paddling practices and weekend regatta races. a healthier alternative for the utilization of their time. 4)Teach the values and processes necessary for the maintenance of Keaukaha Canoe Club's historic koa canoes and other equipment for current and future generations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 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 Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served 120 youth Volunteer hours of four people 850 hours ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees $500.00 $500.00 $500.00 Operations $6,000.00 $6,000.00 Supplies $2,100.00 $4,500.00 $4,500.00 Equipment $1,500.00 $1,500.00 $1,500.00 Other: Travel $2,650.00 $7,500.00 $7,500.00 Other: Other: Other: Other: TOTAL $6,750.00 ; $20,000.00 I $20,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor I I The Managing Director I The Director of Finance I 1 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: III If no conflicts exist, check here. LA/IC(/(41(21 n�� /�IZf�/POv t //0-/-/ 0 �zu�v� f 2 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding reriuect and may remit in nrtianc taken to rernver thece funric, By signing below, you are acknowledging that you have read and understood these requirements. 6C nV Emit raix hf�r3/oar l lel 2o Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 12. COUNCIL AWARD WORKSHEET TABLE I: i 1 PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 120 i°'`" Volunteer hours of four people 1 a5c.naffs **"See attachment TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages Professional Fees $500.00 Operations $6,000.00 Supplies $4,500.00 Equipment $1,500.00 Other: Travel $7,500.00 Other Other,- - --- --- --- -- --- --- ---- - Other: Other: TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2017-18 Keaukaha One Youth Development (KOYD) Youth Paddling Program Reference to Page 4, Question 8: Table I —What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I — Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 120 youth 2) Volunteer hours of four people: Youth Approximately 850 hours (see breakdown Division Head Coach, two Youth Division below): Assistant Coaches, and one Youth Division * 16 two hour practices per month x 5 months Program Assistant (March-July) = 160 hours x 3 coaches = 480 hours * 9 ten hour Saturday regattas x 3 coaches = 270 hours * 20 hours per month for Program Assistant x 5 months = 100 hours Reference to Page 4, Question 9: Table II —Program Expenditures Reference to Page 8, Question 12: Table II — Council Award Worksheet Program Expenditures Additional Details _ Budget Professional Fees: CPA - Year End Financial $500.00 Statement Generation Equipment: Paddle and canoe repair $4,500.00 Various paddling equipment S4,500.00 and supplies Escort boat repair and S1,500.00 maintenance Portable toilet rental for S 1,500.00 program site Other: Travel Costs (bus rentals, $7,500.00 gasoline expenses, airfare, etc.) 1 Kailapa Community Association Ka Wai Ola - Water is Life 104 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kailapa Community Association Program Name: Ka Wai Ola ( Water is Life) Agency Director: Diane M. Kanealii Phone No.: (808) 640 — 3195 Contact Person: Diane M. Kanealii Phone No.: ( ) — Mailing Address: Address: 61-4016 Kai Opae PI. Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: 614016 Kai Opae PI Address: City,ST,Zip Kamuela, Hi 96743 Email Address: dkanealii02@gmail.com Fax No.: ( ) — Accountant/CPA: Lynelle Paranada Phone No.: (808) 989 — 8782 Firm (if applicable): Hilinai Bookkeeping and Payroll,LLC Mailing Address: Address: P.O.Box 4280 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 gi 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 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Kailapa Community Association Program Name: Ka Wai Ola ( Water is Life) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: Vision:Ehuehu i ka pono(Thrive in balance) Mission: To empower Native Hawaiians living in Kohala,specifically the Kailapa Community,supporting physical, mental,spiritual,and cultural health of people and place Goals: Build community self-sufficiency and independence through Social Economic Development Educate and strengthen the cultural identity and self-esteem by facilitating opportunities to learn,practice and share Hawaiian knowledge of history,culture,values and traditional practices Preserve and protect our natural environment through stewardship of our islands and resources that are appropriate to traditional practice and perspective. Strengthen and engage community relationships and encourage active participation in issues that impact Native Hawaiian culture,resources,health,wellness and lands 3. Program Description: Kailapa Community Association(KCA)is working towards self-sufficiency and self-sustainability through many programs and projects. The funding from this grant request will be used to plan and drill a irrigation well. Water is key for the success of the many programs and projects as nothing can be done without water.The Department of Hawaiian Homelands(DHHI)entered into a contract with the Kohala Ranch Water Company(KRWC)to provide potable water to the Kailapa Subdivision.There is limit of 117,000 gallons of water per day for the entire community.The contact does NOT allow water use for ANY purpose outside of domestic use. Since the projects Kailapa fall under Community use,KRWC will NOT allow the Community to use ANY water for agricultural use.The food-security and self-reliance,aquaponic, native plant propagation, food production, re-vegetation, erosion control or landscaping projects all all considered AG use. Therefore the only long term solution our community has is to drill an irrigation well.Brackish water can support our projects without using the KRWC potable water source.This well will give the community the freedom to grow brackish water tolerant native plants, begin re-vegetating erosion prone areas,support the growing of food,landscape and really begin to be self-sufficient and self reliant and to be prepared for emergencies,disasters and to be good stewards the'aina and ocean resources. Potable water supply is dwindling in coastal areas,we at Kailapa, hope to set the standards of"can do"and lead the way to reduce the need for potable water used for landscaping,erosion control and mitigation and reforestation efforts. 4.Total Budget&Position Count: Total Program Budget: 238,000 Total Program Position Count: 1 Total Agency Budget: 600,000 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kailapa Community Association Program Name: Ka Wai Ola ( Water is Life) 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate NOAA Coastal Resilience Grant 135„000 Community Aquaponic program 3,000 County of Hawaii Non-Profit Grant 100,000 TOTAL: 238,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Applying for funding through the NOAA Coastal Resilience Grant grant to support the planning ,design and some of infrastructure of the well. County of Hawaii Non-Profit Grant use as match the NOAA grant Kailapa's aquaponic program will generate income from sales of the produce that is not needed for consumption Working with Hawaii Rural Water Association to begin planning of well site for best results and viability as well as bringing in USDA support once the well is drilled and running to support it's operation and maintenance. Once the well is up and running,we will be able to propagate and sell native plants to create a long term revenue generating source 7. Program Objectives Using County Nonprofit Grant Program Funds: This grant will support the planning,design and building of the Irrigation well that will create and support: 1.Community aquaponic project for food production for community use and sale to generate income to support projects that fit into vision and mission of Kailapa. 2.Native plant nursery for use in erosion control,beautiful the area,and for sale to generate income 3.Out-planting and establishing the growth of Native plants in the most erosion prone areas 4.Landscape of community common areas 5.Support Kailapa's vision of self-sufficiency and self-sustainability 6.Support Kailapa's vision to begin the re-vegetation and reforestation of the Kohala Mountains on Hawaiian Homes lands to re-establish and expand the watershed EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Kailapa Community Association Program Name: Ka Wai Ola cWater is Life) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Native plant propagation workshops to teach and encourage growing native plants x 2 Knowledge of how and why to use natives 15-50+ Volunteers out-plant in high erosion prone areas within Kailapa Improved relationship with land base Succulent plants grown and out-planted to create firebreak around community Decreased fire risk,improved safety Reduction of sediment entering ocean during heavy rains Decreased impact on coral,improved fishery Natve plant nursery established and serving as native plant source for out-planting Plants to decrease erosion,generate income Collect water samples w/volunteers(students) from UH SeaGrant program Monitor water quality Aquaponics program feeding local residents Healthy food,healthy people,generate income Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 45,000 20,000 Operations 0 3000 0 Supplies 0 10,000 5000 Equipment 0 150,000 75,000 Other: Planning 5,000 0 Other: Permits 200 0 Other• Test well 24,800 Other: Other: TOTAL 238,000 100,000 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-1 S Agency Name: Kailapa Community Association Program Name: Ka Wai Ola ( Water is Life) 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. Ail disclosure forms must be signed, regardless of whether a conflict exists. NAME: Diane M. Kanealii 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 9 The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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. XdrAtile/. 4041) VA440e6:-: 4etzthid-)elired-tY— 'ZbY/ Signature g e of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kailapa Community Association Program Name: Ka Wai Ola ( Water is Life) 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 Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, 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 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Kailapa Community Association Program Name: Ka Wai Ola ( Water is Life) ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to.and accepted by.the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's ftiturp funding rprpiPct rind mny rpailt in nrtinnc tnkpn to rprnvpr thpcp funrk, By signing below,you are acknowledging that you have read and understood these requirements. t _ a 7 I/ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kailapa Community Association Program Name: Ka Wai Ola ( Water is Life) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Knowledge of how and why to use natives Improved relationship with land base Decreased fire risk Decreased impact on coral, improved fishery Native plants used to mitigate erosion Improved realationships with neighbors Community closer to self-sufficiency TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages 0 Professional Fees 20,000 Operations 0 Supplies 5000 Equipment 75,000 Other: Planning 0 Other: Permits 0 Other: Test well Other: Other: TOTAL 100,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Kamuela Philharmonic Orchestra Society Kamuela Philharmonic Strategic Realignment 105 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strategic Realignment Agency Director: Nancy Stephenson, KPOS President Phone No.: (808) 365 — 4466 Contact Person: Kevin D Fenner, KPOS Board Member Phone No.: (808) 640 — 7784 Mailing Address: Address: Po Box 2597 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: Address: City,ST,Zip Email Address: Grants@KamuelaPhil.org Fax No.: (866 ) 611 — 4602 Accountant/CPA: Adam K.Campbell,Tax Supervisor Phone No.: (808 ) 791 — 1439 Firm (if applicable): Wikoff Combs&Co.,LLC Mailing Address: Address: 1001 Bishop Street Address: Suite 2760 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 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 D 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strategic Realignment 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 N/A N/A N/A 2.Agency Mission Statement: The Kamuela Philharmonic Orchestra Society is a non-profit organization dedicated to bringing live, high-quality orchestral music to audiences on the Big Island of Hawai'i.The Kamuela Philharmonic celebrates and promotes the timeless beauty of classical music,as well as the rich cultural and musical traditions of the Hawaiian people. The Mission of the Kamuela Philharmonic Orchestra is to present live,high quality,orchestral music to Big Island audiences and to further the musical education of young people. Our mission has always been and will always be simple and clear: provide the best classical music to the broadest possible audience with special attention to youth and music education. 3. Program Description: The Kamuela Philharmonic Strategic Realignment Program is focused on created a self-sustaining symphony on the Big Island. A key component of the strategic realignment is the capitalization of the KPOS. For the organization to become sustainable we need Working Capital,Capital Reserves,and Risk Capital for new and innovative programs. Funding to recruit,compensate,train,and mentor a new Executive Director is key to fulfilling the mission of the Kamuela Philharmonic Orchestra Society(KPOS).As part of our current executive transition we have initiated a strategic realignment of the organization in conjunction with our stakeholders(customers, board members, musicians,funding entities). The funds from the County of Hawaii will be used to reimburse 30%of the funds to recruit,compensate,train, mentor a new Executive Director. During the transition from our current Executive Director(ED)to the new ED,the Board of Directors is reviewing the organization's mission,strategic position and direction; and is clarifying the skills and qualities for a new ED.We are working with the Hawaii Community Foundation and our key funding partners(Dorrance Family Foundation,Bank of Hawaii)in this process.The transition process has been well thought out,communicated appropriately to internal and external audiences,and new Board members has been added to facilitate this strategic realignment. 4.Total Budget& Position Count: Total Program Budget: 61,000.00 Total Program Position Count: 1.5 Total Agency Budget: 119,610.00 Total Agency Position Count: 2.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strategic Realignment 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Donations& Fundraising 5,500.00 Dorrance Family Foundation 10,000.00 Ticket Sales 22,000.00 Hawaii Community Foundation 5,200.00 County of Hawaii 18,3000.00 TOTAL: 61,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Revenues for the Kamuela Philharmonic Strategic Realignment Program will be increased specifically through increased ticket sales,additional grant funds focused on creating a sustainable organization,increased donations, increased merchandise sales and increased advertising. 7. Program Objectives Using County Nonprofit Grant Program Funds: The overall impact of a thriving performing arts scene on the community is extensive. Numerous studies have shown that just about every group of people benefits from access to culture and art. Examples include strengthening overall ties in and to the community,giving people of all ages something positive, inspiring,and engaging to participate in,and the increased mental and physical stimulation that the performing arts provide. Expand educational concerts to develop a deeper relationship with the public schools and improve accessibility for students. Education is a priority and the cornerstone of our mission. Future players and future audiences are directly tied to music education. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strategic Realignment 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Big Island Concerts 3 Major Concerts Educational Chamber Events in Schools 10 School Programs Volunteer Hours Donated 1,800 Hours Donated Customers Served at Concerts 3,000 Students Served in Schools 1,200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages N/A 40,000.00 12,000.00 Professional Fees N/A 15,000.00 4,500.00 N/A 6,000.00 1,800.00 Operations N/A Supplies N/A Equipment Other: Other: Other: Other: Other: TOTAL 61,000.00 18,300.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strategic Realignment 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. t�vtic ►. Ili • c ; Signa re of uttiorized Person (specify title) )(8t3L__PIo EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strategic Realignment 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strate•is Reali•nment 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 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 futures funding rarpupct and mny racult in nrtinnc tnkan to rprnvar theca firndc, By signing below, you are acknowledging that you have read and understood these requirements. Lk I L‘.. inketr.NAI k.t.4414 iii i a,A.a&.1. ki-/ . 6 ICI i Signatur- of Aut orize• Perso (specify title) 'late EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kamuela Philharmonic Orchestra Society Program Name: Kamuela Philharmonic Strategic Realignment 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 3 Major Concerts 10 School Programs 1,800 Hours Donated 3,000 1,200 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 12,000.00 Professional Fees 4,500.00 Operations 1,800.00 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 18,300.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Kohala Animal Relocation and Education Service (KARES) Canine Spay and Neuter Program 106 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine Spay and Neuter Program Agency Director: Deborah M. Cravatta, President and Founder Phone No.: (808) 333 — 6299 Contact Person: Deborah M. Cravatta Phone No.: (808) 333 — 6299 Mailing Address: Address: Kohala Animal Relocation and Education Service(KARES) Address: P.O. Box 44670 City,ST,Zip Kamuela, Hawaii 96743 Facility Address: Address: Kohala Animal Relocation and Education Service(KARES) Address: 59-241 Kipa Mai Place City,ST,Zip Kamuela, Hawaii 96743 Email Address: pets@kohalaanimal.org Fax No.: (808 ) 880 — 1925 Accountant/CPA: Randall Macaluso Phone No.: (sob ) 881 — 1040 Firm (if applicable): Kamuela Taxpros Mailing Address: Address: Kamulea Taxpros Address: 65-1190 Mamalahoa Highway City,ST,Zip Kamuela, Hawaii 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: #1/8, CO. Geographical Areas To Be Served: (One or more can be checked) Q✓ Puna Q✓ Hamakua 0 North Kona 2 South Hilo n North Kohala [✓ South Kona U North Hilo n South Kohala 0✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) • Educational concerns n Youth [ Victims of Crimes ❑Culture and the arts n Aged ❑Victims of Health or Social Crises Q✓ Needs of the poor n Physical/Emotional Disabilities • Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine Spay and Neuter Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $10,000 $15,000 $20,000 2. Agency Mission Statement: A widespread interest to create an organization adhering to a"no kill"philosophy gave birth to the Kohala Animal Relocation& Education Service(KARES)which serves the entire Big Island of Hawaii. The mission of KARES is to rescue and relocate abused, abandoned and stray domestic animals,to provide temporary housing for them through our foster care network and to facilitate adoptions into caring permanent homes. KARES focuses on community education to promote responsible pet ownership and to prevent animal cruelty. KARES raises awareness about the causes of animal overpopulation and advocates alternative humane solutions for population control including spay and neuter. KARES makes possible free or affordable spay/neuter surgeries and conducts spay/neuter clinics in various community locations. 3. Program Description: Provide free spay and neuter(S/N)surgeries and wellness care for 400 companion dogs that are owned by low income or economically-troubled residents including many elderly who cannot afford this service for their pet(s). 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 to communities throughout the island that lack affordable or accessible services. Since late 2010 KARES has sterilized a total of 3,880 dogs at no cost to pet owners. In FY 2017-18 KARES plans to assist pets of low income residents with S/N of 700 dogs,depending on available funding. KARES is requesting that the County of Hawaii assist us with 57%of the total costs. This S/N project could help to prevent the birth of 4,200 unwanted or unplanned puppies(average 6 pups per litter;range 4 to 12 for large breeds). Important features of this program are S/N clinics hosted in community locations,provision of pet transportation as needed for those owners without vehicles,and provision of preventative health care(vaccinations,treatments for internal and external parasites)as the visit to a KARES clinic may be the first and only time the dog is seen by a veterinarian. 4.Total Budget & Position Count: Total Program Budget: $85,250 Total Program Position Count: 12 Total Agency Budget: $120,000 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine Spay and Neuter Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Applications to be submitted for 2017-18 or Anticipated revenue sources for program Corporate foundations (Petco Foundation, Bissell Foundation) $33,000 Community Foundations and/or County of Hawai'i $30,000 Private Foundations and Individual Donors (anticipated estimate) $18,750 Fundraising events (dog washes, garage sales) $3,500 TOTAL: $85,250 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 explore every possible funding source to support the canine spay and neuter(SIN) program, albeit resources for this specific type of service have very limited opportunities for funding. Applications will be made to animal products corporations(e.g. Petco Foundation, Bissel Foundation),community(e.g. Clark Realty)and private foundations. Our canine S/N program began in 2010 and in the first 2 years KARES sterilized 456 dogs representing the bulk of our annual income. Since 2012 when we first sought grant funding and to date we have provided spay/neuter surgeries to an additional 3,425 dogs, all services free to owners. For each grant for S/N, KARES has exceeded performance expectations(number of S/Ns)and thus feels confident to sequester additional funding. Since 2012 the majority(84%)of S/N funding has come from Mainland organizations,the County of Hawaii has funded 16% (in 4 grants)of our total S/N costs of$296,673(vet fees only). The award of County of Hawaii nonprofit grants has validated the importance of the animal population control on Hawaii Island to other funding agencies,and for this KARES is most grateful. We anticipate that with increased education and awareness of the Canine S/N Program throughout the island that more donations from individuals may be forthcoming. We would also like to inspire the interest of many second homeowners,who likely support animal welfare in their own home communities,to also think about giving back to Hawaii with donations for this community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The KARES Canine S/N Program objectives are intended to benefit the people of Hawai'i by the following: 1) Providing free S/N surgeries and wellness care for pets of indigent and elderly residents, an expense that most cannot afford 2) Bring our MASH-style S/N surgical unit into communities that have no available affordable S/N services or resources too distant for those without transportation 3)Conduct 10 to 12 clinics in these communities 4)Prevent the birth of unplanned puppy litters for which residents cannot cover the costs of food and veterinary care; allowing families to keep the pets that they have without the additional economic burden of unwanted puppies 5 Reducing the number of free-roaming (stray) dogs which cause damage to property and livestock and could cause potential health risks due to bites and the spread of disease. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine S.a. and Neuter Pro•ram 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Please see additional pages 4A and 4B for details in Table 1. Thank you. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Please see page 4C for Table II details &explanation of expenses Other: Thank you Other: Other: Other: TOTAL $63,097 $85,250 $48,250 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 1 0 0 o ti "cc 0 0 Cl) 3 c ° O Co z to c m a) as m O i a) 3,Z E c a)a) N -t o 0 o c c s O F a) a) C :Q co .� ° E o u) Cl)" a) v7 Cl) 4- CU -0 .a? Cl) C m .. a) a) .0 3 a) 0 rn C U 4- 0 CO 0 to v- ° c U .., Ch as :«, CO 0 �. _c a) E a) w C >. o u, = N E ( -co2) '' aci 0 ° CD LCI3C o L C CD c O E U U C U N 'a 7) CO Q L O O O C 0 11) N O C a) to s_ •� .L u a) 0 = }. - N- as as a) as as U -p c 4? a) N a) .0 -0 'C Co +0+ O to p 0 U (L6 ; 0 a) C O Cl) too w 'O to N U H w M '0 .Cc N c = 0 co Cl) _A a3 °c .c (0.__ _ W ° •C7) w _c U U C L" to i O 0 0 C cu Co ° To co N .-. to a) c i U c 0 to c13 o cu N uQ) O c >>' o to C •C '= o U N .c ms c c 0 ca N LJJfli tn � ° , c = 1-0"oca ° U �, 3 - Co a) a) °� cc t8o •E a -E aa)) C 3 -c a) > > N +- a) Uc o m 0- aP. G (9, e- = 0_ coo = -0 m u) cCU •'. u) QWQ �E ax) tn .n (5 > �► G >. � � o -c .cofc�oa ° C > 0 o - .Cc a' mto 0O a1 as � � � o - tno 'c3 � � � r ° tri =_ opo Lca v c N o a) 0Z .` 9- o) 0 aa) 0. ca _c 0 E as 0 3 � • _ 09- CO � Cl) C +>. L+ NCD > L X ° 0 ° (a Esc a) � -* a) a) 0 N -C W � a) CO L :f 0 U a) as .c 0 O a) N c O c O O O a) c O c -c + ... (/) .D. :c � tn "''co U > u' mto > � C) a> -o - cas -° nscooc �. C c - as ... oas >. tn2. a) a) .... 2a) (oa) 3a) 3 ° ° o 050 U2 O ° 2 c0 op CZ - � aX mm c [tc 1.- L° O O Q Q • • U • • C > • (B • 0 • v0- • O Co . • L • 0 • 0 .Q () *F+ — (n V C U > .0 :O a) O O a) 03 CU C L L 3 —a to too ° O " o Q 2 .� 0 0• 00 > c � a) �� o o LLI C N Q _ N 0 0U0 t4 c N '- 0) `n a) O 0 m Q 0 0Ta (0 co � 0 ID' O Q a) o L 0 s CV U �. E C L 00 0 a0 0 Q— U ° L - c } 0 0 }+ �. 46.3 C L U O to I L 0 L 2 _QO • (nc C CC -p > 00 Q0 r U C O0)7E, U a) 0 a) a) ` a) c O C.) V1 U O t O _O Z W p (VO �'ccu _� Z o V O O L 1 5-a Q -00 as }Li. U as a) p = E u) as o c 0 cU) 0 cUa �_ C Y c o EEo >> � o g Li Wo Z � (u = Nvt- cE ea .X. c t c/) CO U O C '� Ts --. a) U as c6 a, (CoQ 0 m QE N Q — W 0 .'q > ` U 'L Y (6 Cl)i) U N �. O > 0) .0 0. Co E 4< >, a�i -c E as °� �' ° o •� 5 - E o co a c o c Q U) H U S Q x v o to O (n c E '0 vi C E L fl._ co a) O i w; a) C to a) a) as _o 0 a)'_ N y- (n c o to _Q- - ° m -0 .. �� O c — � '� o � � � �w "S E ° o � CD c _C >. e0 o E � .0 o a) -c oL •cpsoc C (n as � a) o > 0La) Y co cu c) - w -s' to E >. o c as o o L m n7cf) ° E 0 c LaOCc -0 -C as ° .0 -, aso0 Casa) 0 ..... a) 1- E (5 U (n r a a co LO CO > as as •C all E co `o N cUu4•-- •> •u; a- - .00) C0 .- a0) ,Q � on t oho R1 co t •L H a) Z a) O c 3 N a) Cl) Q 0 O N -1,-•_ 194 a) a3 0) Z Z us C') -o E to U 0 _o 0 c0 ._. ,., ._ U a) .... _ a � (1) o ma'v, ooa) a) c (aL oLococ : LO v E >. c -o ,� aa)) " ' •c := aa) wtn � � � oL � Eas a) 0)- ° a c as «. o � L � c = L .� i iii E 0 a) a• o >, a) > .0 a) —_ a) ° co 'N c Ql U -a • L = :o co- +. U U 0. a) 0 N +. O O120 c > a) > > v Ytoui CooE ° too W cL - i L C cL0 O o 'a 0o O °) o o O as o o a) 0 c36 0 a) rn_ Q 0- w o. v) 0) as a) en z ca o o. o 2T3a f 2 32v 3 s_ o as >. .§ 2 C m c E ca 4- a� &2 JD C OEt1) ) 2 � 2 6 CD % — d 2 ® 0 Z > ■ ° g U) E k4) � �o = Cc CL R 2 : 0 70 « _ a e .g L02 ) - o a 2 @ d § 73 a - _� § E k 0 0 k 5 0 5 �� � k 0 = E z ■ o CD m £ 0 0 E Ce LLI722 7 O 20 / - ¢ 2 � 02 C0 § Q -02k ) -o@ kfa L) p Cl) c 0 � ja a .0 a) c ' „,to 42 22 0 c o 0 § 2 k = a) 0 0 CO % b Co C > 0 6/ 0 o. 0 m a a- -a 0 c E a E « CL 7i= 0- 0. ƒ c c 3 I ._ 4- ..o 2 u = c � T _ F 03 W �_ % « ca 45 0. "5 713 - co § v, r73 v C 0 & 2 Z - cu E \ e a 0 m m -0 0 � ? 0 0 0 o L @ 0 0 ° c = >- E c co a) 0 ° c / e U a f 2 u CD ce c3 w : c ® CO « 0 k 2 0 — o 2 0) m 0.0 4- ... @ c / 0 , ° E • o u) 0 3 •c Q U) § 0o 2 a) a) to 03 @ = ° c >_ .- 70 2 ca ; § } k c ■ @ = 0 c o @ 2 \ 2 o - - 2 k2 - � 7 E2 20 = ■ a - -...a. Ec -a E % ▪ § \ 0 0 \ w z 0 0 x 0 & 0 > c E _ CL 2 -o -i-€ k 2 2 ■ g p ■ E k k a) 0 a) 2 co ° q & 2 % •2L.(42 co o I— 0 2..) -5 -0 MI E 2 Q Q. 05 a. < o 3 ƒ % I- 2 a 7 : L V) ,.F. 0 cf10 c COCO3 CoA +a) co ria -0., = N g-I CT O m fyioOOOLl^ QO a) •-, . O `i E r.( O N 0. N 4., n Tr 0 O N 4-,y 4 - r- p ' CCa V �(O NO 4..+ -a -- CU .w .7.,..'' s a 'v (O ' dD a) a ( o. C C a) re.( 'a 00 0 I �- > m O co Li) 00 0 O1 O O N No a� C '- CUc ao t10 Q., (o O >. Otip n rl N VI >' 70 L U _ U. o "� 00 L a > O '3 .� I- 1.6 �° 4a-_ -C r o d0 H Cl) L �' >F +' o t +' Ce �p -p 0)) CO_ "C up vi a) C On 0 N 2 s 0 0 '1 0 0 ri 0 0 E bA 'a LL 3 0 N 0 0 CNI N o 0 0 GCi 3 4-. O O C O W Q 00 to LA N 01 M +� 0 C C . 1:30) O IX Tr L O = I� •� Y o C N aJ s a) co 4- A, O co v) ( O n 4J O O N a.d 0 .V Q. 'y) O LJ i Q O a) Q ar (O co Z co v 0 U � Y 03 V _ 0 C N v) '0 vi O .... O o a1 a) a) C v- `co a) 0 a C qp a) +J C vii L W RS o '� N C a) -7, C NCU s fl as .0 L ra Ln ..o 76 13.0 vi c E fa 01 C0 a v +' +'' 0 i y a) v) O a) +-, 2d a1 a C a1 0Z Z L y_ +.1 4- O L C L 'U S 1 0 (O O } O (73 L R :W AO+ ,., C C U sar • O a0 ' ti.r (13 > O C O LL •Oo c= Z c s ZQ ca -OV Cl) a) o a, (5crs O. a a -a Z U Q C42 C[ 0UN , aO o O 0. O c Lo •� Q C L �O Q aL '(/)• aJ .L ;N (6 s !� /� O N L fB0. W (O Q U U -0 .N F- aJ iv C N i'' tin �=4.4 C. O CU U L a) cu a) O 73 U Q �,, `�- > C (O C U U 4- . v, __ O CU 'q0 Cl) V) o (� L O v) ,.F:, 107.) a) N L f0 L CD L O -0 O a1 ++ fl 0 V co .� C C 0) (C L U f0 0 (C ;N CU CO a) '" L CU a) a0J CU y) aJ 40 V o coi w •L E a) C N o. fE O. = dl Q � (ap ro O C of OC a; 'II L -0 06 x C y C Z N w Q- ... 4 -a vi d 2 Y > Q. 3 0 CO .� a, cCo �, o = ro o aO, o a CU v °' o 'a. 0. U .> ++ 0 3 Q "CI v �, ami Q' 3 v s C c Q. m in N +, a O C (w a) a -- v; E a (O 0) t '17 a, w. 3 = o w = V) > O_ c Z 0. co LL cu Q iri - > i +_' - V E >. 0 CU O O u 0 O L O Z - W X- (n p u O •• = a1 ti > ° 0 o0A a coO CJ C O •aJ v ++ +, OD C C -p ii 4.1 (o ,v1 L 00 06 L as .y s '� U Q N U O. G Q („ C N a) ^ O 40 o o }W CD fa COto L 0 U -� Q1 v COSL -Lo (n Q� •dcc c>a O O o a) (L° o O Wy/ O H O (d O 0 Z cC� O O a� O +r s s < a CU � _ 0 L CU O 0 i' s \ G (O .2 O G. N a, +.' ++ Y X s 0 O > L 00 Q Cl. 01 a V) a +•' (/) (n 0 a O O * W F- I- 3 O a CN.I. County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine Spay and Neuter Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor The Managing Director The Director of Finance U The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. � • �o Signature of Authorized Person (specify title) = Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine Spay and Neuter Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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://venr ors.ehawaii.gov, complete the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine Spay and Neuter Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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 durinithe grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http.,',/,.0,1\,v.;-mAiaiicounty.gov/fn-nonprofit-grani.--formi on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPrluPct and may recult in nrtinnc taken to rernver theca fundc, 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 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Animal Relocation And Education Service (KARES) Program Name: Canine Spay and Neuter Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Please see pages 8A & 8B for Table I-Worksheet for details.Thank you. TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Please see page 8C for Table II -Work details . Other: Thank you Other: Other: Other: TOTAL $48,250 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 t 00 -a N a +' N = O VI OCD O: d 'a N 'u v C C7 O• O U d CO w Ce N4.4 .§ N 0 o ro 4- O a, O Cl.) v yJ C a ;_, 4, co L Tj�' vim-. O Np E `� V N aL•+ W L /w�' 0 N Qo 0 V 7cu z a) N a, C co 00 m0 @ on N > C o o •N coca, N •� (� om o s N S L co 0 > Q) .Y. C C7 0 u) N a, -c cc.> +, w n n 0CU ` a C o CO L u Cd z v a0 o 0 ;° :F6 3 CO 0 0 COc \ �n u >- 0 0 O ,n LCD O a t L = f c o ° = s c a <• d a; o C a� s u +- ( > OA 4- •� 7 U 0 a, w 3 L "O O D 0 C C CO O co a v 0 a, +, u T O 0 CD +, o +_ +_ o a 3 s Y +' t c ° ° `� c, -° c CO CS T co Z a, u f° 0 L o 2 a, 3 -0 +' 1:3 CI3 a v o N o z E � c m CO y ED m a, of ++ >. +, \ vi +, a) i Q > bO W a, C y ° H j Z.;-) cv p 7 c N O U, -p Q Cl.)> C fLo :� a ° > fi, ami > a, 0 O c7 > V O 4, 2 Z o z N D co 0 0 0 CO MOM •MIN < U • • C • U • L +, N N • w • N • +. U C 114) O L' C on > t +4�'' o s O = 0 a, C CO /1=� O `, U) 3 fa E 0 0 o W [ ] C 0 to 0 a) C 0 ' DD 7 L ro O Z �•I U 0 0 p a O .>_ O N N C CO u_ 7 C 0 ;„ LL 0 E E a' LL = W 3 YO C C T 0 0 C +' u COo `' N N o L v o v, 0 Q o * T o 0 4 �o �O ,7 0 Cl)( E 0 - c o a, c L m < 3 Ry N '0 0 E "0 7 - a, Y a1 L Q +'�•+ N C c C E C ° O • C = E C Ln >. 0 L E • 7 tO +' L ._ 1/11 c0 00 N Q - •Cq N O O C c6 N +s, O Cd OO L a, > ,C -0 �oO 7 O.O V G 0 c = O w N s a 0 -0 • L U 3 a) _u ,� v u ° '�' a, 0O o 0 C s a; o N C) C ▪ ,s ba a, ca 0 C : ' • c' c E ca o 0 -°0 °- a, z . 3 > i E ( N -a o o oh u a, Q ra Cu Z 0 c a, 4- v aO 0 a, - = v, �i n�i 0 +-• '0 C 'O - L C v Z 5- .CU C v Z •Q a, 0 U 7 > L a, a,, •0 N -0 -a-, C L E 0 ++ ,� t• Co L N C O OO ° a, CLo V i — E >. m v � " co o > • O C cs) al coT. :� a c ocn 3 7 •4' L CU O °L° o o o nn i ° o .> < 0. 1— a z o n`. i- (0 C z � V) o a s bo H 3 H d CC CU t 4J .5 L a .a a) col0 0. 0 L II. C ,... 0 (/) 0 W U ccin Q a) - Y v f0 a) an 4., �./ C 4' O Ccr 0C to ° O N t0 .� V L N N O = ,., `L° a `C O O a Q c6 O w .O L C OD >. a) U 0. 0 to L 0 U -0 `i' Q o ,n Y t 0 to t E ° 0 O _o a) v vi Q '� 43 ,-C., Y C •+�—, , 00IA a) ` O. co O U 3 Y O L Y C N ° N GC1 d p a ON O .fl +Y' YO a. a) E T C o .O 3 v O O !^ O trs a) +N+ C cu E L vii O in o_ 3L 0.1 V) a) 0 CCL3 v ° gyp _ ° 0- 7- u 03 3 aa+ w ° N s °' 0 ° 3 0 o to a 3 o L cc C 3 Co m .0 , _o .0 o a� ai ,F g o c — 00 co = ° v w VCO M O +^ m N O ,C, ,�° O tco o U to w o O C v,i Q) .13 'Q w a) G) C co 3 c o a) c Y L v ° ° a o a, !1J Q O. `•° CD @ C c a) C u, a; a) 0) ° C ° C °. > a o a) > C Q p c v Y a� = y to C _ + o �; = =° ;, " C aJ c� a1 v �O t C y'^ O co 4' a) v O 'O a� jI C •_ ' ,.. C S L a) ,., CU co a) L co a a O .N O (a •Z cu ,. Cl. d' O CO CO L ° N ° L 0 O L 0 > O • • a) • >. a • u .-i U a. CC a M _0 ? CL C O. o°o C U 0 el L ., > O C.) QJ "O r O ,C+ O> to u a Z _ O ° o a a RI �; c c a ° a) to op 0 1.3 +�+ E N to tQ U a) ` U V a) •a) C 4-, o ts- -O fo E L E > in C Vf L v to N j a a .= 0 a) o a) co W c ~ 4., C a) , is, v tp ° a a Q o ° L 0.0..........c co >•• v v O a) v o Y a, ° ° ° Z L 06 to .° ° E ° ,�.i L m N C O •C y .N +, �6 = L a) C a O. 00 ° H C .0 > C 0. ,- (13 o ° ) co 0 lc C 4_ O +, to co V) N > to Y 2'..i ca o4 03 C 3 O C 0 o C O 00 }' C 00 C CU y ,"' C a) .O Vf ' 0 d0 Lfl C E a) V• YO co 'C CD y > > m o -°° .-' to c p v ° Q U a +L. ` to 0 a) 4.4 O O0 i C U .? L �/ I U C 2 cn a) C al C O i v O m a) a) ° °{ C1:3 4. v °) t C _ -0 aJ E t ,n w — L a) +, -0 t0 5 to O 13 CO 0 Y N O M N 0 a O O. L .�R N O u N a C_ d -O c +, O 00 E co _ O L co 3 ' O E bD a f0 s 0. N Z Z o+ L C O LON .> O w •,,, `^ O O m - C a) s a ° O OU0 4 • UCL C L o C ,+ i0. 3 a, v LL v O CUL U 0 o0to CD E L) -o 0 L N C u O `- S N ,-i -,-:: a) CD 0 CO C a) to Q �- tf° C. ° n E O CC a v in O CL° a, CO s a Q a o oc in Ti 12 c m a o a v LU N CO al • ri OAC 0 ODi 0r•-• 0 0 0 D N W > c m rr � Ni o0 CU u. L 0 0 c� a) -v u) s.. I = 0 _ 'h a mO 0 CC mivi a V1:1 y v a v c N cu = ix) cc C CU S. ta W °' _ C i V1 t0 13 Q _c Q. N •cam Q ++ N E L a •� a y C 0/3 C u L v L O L C +r �, to cco v 0 Q. -0 CD :47., --• EN NC5v �' 3 V 0 Z O L L a O U > '^ a; a 2O a c Q • CD as CU a E C +; fy 13 N t/► O C c0 '- to w co lam C il w Q. A cLo u X 4CD a ma s. E td C i O •C Q a ut m •C Q o ca w °i a u N c Ce > c co C F u ell 0 CU ' CO i U "o ON as C V a in CO .0 a 't� Vf L C O N N C C in 4 a coo ? _i V w 41 C N X Q 0 3 Y > Q. 3 v, t-Lo 4 a 41 O .� 03 c a) as v - v Q. 3 v C C C Q. C as Z a c':i a Q. iri a 2 > +_ U U o LL -0 C cu cn p v 0 vii iii Q U j fC V• CI ... CO a v +, -p C = L coo co •N _c c (., O_ vi +, u Q Q •O d a L L.' a b .Q a u roo 'Fa Q L L +r w. 0 Da O to o 0 Z a C o '" Q. N *' ++ C Q G. F- a vcoi a s V) co *' cn O a 0 0 Q Kohala Institute GRACE Leadership Journey 107 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey Agency Director: D. Noelani Kalipi Phone No.: (808) 889 — 5151 Contact Person: Katie Schwind Phone No.: (808 ) 889 — 5151 Mailing Address: Address: PO Box 344 Address: City,ST,Zip Kapa'au, HI, 96755 Facility Address: Address: 53-580 tole Rd Address: City,ST,Zip Kapa'au, HI, 96755 Email Address: grants@kohalainstitute.org Fax No.: (808 ) 889 — 0615 Accountant/CPA: CW&Associates Phone No.: (808 ) 531 — 1040 Firm (if applicable): Mailing Address: Address: 700 Bishop St, 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: $25,000 Geographical Areas To Be Served: (One or more can be checked) O Puna 171 Hamakua n North Kona n South Hilo ❑✓ North Kohala ri South Kona I-1 North Hilo ri South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) • Educational concerns n Youth ❑Victims of Crimes ri Culture and the arts n Aged ❑Victims of Health or Social Crises ❑ Needs of the poor n Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 - 2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $0 $0 2. Agency Mission Statement: Kohala Institute's mission is to provide opportunities to connect with the land and universal values to foster a better world. Guided by the core values of Gratitude, Respect,Accountability, Courage and Engagement(GRACE), Kohala Institute provides a rich environment for discovery through place-based experiences that encourage connections with place, self and others. Kohala Institute manages 2400 acres in North Kohala, including the'tole ahupua'a. Maximizing its diverse natural resources and historic and cultural sites, Kohala Institute forges connections between the past and the present, east and west, and indigenous and non-indigenous thereby creating a safe atmosphere that encourages exploration,discovery, and overall learning. Utilizing a systems integrated approach, Kohala Institute's programs, projects and activities reflect the focus areas of sustainability, culture, education, and contemplation while also enabling capacity building in a rural community. Kohala Institute's facilities include the newly renovated GRACE Center, a state of the art meeting and education campus which features six buildings and 10 cabins (80 beds), housed in the historic Kohala Girls School which was originally constructed in 1874. Kohala Institute's signature program, Collaboration For Solutions, is a community engagement methodology for that focuses on establishing relationships between participants before fostering substantive discussions about emotional and challenging community issues. Its professionally facilitated discussions utilize the"No Hero, No Villain, No Victim"approach and focuses on proactive and practical solutions that benefit the collective. GRACE Leadership Journey is a subset of Collaboration For Solutions that focuses on providing our youth with the skills and tools to seek solutions rather than divisive and adversarial zero sum approaches. 3. Program Description: The goal of GRACE Leadership Program is to provide future leaders with the skills, knowledge, and experience to bring people together for positive action that benefits the collective when faced with challenges and controversy.At the most basic level it seeks to shift the mindset from"not my problem"to"if not me,then who? If not now,then when?"from"no can"to"How can?"by empowering 15 high school juniors with the experiences, skills, and relationships to lead the way to making collaboration the"new normal."After five years, 75 future leaders will have shared experiences and common understanding of techniques to help navigate difficult conversations and problem solving. The program does this through practical application and place-based learning experiences, and providing the foundational skills for future leaders to seek collaboration as a common and realistic outcome to challenges facing Hawaii.This program is a subset of Collaboration For Solutions, an innovative method of community engagement focusing on building relationships between stakeholders prior to challenging discussions that require collaboration and focus on benefiting the collective. Specifically,the GRACE Leadership Program works with students to(1)build relationships with others from different geographic locations and backgrounds that they otherwise would not interact with; (2)navigate difficult and challenging discussions with others, particularly when discussing emotionally laden issues, by providing them with the specific communications tools; (3)seek to"step up"rather than letting someone else take care of"it", (4)learn about different perspectives and the multiple contexts that inform decision-making processes, (5)learn about different leadership skills and styles and adapting those skills for different situations, (6)learn about their specific strengths, leadership styles, communications skills, (7) learn through the experiences of others via their mentors, guest facilitators, and leadership conversations. 4. Total Budget & Position Count: Total Program Budget: $176,142 Total Program Position Count: 2 Total Agency Budget: $2,029,991 Total Agency Position Count: 12 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate First Hawaiian Bank- Community Giving (committed) $25,000 Atherton Family Foundation (committed) $15,000 HPM Foundation (committed) $5,000 Kohala Institute's Contribution $32,500 Hawaii Leadership Forum - in-kind (unconfirmed $40,000) Kamehameha Schools Community Giving Program (unconfirmed $87,000) Sorenson Impact Foundation (unconfirmed $30,000) TOTAL: $80,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Kohala Institute's strategic plan focuses on the development of revenue generating projects, including a fish farm, agricultural park, and land and water management tours,to yield the necessary revenue for long-term financial sustainability for Kohala Institute overall operations which mission-based educational programming like GRACE Leadership Journey. Kohala Institute is currently in year three of its strategic plan that was initially started by its landlord, New Moon Foundation. Additionally, Kohala Institute has just begun its three year fundraising campaign with a targeted goal of$10 million to support programs,operations, and project development until the revenue generating projects identified above reach full capacity. A campaign committee of well-respected business, policy, and nonprofit leaders across the state have volunteered to assist with this effort. Kohala Institute's overall long-term financial sustainability plan incorporates revenue generating activities with a successful fundraising effort. For GRACE Leadership Journey in particular, Kohala Institute is engaged in a fundraising effort with a target of$171,000 and has raised $40,000 in grants and contributions. Kohala Institute is also developing a sponsorship campaign with businesses, foundations, agencies, and organizations that is designed to garner additional support as the program grows from its initial pilot stages. 7. Program Objectives Using County Nonprofit Grant Program Funds: Locally and globally,we have failed within our current structures to effectively address significant issues facing society, resulting in increasing polarization that divides communities and makes attempts at reconciliation and collaboration futile. Reaction to any proposal draws immediate opposition, often based on mistrust of motives, instead of analysis of substance. The trend is disengagement,distrust, and misuse of facts to serve individual rather than collective benefit. How do we reverse that trend?How do we reengage in the civic process and create a solutions-based, not obstructionist, mentality. Our answer is to: (1) provide a process that builds relationships between stakeholders through place-based experiences as a precursor to facilitated discussions focused on collaborative solutions and (2)by providing future leaders with tools, skills, and practical experience to deal with difficult conversations,to seek to better understand the emotional and historical context of issues, and to pro-actively identify and implement solutions that benefit the collective. This 12-month program begins with a one-week retreat employing academic sessions, guest instructors, place-based learning, physical challenges, and practical application of skills being discussed and studied. Each month, students return for one weekend—Friday evening: "Conversation with a Leader"; Saturday: place-based activity, practical application of leadership skills and processes and communication techniques using a highly charged issue; Sunday:assessment of application. The relationships formed and the practical application of skills are vital tools that participants will learn to use to regularly resolve challenging issues in ways that are proactive, inclusive, and yield results to benefit communities collectively. GRACE Leadership Journey brings together best processes and scholarship to equip youth to build a culture of collaboration and incentivize proactive participation in community engagement. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of applications,students who complete the program, and attendance rate 50 applications, 15 students/yr,90%attendan Pre-program interview, post-program interview with family, counselor/teacher, participant 75%improvement in reviews Increase in leadership and civic engagement activities in the community 80%of participants Finishing highschool and attending college 100%of participants Number of leadership mentors and experts committed to the program 29 throughout the program Number of job/internship opportunities generated through relationships developed in LJ 50%of participants within 3 years of program Engagement with future cohorts 66%of participants Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 58,710 6,000 Professional Fees 5,500 2,500 Operations Supplies 14,750 2,500 Equipment Other: Transportation for participants, facilitators, experts (plane/auto) 10,600 2,500 Other: Lodging/facilities rental 11,700 2,500 Other: Food and Beverage (participants/guests for lweek+1lweekends) 52,682 4,000 Other: Promotion 7,200 2,500 Other: Administrative costs 15,000 2,500 TOTAL NA 176,142 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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): E Member or members of the Council ❑ Staff appointed by a member of the Council E The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: vr If no conflicts exist, check here. r /i( I °1i 1K4i P30/fit 4- Signatur;r ffAuthorizedPersi (s9.cifytitle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fllturp funding regiiect nnrl mny rpciilt in nrtinns tnkpn to rprnvpr theca funds, By signing below, you are acknowledging that you have read and understood these requirements. kX . , y1 Wecutfive bfredvz- i1 /o t - Signature of Authorize`d P lrson4` Ipecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of applications, students who complete the program, and attendance rate 50 applications,15 students/yr,90%attendan Pre-program interview, post-program interview with family, counselor/teacher, participant 75%improvement in reviews Increase in leadership and civic engagement activities in the community 80%of participants Finishing highschool and attending college 100%of participants Number of leadership mentors and experts committed to the program 29 throughout the program Number of job/internship opportunities generated through relationships developed in LJ ye50 r ars ofof paprorticipantsgram within 3 Engagement with future cohorts 66%of participants TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 6,000 Professional Fees 2,500 Operations Supplies 2,500 Equipment Other: Transportation for participants, facilitators, experts (plane/auto) 2,500 Other: Lodging/facilities rental 2,500 Other: Food and Beverage (participants/guests for lweek+1 lweekends) 4,000 Other: Promotion 2,500 Other: Administrative costs 2,500 TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Kona Adult Day Care Center, Inc Adult Day Care 108 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE Agency Director: ROWENA L TIQUI Phone No.: (808) 322 — 7977 Contact Person: ROWENA L TIQUI Phone No.: (808) 322 — 7977 Mailing Address: Address: P 0 BOX 1360 Address: City,ST,Zip KEALAKEKUA HI 96750 Facility Address: Address: 81-989 HALEKII STREET Address: City,ST,Zip KEALAKEKUA HI 96750 Email Address: kadcrowena@hawaii.rr.com Fax No.: (808 ) 322 — 0614 Accountant/CPA: RONALD G HAWKES Phone No.: (808) 939 — 7392 Firm (if applicable): Mailing Address: Address: P O BOX 2030 Address: City,ST,Zip KEALAKEKUA HI 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ✓❑North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑,/ Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor Q Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $10,000 $10,000 $8,750 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: Kona Adult Day Center, Inc.is the only 501 C 3 adult day center in West Hawaii providing impaired adults,their families and other caregivers with and alternative to premature institutionalization. Since opening in 1987,service has been provided to over 700 families in our community. A comprehensive program provides a variety of social and related support and service groups of adult clients in a protective and less restrictive setting during the day. Day Care allows caregivers to continue working or having respite days. Sometimes when caregivers don't get the respite, break or rest that they need it could lead to neglect,burnout or abuse. Day Care also provides a more cost effective program than Home Care or Institutionalization. By attending Day Care our client is able to"age in place",which is familiar,safe and comfortable. The caregivers continue to live in our community and stimulate our economy. At Day Care we maintain their health and offer caregiver support training to keep the caregiver healthy. Then our community will be healthy. 4. Total Budget&Position Count: Total Program Budget: $15,000.00 Total Program Position Count: 5.5 Total Agency Budget: $15,000.0 Total Agency Position Count: 5.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State83435/County43176 126611 Hawaii Island United Way 12300 Other Grants4350/Fundraising7680/Membership6745 18775 Private Tuition 99840 Fees17052/Donations1418/food care6976 25446 I nterest86 86 May Templeton Hopper Grant9840/ln-Kind10176/Teresa Hughes Trust Fund36093 56109 TOTAL: 339167 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1. We will continue to seek grants. 2. We will plan our Fund raiser to attract more people. 3. We will increase our client census. 4. We will seek donations through a membership drive. 5. We will increase awareness in the community about our services 6. We will use social media to promote our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: This County Grant will be used to help us attain the following objectives by maintaining skilled,caring compassionate and efficient staff. .Attain the following objectives: For Individuals-a)Mentally,physically and 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 time and place. d)Defer premature or inappropriate institutionalization. For Caregivers-a)Respite. b)Continue working. c)Have access to elderly services. d)Safe and secure environment. For Community-a)Part of our long term continuum as our population ages. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (re.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase client census to 40 average daily attendance/Currenly 30 average daily 95%of clients will stay as we increase by 3 m Age-in-Place at home for minimum of 6 months 98%will stay in their home for minimum of 6 rn Maintain or improve hygiene/we earn$4755 on baths per year 90%maintain&10%have baths Interaction with community groups twice a month 98%interact with groups Survey of Caregivers satisfaction)100%satisfied with our service 100%of surveys are returned Maintain or improve interaction skills 75%will maintain or improve Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Bud:et Grant Re. Salary and Wages 15000.00 15--Or <:.) rf,-« .. Professional Fees —__— i Operations — — —---- -- —` Supplies Equipment • I _._` �_ _____._ --1 w , -- — -- 1 • a- - Other: -_- ___ --- TOTAL 15000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council l The Mayor ❑ The Managing Director 0 The Director of Finance f l The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. /.4111111. C 1 7;)--c) ( -7 Signature of A orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaency's fnturP funding requPct rind mny rPcult in nrtinnc tnkan to rPrnvPr thacp fiindc, By signing below, you are acknowledging that you have read and understood these requirements. �� i1. C 1/28/2017 Signature of A i•rized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-1.8 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 95%of clients will slay as Increase client census to 40 avg daily attendance/currently 30 avg daily weincrease by 3 m Age in place at home for minimum 6 mo 98%wig stay in their home for minimum of 6 m Maintain or improve hygiene/we earn $4755 on baths per yr 9D%maintain 8 10%have be with gro Interaction with community groups twice a mo. 98%interact uPs Survey of caregivers satisfaction/100%satisfied with our service 100%of surveys are returned i Maintain or improve interaction skills 75%will maintain atimprove TABLE II: I PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies _ — Equipment Other: Other: Other: Other: Other: TOTALj Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Kona Historical Society New Living History Activities & Community Education Programs 109 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kona Historical Society Program Name: New Living History Activities & Community Education Programs Agency Director: Joy Holland Phone No.: (808) 323 — 3222 Contact Person: Joy Holland Phone No.: (808) 323 — 3222 Mailing Address: Address: P.O. Box 398 Address: City,ST,Zip Captain Cook, HI 96704 Facility Address: Address: 81-6551 Mamalahoa Hwy Address: City,ST,Zip Kealakekua, HI 96750 Email Address: joy@konahistorical.org Fax No.: (808 ) 323 — 2398 Accountant/CPA: Brianne Atwood Phone No.: (808) 323 — 2398 Firm (if applicable): Mailing Address: Address: P.O. Box 398 Address: City,ST,Zip Captain Cook, HI 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ✓❑South Hilo ❑ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes ✓❑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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kona Historical Society Program Name: New Living History Activities & Community Education Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $10,000 $6,500 $6,125 2.Agency Mission Statement: The Kona Historical Society will preserve the history of Kona to enrich, inspire,and inform our community and visitors. We will do this through collecting,preserving, researching, interpreting,and disseminating the history of Kona,emphasizing the period from 1830 to the present. 3. Program Description: Kona Historical Society(KHS),founded in 1976, is a Smithsonian Affiliate with the only permanent National Endowment for the Humanities exhibits in the State. KHS has received dozens of awards and commendations for its museums, National and State registered historic structures and public programs, including a 2016 Historic Hawaii FDN Preservation Award. KHS operates three living history programs on two historic landmark sites:•The Kona Coffee Living History Farm,a 1920's era coffee farm homesteaded by Japanese immigrants,tells the story of Kona's coffee pioneers. •The H.N.Greenwell Store,an 1890 general store, immerses the visitor in a 19th century shopping experience highlighting the Store's diverse customers. 'The Portuguese Bread Program takes place at KHS and,each Thursday,an authentic Portuguese wood-burning stone oven is fired up to bake traditional Portuguese sweet bread,which is sold the same day to community and visitors. New 2017 programs have been developed for visitors and students to participate in hands-on cultural activities, including Immigrant crafts,trades,and garden projects.This expansion of experiential opportunities represents a broad array of activities at KHS.Also KHS has added free workshops in collections care and preservation to the community. Non-profit organizations such as Hulihe'e Palace, Lyman Museum,and Pu'uhonua o Honaunau will attend in 2017.Our collaboration with the County continues to be valued as we present the annual Hanohano o Kona free lecture series at WHCC. Last year the series was transformed with new and fascinating cultural content for the benefit of all of Hawai'i Island. KHS was successful in attracting high-caliber scholars and cultural experts to present to the community,and 2017's series promises to be excellent.Also this past year,pop-up exhibits in the community,and a free critically acclaimed major museum exhibit on Kona Ranching and its historic roots,was installed in the H.N. Greenwell Store,adding new options for exploring and appreciating Kona and Hawaii's history.And,of course,the October 2016 free annual Open House at the Kona Coffee Living History Farm would not have attracted the hundreds community members without the County's support in providing a parking shuttle and driver for offsite parking.Thank you. 4.Total Budget& Position Count: Total Program Budget: $32,934 Total Program Position Count: 18 Total Agency Budget: $644,262 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kona Historical Society Program Name: New Living Histo Activities & Communit Education Pros rams 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Tour Income $5,784 Grant Income $20,000 Fund Raising $750 Donations $1,200 Sponsorships $2,500 TOTAL: $30,234 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2016 we implemented a new activity program, Hands on History at the Kona Coffee Living History Farm,that attracted 41% more visitors to the Farm than in 2015.The new program was vigorously marketed to pre-arrival and post-arrival visitors,and the marketing campaign will be enlarged and continued into 2017.Additionally,according to HTA,there were higher numbers of visitors to Hawaii Island in 2016,and HTA projects that trend will last through 2017.The increased number of visitors to Hawai'i Island is likely to produce higher visitor numbers for Kona Historical Society and generate expanded sales of coffee, Portuguese bread and other items as well. KHS is also vigorously soliciting sponsorships from Board members,community businesses,and individuals to support the expanded and enhanced free public program offerings:exhibits,community workshops on preservation and cultural heritage, new publication projects,and the Hanohano o Kona Lecture Series. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide unique and authentic programs at landmark historic sites that connect visitors to their own history and experience;2) Through hands on activities and engaging programs, inform students and visitors about the diverse aspects of Kona and Hawaii's history and culture in order to foster understanding and appreciation;3) Demonstrate important themes of sustainability, family values,cooperation,and independence to visitors and students;4) Provide volunteer and internship opportunities to individuals and groups to encourage personal growth,positive environmental behaviors,and enthusiasm for giving back to the community;5)Provide expanded free community offerings including pop-up and installed exhibits,community workshops on preservation and cultural heritage, new publication projects, and the Hanohano o Kona Lecture Series. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kona Historical Society Program Name: New Living History Activities & Community Education Programs 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Farm School Groups(800)&Pre-Scheduled Group Tours(2600) 3400 Farm Annual Open House 350 Farm Independent Travelers 5500 Bread Program Visitors 1400 H.N.Greenwell Store Museum Visitors 700 Volunteer Support at History Sites(Hours) 2650 Free Community Actitivities(Educational Workshops, Lecture Series, Exhibits) 3000 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 2,200 12,780 7,450 Professional Fees 488 5,550 3,450 Operations 2,200 4,628 2,174 Supplies 125 1,150 800 Equipment 0 500 500 Other: Employee Benefits and Payroll Taxes/FY 2017-18 Exhibit Materials 434 3,950 2,250 Other: General Liability Insurance/FY 2017-2018 Printing 108 2,276 1,576 Other: Staff Training/FY 2017-2018 Workshop Expense 220 1,650 1,350 Other: Cost of Goods Sold/FY 2017-2018 Equipment Rental 220 450 450 Other: Repairs and Maintenance 220 0 0 TOTAL 6,215 32,934 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 • Agency Name: Kowa. IAl s}t,rt es..A S.,LA41-1 Program Name: New 1.:•41 lANskv, .N..kwA,, .s + •„_,,,,,,i; Edwc4. . ,, 0" 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council E Staff appointed by a member of the Council O The Mayor n The Managing Director fl The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 11 If no conflicts exist, check here. 46..., 0,j yolli —7 Signat - • " . thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kona Historical Society Program Name: New Livin. Histo Activities & Communit Education Pro.rams is. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of 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 year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kama.NIski)r ic...A Soca-AK Program Name: La;,xc) gi,y}0 i �e A.t 5� t 1 nit Edukco4ton Pro •awe ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiiturP funding rPgquPtt and mny result in nrtinnc tnkPn to recover thecP flinch. By signing below, you are acknowledging that you have read and understood these requirements. ko, .,,A) Vaitri Signature ut�iorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Kona Historical Society Program Name: New Living History Activities & Community Education Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Farm School Groups(800)&Pre-Scheduled Group Tours(2600) 0° Farm Annual Open House 350 Farm Independent Travelers 5500 Bread Program Visitors 100 H.N. Greenwell Store Museum visitors 700 Volunteer Support at History Sites(number of hours) 2650 Free Community Actitivities(Educational Workshops, Lecture Series, Exhibits) 3000 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 7,450 Professional Fees 3,450 Operations 2,174 Supplies 800 Equipment 500 Other: Employee Benefits and Payroll Taxes/FY 2017-18 Exhibit Materials 2,250 Other: General Liability Insurance/FY 2017-2018 Printing 1,576 Other: Staff Training/FY 2017-2018 Workshop Expense 1,350 Other: Cost of Goods Sold/FY 2017-2018 Equipment Rental 450 Other: Repairs and Maintenance 0 TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 AGENCY NAME: Kona Historical Society (KHS) PROGRAM NAME: Living History Programs 2017-18 3. New Living History Activities and Community Programs This past year Kona Historical Society (KHS) developed a broad array of new activities while expanding the quality and reach of existing popular programs: engaging visitors and school children in new immigrant crafts, garden projects, and other pursuits that expanded and complemented the existing award winning programs. This expansion of cultural demonstrations broadened the array of living history visitor options and has proven to be popular among our patrons. In 2017, Kona Historical Society has calendared additional events, newly developed demonstrations, and offerings consonant with quality and increasing in number by providing several additional projects and added program content,which will reach greater numbers of patrons. Kona Historical Society's enhanced Living History Programs, while expanding volunteer and student internship opportunities, also added a number of free community activities, such as 4 free collections and cultural heritage care workshops, over 8 pop-up,temporary, and permanent exhibits to visit, lectures, free family-friendly performances, and specially designed-curriculum-appropriate school group activities, providing ample occasions for educational and culturally enriching experiences for both adults and students and children of all ages. The annual, free, Kona Coffee Living History Farm Open House in October 2016 attracted hundreds of local community members and visitors to enjoy a "Made in Kona" exhibit and wide array of educational activities, such as historic medicinal gardening demonstrations, farm-animal care and petting"zoo,"traditional Hawaiian music by Kona musicians, and Japanese foodways demonstrations. Also this past year, pop-up exhibits in the community, and a critically lauded major museum exhibit, free to patrons, on Kona Ranching and its historic roots, was installed in the H.N. Greenwell Store, which added new options for exploring and appreciating Kona and Hawaii's history through photographs and artifacts not previously seen by KHS patrons. Another dynamic free Open House on the Kona Coffee Living History Farm is planned for 2017, and two major temporary exhibits are planned this year with a full docket of pop-up and other collection-sharing and events for Kona residents and visitors, focusing on the powerful Kona Coffee Story and other locally integral stories. In 2016 KHS added free educational workshops in collections care and cultural heritage preservation categories to the community to assist caring for resources and treasures which reside in Hawaii County and in the State. Participants included non-profit organizations including Hulihe'e Palace, Lyman Museum, Pu'uhonua o Honaunau and Kaloko Honokohau National Historical Parks, Hawaii State Archives, Pacific Aviation Museum, Hawaii Plantation Museum, Konawaena High School Library, Kailua-Kona Public Library, several more, and individual community members. These workshops, facilitated by KHS staff, and provided free to the community, addressed preservation concerns and practices among organizations tasked with conserving Hawaii's history. More such workshops are planned for the coming year. Similar workshops are calendared in the latter part of 2017 and will likely collaborate with the County to have one or more happen at the West Hawaii Civic Center and share sponsoring status on press and promotion of these activities. The past year's Hanohano 0 Kona free public lecture series, hosted by KHS in cooperation with the County at West Hawaii Civic Center for its wonderful venue,was transformed with new and fascinating cultural content for the benefit of all of Hawai'i Island. Several elements were refined and successfully attracted high-caliber scholars and cultural experts to present to the community. The 2017 programs on topics such as Makahiki Traditions; Letters from the Alii:A Collection Unveiled, 1820-1887; The Men Who Loved 1'o and O'o: Bird Catchers and Birds of Hawaii; and 6 other stimulating topics are scheduled from February through October 2017. The series is held in conjunction with County support for the venue and continues to be the only ongoing historical, academic lecture series provided in Kona on a regular basis, bringing continuing education to adults—both residents and visitors—they would not have otherwise. K}IS continues to develop original content and contribute to the expansion of knowledge about Hawaii's history through its newsletters and other publications,which are included in Hamilton Library's Hawaiian Pacific Collection,KHS's collection, and other repositories.The annual KHS publication,Ha'ilono, is leaning strongly toward a historical journal format,to fulfill the need for historical information among the archival community and local residents. Documentary, oral history, podcast, and other historical content production projects are slated to happen in 2017. The proposed support in 2017 by the County of Hawaii Non-Profit Grant of Kona Historical Society's already flourishing programs, as well as of the significant array of new activities and initiatives calendared to happen in 2017 will serve ever increasing numbers of kama'aina, visitors, and students,often for free,while fulfilling our mission obligation to our community to "preserve, interpret,and disseminate the history of Kona and Hawai'i."As stewards of important historical sites and priceless archival collections, we understand and embrace our responsibility. In light of the recent closings of Amy Greenwell Ethnobotanical Garden and the Ellison Onizuka Museum, our commitment to the community is even more important. The County's support of our Living History Programs is gratifying, and has enabled us to focus on program enhancements, new initiatives, growing our membership, and moving forward with improving access to Kona and Hawaii's history for all Hawaii Islands residents.However much the County is able to provide to support our programming this year is greatly appreciated and will have a direct relationship to the amount of free, Arts& Culture and public historical opportunities which will be provided to County visitors and residents since we are the only organization in West Hawaii providing the sorts of proposed services we do at this time. Your support has a wonderful impact on what we do and is greatly appreciated.Mahalo for your consideration. Ku'ikahi Mediation Center Community Conflict Prevention & Resolution Services 110 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Communi Conflict Prevention & Resolution Services Agency Director: Julie Mitchell, Executive Director Phone No.: (808) 935 — 7844 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Facility Address: Address: Same Address: City,ST,Zip Email Address: info@hawaiimediation.org Fax No.: (808 ) 961 — 9727 Accountant/CPA: Gretchen Kremeyer,CPA Phone No.: (808) 968 — 1002 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $8,000 $8,000 $7,250 2.Agency Mission Statement: OUR MISSION We empower people to come together--to talk and to listen,to explore options,and to find their own best solutions. To achieve this mission,we offer mediation,facilitation,and training to strengthen the ability of diverse individuals and groups to resolve interpersonal conflicts and community issues. OUR VISION A peaceful community where people routinely seek common ground. OUR VALUES Communication/Collaboration/Confidentiality/Courtesy/Competence (Founded in 1983 as a part of the Hawai'i Island YMCA. Became an independent non-profit organization in 2006.) 3. Program Description: Ku'ikahi is the sole non-profit mediation center serving East Hawaii and 1 of only 5 in the state. Our agency helps individuals, families,organizations,businesses,schools,and others to find creative solutions to challenging situations. 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. Our 4-year foreclosure mediation program,in partnership with West Hawai'i Mediation Center, has helped over 200 homeowners save their homes from foreclosure. Our small and large group facilitations assist community organizations with sensitive issues. And our skills-building educational programs for adults and youth teach community members how to communicate effectively and gain tools to transform conflict. Education includes:a free monthly brown bag lunch series, workshops/trainings for community members and for volunteer mediators,and peer mediation in the schools. CLIENT SUCCESS STORY:A young couple with 3 small children lost the husband's parents to a car accident. Unable to sell the parents'house,they sold their own house and moved in. After just a month,the husband was laid off. With his unemployment and wife's salary,they were able to get by,though soon depleted their savings and the kids'college funds to cover basic living costs. Then,tragically,the wife was diagnosed with cancer and died. After defaulting on his mortgage,the widower came into the Foreclosure Mediation Program and received a loan modification offer. He credits the mediation process with helping him regain a sense of hope. He and his children are overjoyed they can remain in their longtime family home. 4.Total Budget& Position Count: Total Program Budget: $295,000 Total Program Position Count: 3.5 Total Agency Budget: $325,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Direct contributions 30,000 Foundation/trust grants 70,000 United Way contributions 15,000 County of Hawaii nonprofit grant 15,000 Hawaii state contracts 92,622 Program fees (mediation,facilitation &workshops/trainings) 30,000 Special events ($40,000)+Other($2,388) 42,378 TOTAL: $295,000 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. These include private,customized trainings for businesses and organizations,3 of which have been scheduled during the current FY 2016-17. 2)Hold our fifth annual fund drive to solicit direct contributions, including from major donors,both individuals and business. During FY2014-15 we reported$68,699 in all other contributions,gifts,grants,and similar amounts on our 990. This figure increased by 43%during FY2015-16 to$98,239. 3)Market our services more to local businesses and community groups. This includes workplace mediation opportunities, facilitation of sensitive issues and sticky situations,and workshops/trainings(see#1 above). 4) Research and apply for new and continuing grants from foundations,locally and nationally. In FY 2016-17,we received $13,500 more than the previous year from private family foundations. 5)Explore new partnership opportunities at the county and state levels for program and fund development. These may include applying for county and state RFPs,such as with County R&D, County Office of Aging,and State Grants-in-Aid for FY 2017-18. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Provide low-or no-cost mediation and facilitation services to self-,community-,and court-referred clients. Mediations are provided on an affordable sliding scale,with no one is turned away for lack of funds. 2)Offer a critical alternative to litigation,especially for poor and indigent populations who cannot afford legal counsel and/or have a hard time navigating the legal system as self-represented litigants. 3)Provide conflict prevention and resolution education to community members and volunteer mediators in East Hawai'i. Volunteer mediators may attend any educational program for free. Economically challenged community members may apply for scholarships to encourage attendance by diverse populations. Our educational programs have also attracted people/businesses in West Hawai'i,the neighbor islands,and the continental U.S. We strive to serve all sectors:public, private,and non-profit. 4)Utilize professionally trained volunteer mediators to provide primary service delivery. Annually,we offer Basic Mediation Training,from which we recruit volunteers to join a year-long apprenticeship program. Subsequently,these apprentices are graduated to mediator status and given continuing education to better serve the needs of the community. 5)Support"Finding Solutions,Growing Peace" in East Hawai'i and beyond. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of mediation&facilitation cases opened 425 #of mediation&facilitation clients served(in cases closed) 1,000 #of mediation&facilitation sessions held 300 #of mediator volunteer hours donated 1,250 %of mediated cases that resulted in agreement 65% %of clients who are satisfied with mediation 95% of clients who felt mediation saved them time and/or money 85% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 201,250 194,500 10,000 Professional Fees 20,000 20,000 2,000 Operations 47,750 49,000 2,000 Supplies 5,000 5,500 1,000 Equipment 1,000 1,000 Other: Special events 25,000 25,000 Other: Other: Other: PLEASE NOTE: FY 16-17 figures are estimates Other: since we are only 7 months into the FY TOTAL $300,000 $295,000 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 8.TABLE I (additional page): What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) It of free brown bag lunch talks held 12 #of brown bag lunch talk attendees served 216 of brown bag lunch talk attendees report learning something new&useful 95% it of trainings&workshops held 6 #of training&workshop attendees served 132 of training&workshop attendees who would recommend it to others 95% EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8(continued) County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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- of 2— � January 30, 2017 ignatur of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution 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 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's futures funding requect and may result in nrtinnc taken to termer thece fiindc. By signing below, you are acknowledging that you have read and understood these requirements. `~ January 30, 2017 Signature f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of mediation&facilitation cases opened 425 #of mediation&facilitation clients served(in cases closed) 1.000 #of mediation&facilitation sessions held 300 #of mediator volunteer hours donated 1•250 %of mediated cases that resulted in agreement 65% %of clients who are satisfied with mediation syr %of clients who felt mediation saved them time and/or money 85% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 10,000 Professional Fees 2,000 Operations 2,000 Supplies 1,000 _ Equipment Other: Special events Other: Other: Other: PLEASE NOTE: FY 16-17 figures are estimates Other: since we are only 7 months into the FY TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 12. COUNCIL AWARD WORKSHEET TABLE I (additional page): PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of free brown bag lunch talks held 12 #of brown bag lunch talk attendees served 216 of brown bag lunch talk attendees report learning something new& 95% useful #of trainings&workshops held 6 #of training&workshop attendees served 132 %of training&workshop attendees who would recommend it to others 95% EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 (continued) Ku'ikahi Mediation Center Youth Peer Mediation Program 111 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program Agency Director: Julie Mitchell, Executive Director Phone No.: (808) 935 — 7844 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Facility Address: Address: Same Address: City,ST,Zip Email Address: info@hawaiimediation.org Fax No.: (808 ) 961 — 9727 Accountant/CPA: Gretchen Kremeyer,CPA Phone No.: (808) 968 — 1002 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Pro•ram 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $0 $0 2.Agency Mission Statement: OUR MISSION We empower people to come together--to talk and to listen,to explore options,and to find their own best solutions. To achieve this mission,we offer mediation,facilitation,and training to strengthen the ability of diverse individuals and groups to resolve interpersonal conflicts and community issues. OUR VISION A peaceful community where people routinely seek common ground. OUR VALUES Communication/Collaboration/Confidentiality/Courtesy/Competence (Founded in 1983 as a part of the Hawai'i Island YMCA. Became an independent non-profit organization in 2006.) 3. Program Description: In 2010,the Hawai'i Department of Education(DOE)Safe Schools Community Advisory Committee established several recommendations to address conflict in the schools, including establishing a school community culture that creates and encourages an environment of safety and respect. To support this directive,we launched a youth peer mediation program in East Hawaii in 2015. Peer mediation is both a program and a process where students of the same age-group facilitate resolving disputes between 2 or more people. Students in conflict can request mediation or be referred by staff or other students. Mediators work in pairs and help disputants reach and document agreements that are fair,safe,and doable. Peer mediation training focuses on the nature of conflict,communication and problem-solving skills,and understanding and respecting differences. Through peer mediation and conflict resolution,students learn to work effectively with their schoolmates to facilitate positive outcomes. This process has proven effective in schools around the United States and in the state of Hawai'i. Our"Youth Peer Mediation Program"will focus on deepening the successful peer mediation programs at 3 elementary schools: 2 in the Ka'u-Kea'au-Puna Complex Area(Keonepoko&Mountain View)and 1 in the Hilo-Waiakea Complex Area(Kapiolani), as well as seeking out new partners(including youth clubs and after-school programs). In addition,a comprehensive long-range plan will be developed with Complex Area Superintendents to expand the program into middle and high schools. PEER MEDIATOR QUOTE:"I am proud to be a mediator because I can help out and become a better person. I have learned in peer mediation that conflict can be everywhere but I can mediate anywhere."-Tiare,5th grade peer mediator 4.Total Budget& Position Count: Total Program Budget: $30,000 Total Program Position Count: .5 Total Agency Budget: $325,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Pros ram 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Direct contributions 8,500 Foundation/trust grants 11,500 County of Hawaii nonprofit grant 10,000 TOTAL: $30,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1)Research and apply for new and continuing grants from foundations, locally and nationally. To support peer mediation in FY 2016-17,we received $1,500 from the HEI Charitable Foundation,$5,000 from the Anderson-Beck Fund,and anticipate$5,000 from the First Hawaiian Bank Foundation(which is what they gave in FY 2015-16). 2)Approach private donors,both individuals and businesses,to support the program. Both KTA Super Stores and Big Island Candies(BIC)pledged 3 years of support for peer mediation. Starting in 2015 and continuing until 2017, KTA has committed $5,000 per year($15,000 total)and BIC has committed$2,500 per year($7,500 total). BIC shared that,"It's a great idea to start at a young age." And KTA shared,"We look forward to a most successful[peer mediation]program because we also believe that early intervention is the best means of prevention." 3)Explore new partnership opportunities on the local and state levels for program and fund development. These include working with School Principals,Complex Area Superintendents,and Department of Education to cost-share the program in each school,plus consider applying for a State Grant-in-Aid to support peer mediation in FY 2018-19. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Peer mediation activities will be conducted at 3 elementary schools. 2)Approximately 45 students will be trained as peer mediators to serve 1,500 students. 3)Peer mediation sessions will occur on site throughout the school year with a 75%resolution rate. 4)Peer mediators will score 80%or better on a post-training test assessing their skills in conflict resolution. 5)By school year-end,90%of students trained will know how to help other students resolve conflicts peacefully. 6)By school year-end,90%of faculty/staff will be very satisfied with the Peer Mediation Program. 7)A comprehensive long-range plan will be developed with Complex Area Superintendents to expand the program into middle and high schools. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of schools participating 3 #of youth trained as peer mediators 45 #of peer mediation trainings held 6 %of peer mediation sessions that result in successful resolution 75% %of youth who comprehend conflict resolution skills post-training 80% %of youth who know how to help peers resolve conflicts at school year-end 90% %of faculty/staff who are satisfied with the program at school year-end 90% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 23,750 25,500 8,000 Professional Fees _ Operations 2,000 2,500 1,000 Supplies 1,000 1,500 750 Equipment Other: Mileage 250 500 250 Other: Other: Other: PLEASE NOTE: FY 16-17 figures are estimates Other: since we are only 7 months into the FY TOTAL $27,000 $30,000 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council H The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. /�` �- v2 January 30, 2017 Si ature of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's fl/t11rP funding rpl,Ilpct rind mny r ciilt in nrtinns tnkpn to rprnvpr thecp funds, By signing below, you are acknowledging that you have read and understood these requirements. eye e-esi 1 January 30, 2017 Signature o Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of schools participating a #of youth trained as peer mediators 45 #of peer mediation trainings held 6 of peer mediation sessions that result in successful resolution 75% of youth who comprehend conflict resolution skills post-training 80% %of youth who know how to help peers resolve conflicts at school year-end 90°, %of faculty/staff who are satisfied with the program at school year-end 90% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 8,000 Professional Fees Operations 1,000 Supplies 750 Equipment Other: Mileage 250 Other: Other: Other: PLEASE NOTE: FY 16-17 figures are estimates Other: since we are only 7 months into the FY TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Legal Aid Society of Hawaii Expanding Civil Legal Access to Rural Communities 112 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawaii Program Name: Expanding Civil Legal Access to Rural Communities Agency Director: M. Nalani Fujimori Kaina Phone No.: (808) 527 — 8014 Contact Person: Dawn Henry, Managing Attorney, Kona Office Phone No.: (808) 329 — 3910 Mailing Address: Address: 924 Bethel Street Address: City,ST,Zip Honolulu, Hawaii 96813 Facility Address: Address: 75-170 Hualalai Road, Suite B303A Address: City,ST,Zip Kailua-Kona, Hawai'i 96740 Email Address: dawn.henry@legalaidhawaii.org Fax No.: (808 ) 334 — 9650 Accountant/CPA: Wayne Keawe, Comptroller Phone No.: (808 ) 527 — 8060 Firm (if applicable): Mailing Address: Address: Legal Aid Society of Hawai'i Address: 924 Bethel Street City,ST,Zip Honolulu, Hawai'i 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua III North Kona ✓Q South Hilo Q North Kohala ❑✓ South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns [71Youth 2 Victims of Crimes n Culture and the arts III Aged Victims of Health or Social Crises H Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawai'i Program Name: Expanding Civil Legal Access to Rural Communities 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $10,000 $16,250 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 Lana'i to urban Honolulu. Legal Aid has two offices on the island of Hawai'i. 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$25,000 to contribute to a full-time attorney position,currently based in our Hilo office,to provide critical civil legal services throughout the Island and with a continuing emphasis on the Ka'u area, on farmworking families,on Native Hawaiians,on the Micronesian community and on the homeless. Legal Aid humbly requests the County's continued support through this grant application. Last year,the generous support of the County enabled Legal Aid to add a staff attorney position to our island's resources. The attorney we hired graduated in May 2016 from the University of Hawaii Richardson School of Law. He regularly appears in court on behalf of Big Island families on guardianship and other family law matters. Additionally, he has, along with our Kupuna Kokua Paralegals from both offices,set up outreaches in Ocean View, Pahala and Na'alehu, assisting seniors with legal issues and spreading the word in these communities about services available to them through Legal Aid. We anticipate conducting similar outreaches in Pahoa,Waimea and Kohala in 2017. Our aim through this Project is to help stabilize the many inter-generational households in our rural communities through the use of powers of attorney, advanced health care directives,simple wills and transfer on death deeds. In addition,we wish to continue to provide services such as guardianships, adoptions, divorces and custody orders, as well as to assist individuals in accessing health care and public benefits. Our umbrella of services assists individuals with disabilities,works with families facing foreclosure,and reaches out to children, parents and elders in unsafe situations. Our outreach is focused on reaching those who could easily be left behind in our increasingly busy world, making sure that our entire community is heard in the halls of justice, and some of our most vulnerable populations have a chance of getting their legal needs met. The other funding sources for this attorney position are likely to continue to be in place for some time. We request a monetary contribution from the County similar to its generous award for the 2016-2017 fiscal year, and with a small increase to assist with increases in salary, administration and travel costs. 4.Total Budget& Position Count: Total Program Budget: $25,000 Total Program Position Count: 0.50 Total Agency Budget: $6,944,526 Total Agency Position Count: 107 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawaii Program Name: Expanding Civil Legal Access to Rural Communities 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii Island United Way $4,800 County of Hawaii Nonprofit Grant $25,000 Judicial- Guardian Ad Litem $62,000 Hawaii County Office of Aging Title III $72,500 Federal Funding $232,919 State of Hawaii DHS Funding $258,653 See Continuation Page $103,211 TOTAL: $759,083 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 pursue grants out of the funding streams listed above, as well as through federal,state and private funding sources. One of the new funding streams that has become available to us during FY 2016-2017 is a Victims of Crime Office (VOCA)Grant that supports the work of our Big Island offices. We continually work to identify new sources of potential funding. 7. Program Objectives Using County Nonprofit Grant Program Funds: Under this grant, in FY2017-18, Legal Aid will continue to provide outreach and community coordination, as well as intake, counsel &advice, brief services and/or full representation in 100 cases.The services will be provided free to low-income individuals and families whose incomes are less than 200%of the poverty level. Potential clients will also be screened and provided assistance through other Legal Aid funding streams which allow us to assist other segments of the population, i.e., seniors and victims of domestic violence regardless of income levels. With the requested grant money and within the proposed priority areas,we are excited to make a real difference in our community. Having one attorney who can focus more energy and assistance in our rural and far-flung neighborhoods can ease suffering and the sense of isolation in those communities. It will also help identify issues that can be shared with other agencies, and with County and State governments. Ultimately we can create more vibrancy and health for all on our island.One person can make a difference in our goal of building a just society for all. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawaii Program Name: Expanding Civil Legal Access to Rural Communities • 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Supporting families 15 clients served Keeping children safe and secure 15 clients served Promoting safety,security and health 30 clients served Preserving the home 15 clients served Maintaining economic security 15 clients served Assisting culturally and linguistically isolated communities 10 clients served Outreach, education,workshops and events 15 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $13,389.08 $54,566.00 $22,325.00 Professional Fees $105.96 $500.00 $75.00 Operations $1059.60 $5,000.00 $1,000.00 Supplies $529.80 $2,500.00 $500.00 Equipment $317.88 $1,500.00 $300.00 Other: Telecommunications $317.88 $1,500.00 $300.00 Other: Mileage $529.80 $2,500.00 $500.00 Other: Other: Other: TOTAL $16,250.00 $68,066.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawaii Program Name: Expanding Civil Legal Access to Rural Communities 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council I I Staff appointed by a member of the Council I I The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. 1 /26/2017 M.Nalani Fuj'me ama,Ex- utive Direct'r, Signature of Authorized t'erson (s. '•cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawai'i Program Name: Expanding Civil Legal Access to Rural Communities 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawai'i Program Name: Expanding Civil Legal Access to Rural Communities 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding regIIPct and mny rPcillt in nrtinnc tnkPn to rernvPr there funchh. By signing below, you are acknowledging that you have read and understood these requirements. 1 /26/2017 M.Nalani Fuji i Kaina,Ex- utive Directo Signature of-Authorized Person (specif tle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawai'i Program Name: Expanding Civil Legal Access to Rural Communities 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Supporting families 15 clients served Keeping children safe and secure 15 clients served Promoting safety, security and health 30 clients served Preserving the home 15 clients served Maintaing economic security 15 clients served Assisting culturally and linguistically isolated communities 10 clients served Outreach,education,workshops and events 15 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $22,325.00 Professional Fees $75.00 Operations $1,000.00 Supplies $500.00 Equipment $300.00 Other: Telecommunications $300.00 Other: Mileage $500.00 Other: Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Legal Aid Society of Hawai i Project Name: Expanding Civil Legal Access to Rural Communities 5. Program Funding Sources (Continued) Revenue Source FY17-18 Estimate Foreclosure Assistance Project $37,210.00 Indigent Legal Assistance Fund $64,001.00 Fee for Service $2,000.00 Subtotal $103,211.00 Grand Total $759,083.00 Continuation Page 1 of 1 Lokahi Treatment Centers Adolescent Substance Abuse Treatment Programs 113 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Pro.rams Agency Director: Dr.Jamal F.Wasan, Ph.D Phone No.: (808) 895 — 0444 Contact Person: Kimi Palacio Phone No.: (808) 430 — 0932 Mailing Address: Address: P.O.Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate Office)Waikoloa Highlands Center,68-1845 Waikoloa Road Address: Suite 224-B City,ST,Zip Waikoloa,HI 96738 Email Address: kpalacio@Iokahitreatmentcenters.net Fax No.: (808 ) 965 — 5535 Accountant/CPA: Hanako K.Anderson/Kohala Tax&Accounting Services Phone No.: (808) 987 — 6762 Firm (if applicable): Carbonaro CPA's&Management Group,(808)930-9850 Mailing Address: Address: P.O.Box 1514,Kapaau,HI 96755(Kohala Tax&Accounting Services,LLC) Address: P.O.Box 4372,Hilo,HI 96720(Carbonaro CPA's&Management Group) City,ST,Zip**See above;two different service providers** YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna [✓ Hamakua Q✓ North Kona Q South Hilo 0 North Kohala Q✓ South Kona Q✓ North Hilo South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) dQ Educational concerns ✓Q Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged 0 Victims of Health or Social Crises 7 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 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Pro•rams 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0.00 $5,000.00 $ 14,875.00 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Hawaii Island adults,adolescents,and children. "E Komo Mai,Nou Ka Hale."—"Come Inside,This House Is Yours." 3. Program Description: Lokahi Treatment Centers(LTC)Adolescent Substance Abuse Programs provide comprehensive treatment services for adolescents(aged 10-18)at all six(6)office locations throughout Hawai'i Island.Treatment services are for individuals that complete a substance use assessment and through this detailed assessment are determined to be in need of treatment services that includes the provision of education to abstain from the use of substances,the development of relapse prevention skills and a treatment plan,individual counseling to address other problematic factors,and case management services.LTC's continuum of care(levels of care)includes:Intensive Outpatient,Outpatient,Continuing/After Care,and Prevention Programs. A majority of adolescent clients are referred for substance treatment services from Juvenile Probation or Teen Court.Recently, local schools have begun to refer students who are in need of treatment as evidenced by behaviors during school attendance that lead to suspension and/or expulsion.LTC's adolescent substance abuse treatment programs are integrated to include mental health services,to address co-occurring disorders that are impacting their recovery process. LTC's adolescent substance treatment program utilizes evidence-based methods and best practice standards that comply with the Commission on Accreditation of Rehabilitation Facilities(CARF)standards.Evidence-based curriculum's are consistently updated to include well-developed strategy models that are proven effective by behavioral health care treatment accreditation facilities throughout the nation.These curriculum's encourage the inclusion of family members and other supportive individuals; through these individuals,adolescents become well adjusted and develop the ability to create healthy long-term relationships that aide in relapse prevention,ending criminal thinking and behaviors,and reduces trauma-induced mental illness factors. 4.Total Budget&Position Count: Total Program Budget: $144,375.00 Total Program Position Count: 6 Total Agency Budget: $1,166,370.65 Total Agency Position Count: 22 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Pro.rams S. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Managed Care(Third Party Insurance) $100,000.00 County of Hawaii, Nonprofit Grant Contract $14,875.00 SOH, Dept.of Human Services Contract $29,500.00 TOTAL: $144,375.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Lokahi Treatment Centers continues to expand services to meet the multiple needs that the population we serve require in order to maintain sobriety and achieve long-term success in other aspects of their life that are negatively impacted by addiction and mental health issues.Program expansion includes continuous development and alteration that includes group sessions schedules,assessment availability,individual counseling and therapy sessions,etc. In order to strengthen our adolescent substance abuse treatment programs,we now have a full-time program coordinator who is solely dedicated to the growth and expansion of treatment services for adolescents.Steady increase in the amount of treatment services provided to adolescents will reflect in an increase in managed care billing,which will assist in a baseline cash flow to aide in the sustainability of the programs. In addition,the State(Third Circuit Court,Department of Health,Department of Education)and Federal governments have contracts that are specifically for substance abuse treatment services for adolescents.LTC plans to apply for these funding opportunities when they become available to help support the programs as they continue to expand.Managed Care billing will be assisted by the utilization of electronic billing.This billing method will increase the accuracy and effectiveness of third party insurance accounting requirements. 7.Program Objectives Using County Nonprofit Grant Program Funds: 1.Provide immediate access to treatment services to any adolescent that is assessed and diagnosed with any substance use disorder.Treatment services will also include linkages to mental health treatment services(integrated)and other behavioral treatment that may be deemed necessary in order for long-term recovery and to maintain sobriety. 2.Increase the availability of outpatient treatment services to adolescents in need of treatment services.Partner with community service providers to develop accessible locations within existing locations;will aide in the ease of access to treatment. 3.Increase LTC's participation in community events that are targeted for adolescents(outreach and engagement).This will include strengthening partnerships with community service providers and school officials(Dept.of Education;principals, school-based counselors,teachers). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Programs 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 of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase substance abuse treatment units 50%increase=150 total Increase referral sources through outreach and engagement Attend 2 workshops I Coordinate at least 8 in- service presentations. Increase referrals/linkages(wraparound service engagement) 50 units Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $50,000 $50,000 $15,000 Professional Fees $5,000 $5,000 Operations $12,000 $12,000 $2,500 Supplies $5,000 $5,000 $1,250 Equipment $2,500 $2,500 $1,250 Other: Other: Other: Other: Other: TOTAL $74,500 $74,500 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Donna Guerpo POSITION: Human Resources Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑✓ M- ember or members of the Council ❑ Staff appointed by a member of the Council n T- he Mayor O The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑ If no conflicts exist, check here. _ ( gnature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Programs 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. I(we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Pro.rams . ......_..... 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPgiwct nnri mny recult in nrtinnc tnkpn to rernvar theca funds, By signing below, you are acknowledging that you have read and understood these requirements. (f _ 2 < 1L, /,)signature of Authorized Person(specify title) ._/ 4Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result increase substance abuse treatment units 50%"crease=150 toter Increase referral sources through outreach and engagement Attend z workshops i Coordinate at least s in- service presentations. Increase referrals/linkages(wraparound service engagement) 50 units TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $15,000 Professional Fees Operations $2,500 Supplies $1,250 Equipment $1,250 Other: Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Lokahi Treatment Centers Adult Substance Abuse Treatment Programs 114 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Pros rams Agency Director: Dr.Jamal F.Wasan, Ph.D Phone No.: (808) 895 — 0444 Contact Person: Kimi Palacio Phone No.: (808) 430 — 0932 Mailing Address: Address: P.O.Box 383401 Address: City,ST,Zip Waikoloa,HI 96738 Facility Address: Address: (Corporate Office)Waikoloa Highlands Center,68-1845 Waikoloa Road Address: Suite 224-B City,ST,Zip Waikoloa,HI 96738 Email Address: kpalacio@lokahitreatmentcenters.net Fax No.: (808 ) 965 — 5535 Accountant/CPA: Hanako K.Anderson/Kohala Tax&Accounting Services Phone No.: (808) 987 — 6762 Firm (if applicable): Carbonaro CPA's&Management Group,(808)930-9850 Mailing Address: Address: P.O.Box 1514,Kapaau,HI 96755(Kohala Tax&Accounting Services,LLC) Address: P.O.Box 4372,Hilo,HI 96720(Carbonaro CPA's&Management Group) City,ST,Zip **See above;two different service providers** YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua 0 North Kona 0 South Hilo 0 North Kohala CJ✓ South Kona D North Hilo 0 South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged �✓ Victims of Health or Social Crises j Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0.00 $0.00 $13,750.00 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Hawai'i Island adults,adolescents,and children. "E Komo Mai,Nou Ka Hale."-"Come Inside,This House Is Yours." 3.Program Description: Lokahi Treatment Centers(LTC)Substance Abuse Programs provide comprehensive treatment services for adults at all six(6) of our office locations throughout Hawaii Island.Treatment services are for individuals that complete a substance use assessment and through this detailed assessment are determined to be in need of treatment services that includes the provision of education to abstain from the use of substances,the development of relapse prevention skills and a treatment plan, individual counseling to address other problematic factors,and case management services.LTC's continuum of care(levels of care)includes:Intensive Outpatient,Low-Intensity Outpatient,Outpatient,Continuing/After Care,and Prevention Programs. Substance abuse has a significant impact on the entire community and creates various difficulties for individuals themselves, family members,children,employers,etc.More so,the safety of our community is impacted when substance abuse is involved; typically a rise in crimes associated with substance use begin to occur more frequently as a result of continuous use without proper treatment interventions.This creates a substantial burden and strain on the criminal justice system,service providers, and emergency medical services.As our jails and prisons become overpopulated due to the incarceration rates of drug offenses,the cost to the public is increasingly overwhelming.In FY 2016,the Third Circuit Court reported a total of 708 adults were referred by the judiciary and admitted into a treatment regime.To combat this ongoing cycle,LTC has developed programs utilizing evidence-based methods and best practice standards that comply with the Commission on Accreditation of Rehabilitation Facilities(CARF)standards.CARF evaluates rehab facilities'abilities to meet very strict standards that factor into higher success rates for patients.LTC remains committed to providing substance treatment services that integrate mental health treatment to ensure that all clients receive the proper healthcare services to enable clients to reach long-term sobriety. 4.Total Budget&Position Count: Total Program Budget: $967,750.00 Total Program Position Count: 22 Total Agency Budget: $1,166,370.65 Total Agency Position Count: 22 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Programs 5.Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Managed Care(Third Party Insurance) $800,000.00 SOH,Adult Drug Court Contract $25,000.00 SOH, Dept.of Human Services Contract $59,000.00 SOH, Hawai'i Paroling Authority Contract $40,000.00 Federal Probation and Pre-Trial Contract $30,000.00 County of Hawaii, Nonprofit Grant Award $13,750.00 TOTAL: $967,750.00 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: Lokahi Treatment Centers continues to expand services to meet the multiple needs that the population we serve require in order to maintain sobriety and achieve long-term success in other aspects of their life that are negatively impacted by addiction and mental health issues.Program expansion includes continuous development and alteration that includes group sessions schedules,assessment availability,individual counseling and therapy sessions,etc.When expanding services,LTC ensures that we continue to provide excellent treatment while enhancing programs through new evidence-based curriculum's and best practices models.Since it's inception,LTC has not applied for additional funding offered by Hawai'i County due to it's relatively moderate growth rate.Currently,LTC has grown substantially and opened a new facility in the Puna district. It's because of these expansions and overall enhancements that Lokahi is now applying for additional funding to assist with this rapid growth rate that will enable more individuals with substance use disorders or co-occuring disorders to access proper treatment services. The implementation of enhanced programs and increasing the availability of services has increased revenue and through the utilization of electronic billing for managed care,our revenue should continue to remain stable;however,with an ever-increasing amount of incoming clients in need of services that are unable to afford treatment due to other socioeconomic factors,LTC has seen a rise in referrals that are unable to afford treatment payments and must be linked to proper community resources;during this time,LTC enrolls them in treatment services to help stabilize them and provide behavioral health support. 7.Program Objectives Using County Nonprofit Grant Program Funds: 1.Provide ease of access to assessments and treatment services;to include jail assessments and possible housing placements referral assistance to expedite transition to community status—link to treatment services prior to release.Will include policy and procedure adjustments while still meeting/exceeding accreditation standards at all facility locations. 2.Increase the availability and ease of access to outpatient treatment services—through partnerships with community partners, increasing the capacity of our newest facility in Pahoa,and re-establishing a facility location in the Ka'u district. 3.Strengthen relationships with community partner agencies and supportive service providers—ensure that clients are receiving proper referrals and linkages for appropriate services for proper wrap around care. 4.involvement in more community events to increase outreach and engagement with the public. 5.Increase in revenue through the utilization of electronic billing software,updated managed care software,and enhancement of data management compliance standards with proper software. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Pro•rams 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase the number of clinical discharges(complete all treatment sessions) Increase by 25%;swift interventions Decrease recidivism rates(returning clients w/new charges);continuing care engagement Decrease rate by 25%;engaged follow up Increase professional development opportunities for clinicians(training) 4 workshops/staff member/yr Utilization of web-based data management systems Electronic data records;track outcomes Utilization of electronic billing system Managed Care Billing;efficiency increases Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $780,000 $800,000 $20,000 Professional Fees $30,000 $30,000 Operations $180,000 $180,000 $20,500 $20,500 Supplies $25,000 $25,000 $5,000 Equipment Other: Other: Other: Other: Other: TOTAL $1,035,500 $1,055,500 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Pro•rams 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: Donna Guerpo POSITION: Human Resources Officer May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑✓ Member or members of the Council ❑ Staff appointed by a member of the Council L The Mayor O The Managing Director ❑ The Director of Finance 11 The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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. .�.�5 ._ '4 l f ,:� . -,�. --� urs U - �.�, Z Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Pro•rams 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express,and be compliant prior to final payment. To register, go to http:/fvendors.ehawaii.gov,complete the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Pros rams 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2018 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 rpqupct and may rrcutt in nrtinnc taken to rprnvpr thece fundc, By signing below,you are acknowledging that you have read and understood these requirements. Si/ ature of Authorized Person(specify title) ,} Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Adult Substance Abuse Treatment Pro.rams 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase the number of clinical discharges(complete all treatment sessions) increase interventiarsong""" Decrease recidivism rates(returning clients w/new charges);continuing care engagement engaged fotto Increase professional development opportunities for clinicians(training) 4 workshops/staff member/yr Electronic data records;track Utilization of web-based data management systems outcomes Managed Care Billing; Utilization of electronic billing system efficiency increases TABLE It: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $20,000 Professional Fees Operations Supplies Equipment $5,000 Other: Other: Other: Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Lokahi Treatment Centers Domestic Violence Intervention Treatment Programs 115 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence intervention Treatment Pro.rams Agency Director: Dr.Jamal F.Wasan, Ph.D Phone No.: (808) 895 — 0444 Contact Person: Kimi Palacio Phone No.: (808) 430 — 0932 Mailing Address: Address: P.O.Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate Office)Waikoloa Highlands Center,68-1845 Waikoloa Road Address: Suite 224-B City,ST,Zip Waikoloa, HI 96738 Email Address: kpalacio@lokahitreatmentcenters.net Fax No.: (808 ) 965 — 5535 Accountant/CPA: Hanako K.Anderson/Kohala Tax&Accounting Services Phone No.: (808) 987 — 6762 Firm (if applicable): Carbonaro CPA's&Management Group,(808)930-9850 Mailing Address: Address: P.O.Box 1514,Kapaau, HI 96755(Kohala Tax&Accounting Services,LLC) Address: P.O.Box 4372,Hilo, HI 96720(Carbonaro CPA's&Management Group) City,ST,Zip**See above;two different service providers** YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua 0 North Kona 0 South Hilo 0 North Kohala C South Kona ❑✓ North Hilo 0 South Kohala C Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth 0 Victims of Crimes 0 Culture and the arts 0 Aged 0 Victims of Health or Social Crises ✓2 Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Pro.rams 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0.00 $0.00 $9,250.00 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Hawai'i Island adults,adolescents,and children. "E Komo Mai,Nou Ka Hale."—"Come Inside,This House Is Yours." 3.Program Description: Lokahi Treament Centers(LTC)Domestic Violence Intervention(DVI)programs focuses on evidence-based,cognitive behavioral DVI services for adjudicated adult and adolescent offenders,to include linkages with additional supportive services that may be provided by other community providers.The DVI program is available to adults and adolescents at all six(6)office facilities operated by LTC throughout Hawaii Island.In the last fiscal year,there has been a consistent increase in the amount of adult offenders who are referred to seek domestic violence treatment services;which prompted LTC to expand access to services to all LTC facility locations. The DVI program services provide offenders with the knowledge and skills necessary to prevent further battering,including cognitive-behavioral skills training to strengthen their ability to make different behavioral choices and accept responsibility (accountability)for their unacceptable actions.LTC's overall program objective is to build thorough case plans focused on criminogenic needs and dynamic risk factors aimed at reducing recidivism so that all clients are able to successfully complete the program and go on to lead healthier lives free from re-offending.Domestic Violence has a significant impact on the entire community and creates various difficulties for individuals themselves,family members,children,employers,etc.More so,the safety of our community is impacted when substance abuse and untreated violence issues are involved;typically a rise in crimes associated with substance use begin to occur more frequently as a result of continuous use without proper treatment interventions.This creates a substantial burden and strain on the criminal justice system,service providers,and emergency medical services.As our jails and prisons become overpopulated due to the incarceration rates of violence-related offenses,the cost to the public is increasingly overwhelming. 4.Total Budget&Position Count: Total Program Budget: $179,250.00 Total Program Position Count: 6 Total Agency Budget: $1,166,370.65 Total Agency Position Count: 22 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Pro.rams 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Managed Care(Third Party Insurance) $150,000.00 County of Hawaii, Nonprofit Grant Contract $9,250.00 SOH,Adult Probation Services Contract $20,000.00 TOTAL: $179,250.00 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: Electronic billing system will allow LTC to provide a streamlined billing process that will ensure timeliness and greater efficiency. This streamlined process will create a baseline cash flow to stabilize the program and ensure long-term sustainability through managed care.Through this process,LTC will not be as dependent on grant funding resources. Policy/Procedure changes regarding co-payments;to conform to healthcare insurance provider regulations that prohibit managed care billing of co-occurring behavioral health services. LTC will continue to apply for funding opportunities that become available through County,State,and Federal governments that target treatment for this population in need of appropriate domestic violence intervention services that utilizes evidence-based and best practices. 7.Program Objectives Using County Nonprofit Grant Program Funds: 1.Provide immediate access to all individuals who are assessed and diagnosed as needing domestic violence intervention treatment services. 2.Increase the availability of domestic violence intervention treatment services for all individuals that need treatment. 3.Identify and strengthen the availability of community linkages that support continuity of treatment.This will lead an increase of social support networks that will enable individuals receiving treatment services to achieve long-term healthy behaviors,thus decreasing recidivism and increasing public safety. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Programs 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase treatment service units 25%increase=200 units/year Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $100,000 $100,000 $10,000 Professional Fees $5,000 $5,000 Operations $12,000 $12,000 $3,500 Supplies $10,000 $10,000 $1,500 Equipment $7,500 $7,500 Other: Other: Other: Other: Other: TOTAL $134,500 $134,500 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Donna Guerpo POSITION: Human Resources Officer May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑✓ Member or members of the Council • Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director (l The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: El If no conflicts exist, check here. gnature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Pro.rams 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. (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Pro•rams 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai`i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30, 2018 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 rPqupct nnrl mny rpcult in netinnc tnkpn to rprnvpr tj►PcP fiinric. By signing below, you are acknowledging that you have read and understood these requirements. 4 c (1 I7 : - S— 1-.L f S gnature of Authorized Person (specify title) f Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase treatment service units 25%increase=200 units/year I TABLE II: FY 17-18 t Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $10,000 Professional Fees Operations $3,500 Supplies $1,500 Equipment Other: Other: Other: Other: Other: TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Malamalama Waldorf School Hui 'Ano 'Ano Parent/Child Development 116 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Hui 'Ano 'Ano Parent/Child Development Agency Director: Kelley Lacks Phone No.: (808) 982 - 7701 Contact Person: Kelley Lacks Phone No.: (808) 982 - 7701 Mailing Address: Address: HC 3 Box 13068 Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 15-1834 Makuu Dr Address: City,ST,Zip Keaau, HI 96749 Email Address: admin@hawaiiwaldorf.org Fax No.: (808 ) 982 - 7806 Accountant/CPA: Ron Dolan Phone No.: (808) 935 - 5433 Firm (if applicable): CPA&Associates 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: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua [ North Kona ❑South Hilo ❑ North Kohala n South Kona Ivj North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns n Youth ❑Victims of Crimes ❑ Culture and the arts (1 Aged H 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 2017-2018 Page 1 of 8 f - County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Hui 'Ano 'Ano Parent/Child Development 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 7,500 3,250 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. Objectives: -Create a"child centered"education designed to meet intellectual,emotional,and physical needs. -Express enthusiasm,artistry,and interest in every lesson. -Nourish the child through lively presentations developmentally age-appropriate. -Develop the child's innate ability to think"creatively"through various exercises, including creative arts. -Nuture and cultivate the qualities of wonder, reverence,gratitude,responsibility,decision making,healthy self-image, consideration for others,and cooperation. -Engender a sense of belonging to a community that nurtures and supports the uniqueness of each individual. -Develop in the child a sense of being a"world citizen"through a curriculum utilizing world literature,foreign languages,and multicultural enrichment. -Develop academic excellence,a love of learning,and clear thinking. 3. Program Description: MWS seeks to provide guidance and instruction to parents/caregivers and children ages 1-3. Groups meet two 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 and 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: 82,485 Total Program Position Count: 4 Total Agency Budget: 776,533 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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): FY17-18 Revenue Source Estimate Hawaii County Grant 10,000 Course Fees 45,000 Other Grants 12,000 In-Kind 15,485 TOTAL: 82,485 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: MWS has a grant writer designated to seek and obtain grants for early childhood programs;and an Enrollment Coordinator to engage in marketing and outreach for enrollment. MWS will continue seeking additional grant funding sources, as well as consider future expansion in duration and number of blocks offered each year. MWS will continue to seek in-kind services to offset costs in supporting the program. 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 2017/2018"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 2017-2018 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Hui 'Ano 'Ano Parent/Child Development 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Parents feeling supported 100% Parents satisfaction for a safe and nurturing environment 100% Increased parent and child confidence 100% Parents implementing practices in home 100% Re-enrollment in the program 100% Parent referrals 100% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 12,200 36,565 3,000 Professional Fees 4,500 9,270 1,500 Operations 5,000 27,000 2,000 Supplies 2,000 5,150 2,000 Equipment 2,200 4,500 1,500 Other: Other: Other: Other: Other: TOTAL 25,900 82,485 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Hui 'Ano 'Ano Parent/Child Development 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council ri Staff appointed by a member of the Council The Mayor The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. • 1 -30-2017 Signature •��uth- ed Pert(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Hui 'Ano 'Ano Parent/Child Development 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Hui 'Ano 'Ano Parent/Child Development ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at 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, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fnt;irP funding rcq!Pct nnrl mny recult in nrtinnc tnkPn to rprnvpr thPce funric, By signing below, you are acknowledging that you have read and understood these requirements. 1 -30-2017 Signature Aut ized P rs n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 s s County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Hui 'Ano 'Ano Parent/Child Development 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Parents feeling supported 1ooi Parent satisfaction for a safe and nurturing environment iooi Increased parent and child confidence ioor Parents implementing practices in home ioor Re-enrollment in the program 1ooi Parent referrals ,00% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 3,000 Professional Fees 1,500 Operations 2,000 Supplies 2,000 Equipment 1,500 Other: Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Malamalama Waldorf School Puna Arts in the Park 117 A County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Agency Director: Kelley Lacks Phone No.: (808) 982 — 7701 Contact Person: Kelley Lacks Phone No.: (808) 982 — 7701 Mailing Address: Address: HC 3 Box 13068 Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 15-1834 Makuu Dr Address: City,ST,Zip Keaau, HI 96749 Email Address: admin@hawaiiwaldorf.org Fax No.: (808 ) 982 — 7806 Accountant/CPA: Ron Dolan Phone No.: (808) 935 — 5433 Firm (if applicable): CPA&Associates 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: $10,500 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna E Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala South Kona North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns Youth ❑Victims of Crimes Q 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 15,000 7,000 3,500 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. Objectives: -Create a"child centered"education designed to meet intellectual,emotional,and physical needs. -Express enthusiasm,artistry,and interest in every lesson. -Nourish the child through lively presentations developmentally age-appropriate. -Develop the child's innate ability to think"creatively"through various exercises,including creative arts. -Nurture and cultivate the qualities of wonder,reverence,gratitude, responsibility,decision making, healthy self-image, consideration for others,and cooperation. -Engender a sense of belonging to a community that nurtures and supports the uniqueness of each individual. -Develop in the child a sense of being a"world citizen"through a curriculum utilizing world literature,foreign languages,and multicultural enrichment. -Develop academic excellence, a love of learning, and clear thinking. 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 and south Hilo areas to provide them with arts and sciences educational enrichment through interactive activities, guest specialists,and fieldtrips. Waldorf education in the program will foster respect for one another and care of our aina. 4.Total Budget& Position Count: Total Program Budget: 49,440 Total Program Position Count: 8 Tota!Agency Budget: 776.533 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County Grant 10,500 Enrollment Fees 14,100 Other Grants and Fundraising 24,840 TOTAL: 49,440 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: MWS plans to continue increasing revenue through increased enrollment tuition to full capacity of 60 students;and through additional grant funding sources. Marketing and outreach is being expanded within the Puna and Hilo Districts,as well as internationally,to increase enrollment numbers. 7. Program Objectives Using County Nonprofit Grant Program Funds: MWS objectives: 1)Enroll 60 students in the program 2)Approximately 60 students will participate in art and science instruction with local professionals 3)MWS will employ a minimum of two local art/science professionals per week to provide instruction 4)Continue reaching more children in our community and beyond EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 • c County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Participation in new art experience 100% Participation in new science experience 100% Participation in daily exercise 100% Interaction with local artists and scientists 100% Meet a new friend 100% Parent satisfaction for a safe and nurturing environment 100% Re-enrollment in future programs 100% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 24,000 32,960 3,000 Professional Fees 3,000 4,120 1,500 Operations 3,150 4,326 2,500 Supplies 3,450 4,738 2,500 Equipment 3,296 1,000 Other: Other: Other: Other: Other: TOTAL 33,600 49,440 10,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director The Director of Finance I I The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. , 1 -30-2017 Signature of ,.4rized P r on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park 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 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 o our aro.ram's or a•enc 's uture undin. re•uests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requect and may result in artinnc taken to rernver theca fundc, By signing below, you are acknowledging that you have read and understood these requirements. _ , �� ) 1 -30-2017 Signature ofitthoFedPe oI (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participation in new art experience 100% Participation in new science experience 100% Participation in daily exercise 100% Interaction with local artists and scientists 100% Meet a new friend 100% Parent satisfaction for a safe and nurturing environment 100% Re-enrollment in future programs 100% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 3,000 Professional Fees 1,500 Operations 2,500 Supplies 2,500 Equipment 1,000 Other: Other: Other: Other: Other: TOTAL 10,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Malamalama Waldorf School Puna Off the Streets Aftercare 118 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare Agency Director: Kelley Lacks Phone No.: (808) 982 — 7701 Contact Person: Kelley Lacks Phone No.: (808) 982 — 7701 Mailing Address: Address: HC 3 Box 13068 Address: City,ST,Zip Keaau,HI 96749 Facility Address: Address: 15-1834 Makuu Dr Address: City,ST,Zip Keaau, HI 97649 Email Address: admin@hawaiiwaldorf.org Fax No.: (808 ) 982 — 7806 Accountant/CPA: Ron Dolan Phone No.: (808) 935 — 5433 Firm (if applicable): CPA&Associates 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: $7,500 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala n South Kona ❑ North Hilo ❑South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns [Youth E Victims of Crimes ✓❑Culture and the arts ❑Aged Victims of Health or Social Crises ❑ Needs of the poor E Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 5,000 2,375 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. Objectives: -Create a"child centered"education designed to meet intellectual, emotional,and physical needs. -Express enthusiasm,artistry,and interest in every lesson. -Nourish the child through lively presentations developmentally age-appropriate. -Develop the child's innate ability to think"creatively"through various exercises,including creative arts. -Nuture and cultivate the qualities of wonder, reverence,gratitude, responsibility,decision making, healthy self-image, consideration for others,and cooperation. -Engender a sense of belonging to a community that nurtures and supports the uniqueness of each individual. -Develop in the child a sense of being a"world citizen"through a curriculum utilizing world literature,foreign languages,and multicultural enrichment. -Develop academic excellence, a love of learning,and clear thinking. 3. Program Description: MWS Seeks to continue expanding and offering its aftercare program to include students grades K-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,foreign language, reading,exercise, nature exploration, and homework assistance. MWS aftercare offers a healthy and nutritious meal to students,with most items served being from local sources and organic.Aftercare at MWS provides community parents peace of mind,allowing them to continue to be productive members of society,effectively engaged in their work and free from worry about their children between school hours and those times parents are able to collect them.MWS seeks to increase natural play structures and musical enhancement opportunities with the purchase of new equipment over the next five years. 4.Total Budget& Position Count: Total Program Budget: 41,023 Total Program Position Count: 6 Total Agency Budget: 776,533 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Enrollment Fees 33,523 Hawaii County Grant 7,500 TOTAL: 41,023 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: MWS Enrollment Coordinator continues our marketing and outreach to the community to continue to increase enrollment and MWS Board has planned meeting with neighboring school to discuss areas we can support their programs,such as offering their students aftercare.MWS will continue to work with community and international volunteers to bring enrichment programs to our aftercare students. 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide healthy and nutritious meals to students after school,with the majority being local and organic. Provide a safe and nurturing environment for students. Provide ongoing enrichment activities and experiences. Provide aftercare services to students in the greater community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Students feel safe and supported 100% Students participate in new experiences 100% Students participate in daily exercise 100% Students receive a nutritious meal 100% Students make new friends 100% Parent satisfaction for a safe and nurturing environment 100% Re-enrollment in future programs 100% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 12,000 28,573 2,500 Professional Fees 800 1,650 500 Operations 1,500 3,100 1,500 Supplies 2,000 4,200 1,500 Equipment 3,500 1,500 Other: Other: Other: Other: Other: TOTAL 16.300 41,023 7,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director I The Director of Finance ri The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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. kirk 1 -30-2017 Signature o iAu -orize rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with 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 2017-2018 Page 6 of 8 t . County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare ii. 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 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding rerluect nnrl mny rPcult in nrtinnc tnkPn to rernver theta funds. By signing below, you are acknowledging that you have read and understood these requirements. Ibli 1 -30-2017 � ' Signature .dAut irized er•on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Malamalama Waldorf School Program Name: Puna Off the Streets Aftercare 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Students feel safe and supported 100% Students participate in a new experience t00% Students participate in daily exercise 100% Students receive a nutritious meal t00% Students make new friends t00% Parent satisfaction for a safe and nurturing environment t00% Re-enrollment in future programs 100% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 2,500 Professional Fees 500 Operations 1,500 Supplies 1,500 Equipment 1,500 Other: Other: Other: Other: Other: TOTAL 7,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Mental Health Kokua Residental Rehabilitation Services 119 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services Agency Director: Greg Payton Phone No.: (808) 737 — 2523 Contact Person: Gary Michell Phone No.: (808) 769 — 5728 Mailing Address: Address: Mental Health Kokua Address: 1221 Kapiolani Blvd.,Ste 345 City,ST,Zip Honolulu,HI 96814 Facility Address: Address: Mental Health Kokua Address: 75-166 Kalani St.,Ste 103 City,ST,Zip Kailua-Kona, HI,96740 Email Address: gmichell@mhkhawaii.org Fax No.: (808 ) 331 — 1378 Accountant/CPA: Summer B. Uwono, CPA Phone No.: (808 ) 737 — 2523 Firm (if applicable): N/A Mailing Address: Address: Mental Health Kokua Address: 1221 Kapiolani Blvd.,Ste 345 City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑✓ Hamakua ✓❑North Kona ✓❑South Hilo ✓❑ North Kohala ✓❑South Kona 171 North Hilo n South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor [ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $5,000 $6,000 $5,875 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: 1,800,000 Total Program Position Count: 40 Total Agency Budget: 11,083,000 _ Total Agency Position Count: 276 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services S. Program Funding Sources(identify alt sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 5,875 State of Hawaii—DOH 1,400,000 United Way 19,800 Program Service Fees 200,000 Private Insurance—Case Mgmt 174,325 TOTAL: 1,800,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Ongoing,agency wide efforts are being made and will continue to be made to pursue additional grant funding from trusts and foundations such as the Harry and Jeanette Weinberg Foundation.G.N.Wilcox,the BOH Charitable Foundation and the Visitor Industry Charity Walk. In addition,fund raising events are held to support our program and the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Provide residential services to 130 unduplicated consumers.2)Limit psychiatric hospitalization to less than 3%.3)At least 95%of consumers served are satisfied with services received.4)Improvement in daily living skill scores upon discharge.5) Discharge to more independent housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of unduplicated consumers served 130 %consumers requiring psych hospitalization Less than 3% % discharged to more independent living 75% %of consumers satisfied with services 95% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 978,100 1,000,000 Professional Fees 73,027 50,000 Operations 689,592 700,000 Supplies 47,000 50,000 Equipment 0 0 10,000 Other: 0 0 Other: Other: Other: Other: TOTAL 1,787,719 1,810,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n S- taff appointed by a member of the Council ❑ The Mayor n T- he Managing Director n T- he Director of Finance fl T- he Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 71 If no conflicts exist, check here. CEO 2-5 /7 Signature ofAuthorized Pers n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance,designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract,or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http.//vendors.ehawall.gov, complete the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at )a °� a =;� on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futures funding rPqpuPct and may reciilt in artinnc taken to rPrnVPr thacp fundc. By signing below, you are acknowledging that you have read and understood these requirements. (Ar-- 0/12-5// 7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of unduplicated consumers served 130 consumers requiring psych hospitalization Less than 3% % discharged to more independent living 75% %of consumers satisfied with services ssi TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment 10,000 Other: Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Na Kalai Wa'a Hoea Moku Canoe Garden 120 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden Agency Director: Keomailani Case Phone No.: (808) 885 - 9500 Contact Person: Keomailani Case Phone No.: (808) 885 - 9500 Mailing Address: Address: 65-1206 Mamalahoa Hwy Address: Suite 1-101 City,ST,Zip Kamuela, Hi. 96743 Facility Address: Address: 55-406 Hawi Rd. Address: City,ST,Zip Hawi, Hi. 96719 Email Address: keomailanicase@hawaiiantel.net Fax No.: (808 ) 887 - 1144 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑ North Kona ❑South Hilo ❑✓ North Kohala ❑ South Kona ❑ North Hilo ❑✓ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 $20,000 0 2. Agency Mission Statement: The mission of Na Kalai Wa'a is to protect, perpetuate and honor the indigenous Hawaiian traditions and practices of wa'a (canoe)culture through the Makali'i voyaging canoe programs,for the past, present and future generations. Na Kalai Wa'a provides cultural vessels(voyaging and costal canoes)to support quality educational experiences and community development and sustainability opportunities through programs that incorporate traditional ways of knowing with modern ways of learning. 3. Program Description: Na Kalai Wa'a(NKW)has been offering educational experiences to our community since the birth of our voyaging canoae, Makali`i in 1995. Our programs reflect our vision statement of He wa'a he moku, He Moku he wa'a(The canoe is our island, Our island is the canoe), and our curriculum is holistic and focuses on the relationship of all elements from our most fertile upland slopes to the deepest parts of our ocean.Through this pedagogy, programs are also able to focus on the individual's development and contribution to their own communities.As teacher and crew of Na Kalai Wa'a,our duty is to recognize the strengths of each student in order to help them develop those strengths both as an individual and as part of their community. Our educational pedagogy is also deeply engrained in family learning.We build canoes and programs that build communities, and we believe that when families engage in a program together, that their learning also continues after they have left to return home. Family learning also contributes towards the healthy social development of our communities and our people.Through the years NKW has found that the canoe is the perfect educational platform to engage all learners in basic academics,especially math and sciences. Our programs include sailing,dry dock,professional and personal development workshops,school visits, navigation workshops and community presentations. Hoea Moku, our canoe sustainability project plays a significant part in all parts of our wa'a curriculum. The main focus of Hoea Moku is education and the preservation of canoe culture through the growing, maintaining and use of important canoe plants- or the plants that help sustain the building of wa'a and the plants that can feed the crew during a voyage. Hoea Moku project is located on a 10 acre parcel of land in Hawi, Hawaii.A three bedroom,2 bath home sits on the property and currently houses an office for our Hanauna Ola Project. There is also a large wharehouse that is a storage area for planting materials,tools,and large equipment used to maintain the property. Continued on Attachment 4. Total Budget& Position Count: Total Program Budget: 109,185 Total Program Position Count: 1 Total Agency Budget: 264,462 Total Agency Position Count: 10 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Na Kalai Wa'a(position) 19,500 Administration for Native Americans 23,905 Hawaii Community Foundation (Flex grant) 2,000 County of Hawaii 51,780 Na Kalai Wa'a(in-kind - property) 12,000 TOTAL: 109,185 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hoea Moku is not a commercial farm or profitable venture. The focus of Hoea Moku is education and the preservation of our voyaging culture. Na Kalai Wa'a intends to pursue additional funding for Hoea Moku Project through grant proposals to the Office of Hawaiian Affairs and the Hawaii Community Foundation. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Hoea Moku will provide opportunities to teach 300 Support Crew Trainees'aipono, to provision the canoe with food;pilina kaula,to cultivate various varieties of fibrous plants to braid into cordage with plants grown at canoe gardens established at Hoea Moku,and hanai wa`a,to learn the proper wa`a protocol. 2. Hoea Moku will provide opportunities for 24 Alaka`i or teaching assistants to help extend wa`a knowledge to the 300 Support Crew Trainees to learn and practice'aipono, pilina kaula and hanai wa'a EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Applicant Projected Results Training Workshops to be held at Hoea 4 Students,community members,and NKW crew&families to be trained 300 Alakal to be trained 24 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 31,200 15,600 Professional Fees 7,800 3,900 Operations 2,000 Supplies 27,580 27,580 Equipment 2,500 2,500 Other: Utilities (water) 1,200 1,200 Other: Use of Property at Hoea 12,000 Other: Support Crew Training Workshops 21,655 Other: Stipends for Cultural practitioners 3,250 1,000 Other: TOTAL 109,185 51,780 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ 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. TIA/Ck.k) 612/" ("I - EAeou-kve January 30, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden __._. _ .... ... _.._ _. ._ 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 aaency's flit-lino funding rPrinpct and mny rptult in nrtinnc tnkpn to rernvpr theca fllndc, By signing below, you are acknowledging that you have read and understood these requirements. J Cr‘A.CILts-1(Qry xoeu.--kie—Avec-itv January 30 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Plant Cultivation, Food Preparation, Cordage, and Canoe Protocol trainings at Hoea a Students,Community members and NKW crew and families to be trained 300 Alaka'i to be trained to assist with aipono, pilina kaula, and hanai wa'a trainings. 24 TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages 15,600 Professional Fees 3,900 Operations Supplies 27,580 Equipment 2,500 Other: Utilities (water) 1,200 Other: Use of Property at Hoea Other: Support Crew Training Workshops Other: Stipends for Cultural practitioners 1,000 Other: TOTAL 51,780 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 County of Hawaii Nonprofit Grant Application FY 2017-18 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden 3. Program Description (Continued from page 2 of 8) Hoea Moku is a request for funding to supplement a portion of Project Hanaunaola : Sustaining the Generations through Voyaging which was selected in 2016 for funding by the Administration for Native Americans (ANA). The project goal of Hanaunaola is to restore and perpetuate Hawaiian cultural knowledge and practices of voyaging that support physical, spiritual, and psychological health and well being. One of the objectives of this project is to teach the knowledge and practices of voyage support to 24 alaka`i 300 support crew trainees. The 24 alaka`i will be trained to assist the Master Navigator in each of the trainings. All trainees will learn to cultivate plants in canoe gardens, prepare food (aipono), braid sacred cordage (pilina kaula), and learn canoe protocol and ceremonies (hanai wa`a). At least 80% of these trainees will be able to complete these trainings and perform these protocols as determined by Master Navigator Chadd Paishon who will measure their progress in learning and performance. The 300 trainees will consist of 165 students and teachers from 10 partner schools, 75 community representatives from Hawaii Island districts, and 60 crew and family members of Na Kalai Wa`a. Therefore, the Hoea Moku project will provide a site to hold trainings and practice sessions for the 300 support crew and will be the site for 4 canoe gardens that will support the trainings. The gardens that currently exist at Hoea Moku include cordage plants such as Olona,Ti, `Uki`uki,Ahuawa, and Hala. Additional cordage plants will be established in the 4 new gardens as well as plants that will sustain the canoe on a voyage. This request is to supplement the Hoea Moku Project by including the following cost items: 1) Establishment of 4 canoe gardens at Hoea Moku in Hawi 2) Acquisition of Cooking Equipment and supplies to be used for the preparation of food 3) A part time position to manage the gardens (Site Manager) Neighborhood Place of Puna Emergency Food Pantry 121 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna (n\ Program Name: Emergency Food Pantry Agency Director: Paul Normann Phone No.: ( 808) 965 - 5550 Contact Person: Paul Normann Phone No.: ( 808) 965 - 5109 Mailing Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Email Address: paul@neighborhoodplace.org Fax No.: (808 ) 965 - 5109 Accountant/CPA: Alex Smith Phone No.: (877 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓ Puna - Hamakua n North Kona 111 South Hilo - North Kohala South Kona I North Hilo n South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) • n Educational concerns n Youth n Victims of Crimes Culture and the arts 7 Aged n Victims of Health or Social Crises n Needs of the poor Physical/Emotional Disabilities [f Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Enver•enc Food Pant 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $35,000 $25,500 2. Agency Mission Statement: The goal of Neighborhood Place of Puna is to prevent child abuse and neglect by ensuring that families have access to the resources and skills they need to raise safe and healthy children. NPP's Mission: "Empowering families and communities in Puna by building strong foundations through healthy relationships that value each person's uniqueness. E malama pono kakou." 3. Program Description: Our program provides Emergency Food Assistance to individuals and families in Puna and South Hilo. Food insecurity is a persistent problem for Puna residents. Several large areas in Puna have been identified by the USDA as Food Deserts.These are census tracts in which a high percentage of the residents are"low income"and have limited access to a supermarket or large grocery store. DOE data supports the USDA designations. Over 75%of students in Puna area schools qualify for the free or reduced lunch program.At Mt. View elementary the percentage exceeds 90%. In Hilo, it is over 60%of students. (51% is the national average.) This January saw the closure or reduction in services of several food pantries serving Puna. Neighborhood Place of Puna maintains the only Food Pantry in Puna that provides"on call" Emergency Food Assistance throughout the entire month. Neighborhood Place Puna provides individuals and families with basic food items once a month on an appointment basis.We also provide some basic hygiene products as needed. Our Emergency Food Pantry can also provide same day emergency assistance on a limited basis. For those individuals who come to us in"food crisis," in addition to providing food we also try to connect them with resources in the community. For families,this will include Neighborhood Place of Puna's Family Strengthening and Home Visiting program. 4. Total Budget& Position Count: Total Program Budget: 50,142.00 Total Program Position Count: 1 FTE Total Agency Budget: 295,000.00 Total Agency Position Count: 5 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Emersenc Food Pant 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 25,000.00 Private Foundation Grants 10,000.00 Donations 15,142.00 TOTAL: 50,142.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is continually and actively working to find resources to continue to support this important program. There are many funders who are willing to help subsidize the costs of food and,to a lesser extent, utilities, phone, and space rental. Unfortunately, far fewer, are willing to pay for the staffing to keep the Emergency Food Pantry operational. We appreciate Hawaii County's continued support in helping us staff this vital program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of the Emergency Food Pantry program is to help ensure that individuals and families in Puna and Hilo have access to one the most basic of life's necessities: Food. In the 2016 calendar year, Neighborhood Place of Puna provided Emergency Food Assistance to over 1300 families or about 5000 individuals. 1957 or over one-third of the total individuals receiving food were children. 632 of those children were five years of age or younger. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Emer•enc Food Pant 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide Emergency Food Assistance 1,000 families in a year Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 41,557.00 39,742.00 25,000.00 Professional Fees 0 Operations 3,500.00 3.500.00 Supplies 2,000.00 2,400.00 Equipment 0 Other: Food 2,800.00 3,500.00 Other: Mileage 900.00 1,000.00 Other: Other: Other: TOTAL 50,757.00 50,142.00 25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council The Mayor 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: [71 If no conflicts exist, check here. / ignature • • horized P- son (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Emersenc Food Pant 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 http://vendors.ehawaii.gov, complete the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Emer•enc Food Pant __ 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's ftltiire fiinriing regiJPct rind mny rPCUIt in nrtinnc tnkPn to rernuPr thpcp fiinric, By signing below, you are acknowledging that you have read and understood these requirements. — exec wt�?.c��\a< VaSz(ti-- Sign ture of Authorize• -• - title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Emer•enc Food Pant 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 1,000 families in a year TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,000.00 Professional Fees Operations Supplies Equipment Other: Food Other: Mileage Other: Other: Other: TOTAL 25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Neighborhood Place of Puna Family Strengthening Home Visiting 122 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna ©@ IRif Program Name: Family Strengthening Home Visiting Agency Director: Paul Normann Phone No.: ( 808 ) 965 — 5550 Contact Person: Paul Normann Phone No.: ( 808 ) 965 — 5109 Mailing Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Email Address: paul@neighborhoodplace.org Fax No.: (808 ) 965 — 5109 Accountant/CPA: Alex Smith Phone No.: (877 ) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu. HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓ Puna Hamakua North Kona ✓ South Hilo n North Kohala South Kona n North Hilo n South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns ✓ Youth n Victims of Crimes n Culture and the arts Aged n Victims of Health or Social Crises n Needs of the poor Physical/Emotional Disabilities 171 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening Home Visiting 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $35,000 $25,500 2. Agency Mission Statement: The goal of Neighborhood Place of Puna is to prevent child abuse and neglect by ensuring that families have access to the resources and skills they need to raise safe and healthy children. NPP's Mission: "Empowering families and communities in Puna by building strong foundations through healthy relationships that value each person's uniqueness. E malama pono kakou." 3. Program Description: Hawaii County has the highest rates in the state, per-capita, of confirmed incidents of Child Abuse and Neglect. Puna and South Hilo account for the highest number of cases of confirmed child maltreatment within the County. Neighborhood Place of Puna's Family Strengthening Home Visiting Program is one of the few child abuse and neglect prevention programs that families can contact directly to get help. Our staff work with families on a weekly basis to ensure that they have the knowledge, skills, and resources necessary to raise their children in a nurturing, safe, and stable home environment. We work extensively on teaching developmentally appropriate parenting skills through a variety of modalities. Our program is built around the Protective Factors. Research shows that the Protective Factors,when present in the home, reduce the risk for child maltreatment and promote healthy development and well-being of children. In 2012 the CDC estimated that the lifetime cost for each surviving victim of child maltreatment was$210,012. Child maltreatment has been shown to have many negative effects on survivors, including poorer healthy, social and emotional difficulties, and decreased economic productivity. Neighborhood Place of Puna's program works to both reduce risks and promote protective factors so that today's children can grow up to be healthy and productive adults who will raise their children in nurturing and supportive home environments. 4. Total Budget& Position Count: Total Program Budget: 244,858.00 Total Program Position Count: 4 FTE Total Agency Budget: 295,000.00 Total Agency Position Count: 5 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening Home Visiting 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate State of Hawaii 153,000.00 Hawaii Island United Way 16,500.00 County of Hawaii 25,000.00 Private Foundations 20,000.00 Hawaii Children's Trust Fund 25,000.00 Donations 5,358.00 TOTAL: 244,858.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is a successful child abuse and neglect prevention program serving a community that lacks many resources, has a high level poverty, and some of the highest rates of child abuse and neglect, per capita, in the state.We aggressively seek diverse funding to support this program. Nevertheless, prevention programs,while vital in preventing of child abuse and neglect, are some of the hardest programs to sustain financially. We will always need government support for this program and, by extension,for the many families that come to us seeking help. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of the Family Strengthening Home Visiting program is to prevent child abuse and neglect through strengthening families We achieve this objective through a combination of risk reduction and promotion of the protective factors.The Five Protective Factors are Nurturing and Attachment, Knowledge of Child and youth Development, Parental Resilience, Social Connections, and Concrete Supports for families. Often when a family contacts us seeking assistance,they are in crisis—on the verge of homelessness, lacking basic resources, or dealing with a"difficult"child. Our first priority is to try and help stabilize the family. This may involve connecting them to resources in the community,teaching basic life skills, addressing underlying Domestic Violence or Substance Abuse. We also work with families on developmentally appropriate parenting including basic nurturing skills. Good parents can experience crisis as a result of poverty. However, instability in the home negatively impacts brain development in young children. Families who are persistently in"crisis"have a higher risks for child abuse and neglect. Neighborhood Place of Puna exist to help stabilize these families and give them the skills and supports they need to raise healthy and safe children. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening Home Visitin. 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Weekly home visits to families 65 Families Family Safety Assesment 65 Families Develop a Family Success Plan(FSP)with family to address identified risks 65 Families Families will successfully complete service plan 80%of Families Protective Factors Survey for families who successfully complete service plan 80%of Families Families will remain free of Child Abuse and Neglect while in the program 95%of Families Families will be free of Child Abuse and Neglect 6 months from completion of FSP 90%of Families Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 205,046.00 207,562.00 25,000.00 Professional Fees 5,500.00 6,000.00 Operations 16,413.00 11,896.00 Supplies 2,400.00 2,400.00 Equipment 0 0 Other: Mileage 12,443.00 15,500.00 Other: Client Emergency Support 2,200.00 1,500.00 Other: Other: Other: TOTAL 244,002.00 244,858.00 25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthenin• Home Visitin• 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. / _______ __ .7....... EXecx•_\A NYC..-ZrcL\a I /431741- Signat - - ' • • ' - . •erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthenin• Home Visitin. 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 Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening Home Visitin. 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requect rind mny recult in nrtinnc tnken to rernver theca funr/c, By signing below, you are acknowledging that you have read and understood these requirements. — ricCc\ or VA-3/( S ature o Ruthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening Home Visiting 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Weekly home visits to families 65 Families Family Safety Assesment 65 Families Develop a Family Success Plan(FSP)with family to address identified risks 65 Families Families will successfully complete service plan 80%of Families Protective Factors Survey for families who successfully complete service plan 80%of Families Families will remain free of Child Abuse and Neglect while in the program 95%of Families Families will be free of Child Abuse and Neglect 6 months from completion of FSP 90%of Families TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,000.00 Professional Fees Operations Supplies Equipment Other: Mileage Other: Client Emergency Support Other: Other: Other: TOTAL 25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 North Kohala Community Resource Center Kohala Coqui Coalition 123 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Co•ui Coalition Agency Director: Christine Richardson Phone No.: (808) 889 — 5523 Contact Person: Megan Solis Phone No.: (808) 889 — 5523 Mailing Address: Address: P.O. Box 519 Address: City,ST,Zip Hawi, HI 96719-0519 Facility Address: Address: 55-3393 Akoni Pule Hwy. Address: City,ST,Zip Hawi, HI 96719 Email Address: megan@northkohala.org Fax No.: (808 ) 889 — 5527 Accountant/CPA: Alida Adamek,Retired CPA Phone No.: (808 ) 938 — 2200 Firm (if applicable): NKCRC Honorary Board Member/former Treasurer Mailing Address: Address: P.O.Box 519 Address: City,ST,Zip Hawi, HI 96719 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ✓❑ North Kohala ❑South Kona D North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth D 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Co•ui Coalition 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $7,000 $8,750 2.Agency Mission Statement: The North Kohala Community Resource Center(NKCRC)is a 15-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 170 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 85 projects we currently sponsor. The Coqui Coalition's mission is simple:to keep North Kohala coqui free by means of eradication,education,and prevention. t`. 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.Today,the Coqui Coalition continues to be managed by a small group of Kohala residents,dedicated to keeping North Kohala free of the highly invasive iF coqui frog.The Coalition has been primarily supported by community donations and in the past two years,support from the County of Hawaii. 3. Program Description: Coquis are not just a Kohala problem.They are a County of Hawaii problem,and should be a concern for everyone living here. The coqui frog is extremely damaging to our ecosystem,our native insects and birds,and threatens our nursery industry, property values,and peace and quiet. We use a three-step approach to achieve our goal of a coqui-free community: 1)Education;2)Prevention;3)Eradication. Education:We publish a monthly ad in Kohala Mountain News informing the public of all sites treated for coquis as well as the hotline number.This year,we will collaborate with local realtors to provide a tri-fold brochure about coqui frogs that agents can give to new home and landowners,educating them about how to protect against coqui frogs,identify their calls,and what to do if a coqui is detected.The Coalition has also been educating major landowners,some of whom have taken on the responsibility of eradication on their own properties.Our hope is that other landowners will follow this example,which will alleviate some of the burden on the Coalition. Prevention:Through flyers, booths at community events,and local radio public service announcements,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. Eradication:Our Coqui Hotline is available 24/7 for reporting coquis and has been very effective.The Coalition receives an average of 6-10 reports of new infestations monthly. Eradication takes place at night and usually requires multiple visits. Previously eradicated sites must be monitored for nine months to ensure effective eradication.About two-thirds of our budget is composed of labor,truck rental,and fuel costs,which are necessary for spraying infestations.To date we have treated 300 • locations,including no less than 50 treatments at Keokea Gulch.Without this, Kohala would be as infested as Hilo or Puna. 4.Total Budget& Position Count: Total Program Budget: $50,000 Total Program Position Count: 3 contract labor Total Agency Budget: $576,605 Total Agency Position Count: I F/T; 2 PIT 'fl EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Co•ui Coalition 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Individual donations 23,000 Business donations 4,500 County of Hawaii Nonprofit Grant 20,000 Dorrance Family Foundation 2,500 TOTAL: $50,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The overwhelming majority of support the Coalition receives comes from the North Kohala community,both individuals and businesses.We are reaching out to increase community support from new residents, business owners,realtors and Kohala land owners,since keeping Kohala Coqui Free helps protect the property values in North Kohala.We also continue to seek funding opportunities with private foundations as well as public funding sources. 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 r;• 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;contract labor costs for spraying, mowing and clearing areas for treatment(a physically demanding job that is usually done at night);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 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) We measure our performance by the number of reported sites successfully eradicated. 100%of reported sites eradicated. Keokea Gulch completely quiet for at least 9 months and determined to be coqui free. Successful by the end of the year Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages n/a n/a 0 Professional Fees -Fiscal sponsorship fees 2,732 4,000 1,600 Operations Contract Labor-mowing, spraying 12,609 22,000 10,000 Supplies Chemicals and Safety Supplies 4,146 6,500 3,000 Equipment Blowers, shovels,tools 927 1,500 0 Other: Education: newspaper ad, printing 631 4,700 2000 Other: Truck Rental 6,524 10,000 3000 Other: Equipment/Sprayer Repairs 225 1,000 200 Other: Coqui Hotline 190 300 200 Other: * Note: FY16-17 costs through January 23, 2017 TOTAL $27,984 $50,000 $20,000 *If applicable 14; EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Co•ui Coalition 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Christine Richardson POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council (1 Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director 0 The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in genera!to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. 1 -27-17 Signature of Authorized^ Person (specify title) Date fyecot-ft'vc 17tfrt.c*sr' EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Co.ui Coalition 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Co•ui Coalition 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fin-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your aaency's fiitura funding rarqupct rind mny racult in nrtinnc tnkvn to rarnvar thpcP filnrlc, By signing below, you are acknowledging that you have read and understood these requirements. CleA14/ 1 -27-17 Signature of Authorized Person (specify title) Date Evecid ,c.. .d5.- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: Kohala Co•ui Coalition 12.COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result �00% We measure our performance by the number of reported sites successfully eradicated. 100:aoftereporter!saes Keokea Gulch completely quiet for at least 9 months and determined to be coqui free. suc�ssfui by the end of the p y year TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 1,600 Operations 10,000 Supplies 3,000 Equipment 0 Other: Education: newspaper ad, printing 2000 Other: Truck Rental 3000 Other: Equipment/Sprayer Repairs 200 Other: Coqui Hotline 200 Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 North Kohala Community Resource Center North Kohala Eat Locally Grown 124 I; r'i County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Eat Locally Grown Agency Director: Christine Richardson Phone No.: (808) 889 — 5523 Contact Person: Megan Solis Phone No.: (808) 889 — 5523 Mailing Address: Address: P.O.Box 519 Address: City,ST,Zip Hawi, HI 96719-0519 Facility Address: Address: 55-3393 Akoni Pule Hwy. Address: City,ST,Zip Hawi, HI 96719 Email Address: megan@northkohala.org Fax No.: (808 ) 889 — 5527 Accountant/CPA: Alida Adamek, Retired CPA Phone No.: (808) 938 — 2200 Firm (if applicable): Honorary NKCRC Board Member/former Treasurer Mailing Address: Address: P.O. Box 519 Address: .1 City,ST,Zip Hawi, HI 96719-0519 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES E Amount of Request for County Nonprofit Grant Program Funds: $7,500 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ✓❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment is EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Eat Locally Grown 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 {s, N/A N/A N/A {I 2.Agency Mission Statement: North Kohala Community Resource Center(NKCRC), is a 15-year-old,501(c)(3)nonprofit serving the district of North Kohala, •.1 on the northern tip of the Big Island.Our mission is to increase the number of successful community improvement projects that benefit the people of North Kohala.We do this by providing education,a fiscal umbrella,and bridges to funding,along with coaching and support for a wide range of community efforts.Currently we sponsor 85 projects that include youth,sports, senior, arts,education,equine,cultural,agricultural and land preservation programs.NKCRC has been the fiscal sponsor for North Kohala Eat Locally Grown(NKELG)since 2009. NKELG was founded in 2008 in response to goals set in the North Kohala Community Development Plan(CDP)for the district to"promote and support a community of diversified agriculture"and to"...produce 50%of the food it consumes."NKELG • primarily serves two populations:small farmers and agricultural producers;and the low-income population. Its mission is to support the North Kohala community to reach its self-sufficiency goal by spearheading initiatives aimed at growing a community-based,culturally appropriate,sustainable food system that addresses the health,environment and economic development of our community. NKELG has an established track record of successfully executing community initiatives focused on growing the agricultural community in North Kohala.This includes the development of"Growing a Local Food System in North Kohala-Planning for 50%Food Self-sufficiency,"a community based strategic plan for food self sufficiency;a"Know your Farmer Directory"; numerous local food market development activities;and various educational workshops and events. 3. Program Description: NKELG uses a four pronged approach to provide fresh, healthy,locally grown produce to the low-income and most food insecure residents in the North Kohala community. In addition,this project provides opportunities for direct producer to consumer sales, promoting a vibrant agricultural community and supporting local farmers to continue to supply their agricultural products in North Kohala.The four components are: 1)The continued operation of the EBT Booth at the Hawi Farmers Market.Since 2012 NKELG has operated an EBT Booth every Saturday at the Hawi Farmers Market,enabling recipients of the Supplemental Nutrition Assistance Program(SNAP)to purchase locally grown and produced agricultural products directly from local farmers and producers.SNAP recipients in North Kohala using EBT at local food retailers have limited opportunities to purchase locally grown and produced food,so the EBT Booth at the Hawi Farmers Market is essential in providing low-income families with fresh produce they might not otherwise be able to afford,and generates over$40,000 in sales annually for local producers. 2)Continue the Produce Program in partnership with Sacred Heart Food Basket(our local food bank)in Hawi.Since 2015,our program provides fresh produce to the 200-250 individuals who receive emergency food and nutrition assistance at the monthly Food Basket distribution.Without our program, most food distributed is processed. 3)Revise the"North Kohala Know Your Farmer Directory"which was first published in 2012. The revised directory will be available on-line and in print and will directly connect North Kohala consumers with over 50 local producers. 4)Revitalize a marketing and advertising campaign for the Hawi Farmers Market to increase the visibility of the market for the resident and visitor populations alike. We are seeking the County's support for the EBT Booth and the Produce Program for the Sacred Heart Food Basket,which were previously funded through a USDA Farmer Market Promotion Program grant. 4.Total Budget&Position Count: Total Program Budget: $43,888 Total Program Position Count: 1 PT Total Agency Budget: $576,605 Total Agency Position Count: 1 FT/2 PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Eat Locally Grown 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 rC' Revenue Source Estimate Kaiser Permanente-pending $10,000 "!s( Friends of Hawaii Charities-pending $5,000 Dorrance Family Foundation-pending $16,000 Sale of Directory($1 per directory)and advertising $1,500 Private donors($2,500 pledged and $300 secured) $3,108 County of Hawaii Nonprofit Grant $7,500 In-kind (EBT Booth at Hawi Farmers Mkt provided in-kind-$65 per month)-secured $780 TOTAL: $43,888 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: To increase revenues for this program NKELG will continue to seek funding from both public and foundation sources as well as individual donors.Currently NKELG has three pending applications with private foundations. In addition,a small fee will be charged for each copy of the"Know your Farmer Directory'as well as sale of advertisements in the directory;all revenue generated will go towards continuing program operations. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives of this program using County Nonprofit Grant Program Funds are to 1)Increase consumption of and provide access to locally produced agricultural products including fresh fruits and vegetables for low-income residents receiving SNAP benefits by managing and operating a weekly EBT Booth at the Hawi Farmers Market every Saturday in FY 2017-2018. Activities include weekly staffing of the EBT Booth, bookkeeping, record keeping,training vendors in protocol and procedure for accepting EBT,and renewing supplies including vendor receipts,checks,and updated Kohala Food Bucks(currency). 2)To provide equal access to locally grown fruits and vegetables to the most food insecure members of our community by supplementing the 200-250 families receiving monthly Sacred Hearts Food Basket provisions with locally grown fruits and vegetables at no cost to the recipients for 12 months. NKELG will source locally grown fruits and vegetables from a contracted local producer and distribute to the Food Basket for their monthly distribution day.This will take place once per month for 12 months. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center If Program Name: North Kohala Eat Locall Grown t 1 1i 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? p+l PROGRAM PERFORMANCE MEASURES Applicant Projected ected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) lNumber of EBT transactions at Hawi Farmers Market annually Increase 5%from 2016 baseline Dollar amount distributed to Farmers Market vendors annually through EBT sales Increase 5%from 2016 baseline Provide fresh, locally grown produce monthly to Food Basket clients 200 families served monthly 1.' 1 Attach additional pages as necessary. 9.TABLE II: 1 PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages (Project mgr stipend-15 hrs/mo @$25/hr x 12 mos+fringe) 4,392 5,625 0 Professional Fees (Fiscal sponsorship fees-8%of donations/grants) 540 3,251 600 Operations (EBT Booth operator/Bookkeeper) 3160 10,245 3000 Supplies (Market table, receipt paper, office supplies) 146 726 726 Other: Printing of Directory N/A 2000 0 Other: CSA Program-fresh local produce for 200-250 baskets per month 1,094 3,000 2,312 Other: Printing of vendor receipts, EBT Bucks - 962 862 Other: Print advertising for Market(KMN, Ke Ola, North Hawaii News) 953 13,699 0 ` Other: Graphic design, photography,web design/maintenance 1,200 3,600 0 Other: EBT booth fee$15/wk x 52 weeks 435 780 0 *Actual FY16-17 reflect costs from 7/1/16-1/21/17(final 5 mos of FMPP grant) TOTAL 11,920 43,888 7,500 F *If applicable i i EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Eat Locall Grown 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for i `s the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Christine Richardson POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor The Managing Director E The Director of Finance E The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct ybenefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • il!I n If no conflicts exist, check here. 1 -27-17 Signature of Authorized Person (specify title) Date Eke(-14.7171,04- EXHIBIT 14.71rwCEXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 4 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Eat Locally Grown Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; in 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. 1i I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Eat Locally Grown 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,.which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from ffuture grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. C I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. ` As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futures funding rerluact rind mny racult in nrtinnc tnkan to rcrnvar thecP funrlc, By signing below,you are acknowledging that you have read and understood these requirements. CIP'e ( (t------ 1 -27-17 Signature of Authorized Person (specify title) Date Ax e c uSVK. ,2i rc.civr EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 L' County of Hawai`i Nonprofit Grant Application FY2017-18 `17 eR Agency Name: North Kohala Community Resource Center Program Name: North Kohala Eat Locally Grown 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of EBT transactions at Hawi Farmers Market annually Increase 5%from 2016 baseline 4, Dollar amount distributed to Farmers Market vendors annually through EBT sales baseliIncrene 5%from 2016 Provide fresh, locally grown produce monthly to Food Basket clients 200 families served monthly TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 0 Professional Fees 600 Operations 3000 Supplies 726 Other: Printing of Directory 0 Other: CSA Program-fresh local produce for 200-250 baskets per month 2,312 Other: Printing of vendor receipts, EBT Bucks 862 Other: Print advertising for Market(KMN, Ke Ola, North Hawaii News) 0 Other: Graphic design, photography,web design/maintenance 0 Other: EBT booth fee$15/wk x 52 weeks 0 TOTAL 7,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 O Ka`u Kakou Family Fun Fest 125 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil Fun Fest Agency Director: W.S. Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: PO Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop Road City,ST,Zip Pahala, HI 96773 Email Address: ebertn004@hawaii.rr.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona El 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil Fun Fest 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $5,000 $3,000 2.Agency Mission Statement: '0 Ka'u Kakou was organized exclusively for charitable, educational,cultural,and economical support of the people of Kau. Operating income and assets are acquired enitrely by donations, grants,and fund raisers.'0 Ka'u Kakou is a 100% volunteer-run community service organization that responds to a wide variety of needs,ofter partnering with other community groups to achieve its goals.The Mission Statement reads:To support and promote a healthy community through education, cultural,and economic development opportunities that improve the quality of life in rural Ka'u. 3. Program Description: This is an annual family-oriented event held in conjunction with the'0 Ka'u Kakou sponsored July 4th parade in Na alehu.We provide fun, healthy activities for people of all ages, including games for the keiki such as inflatable slides,a train, and a rock wall. '0 Ka'u Kakou provides free hot dogs,watermelon,and shave ice for lunch. For kapuna we have bingo where we serve a free lunch and all go home with a prize. 4.Total Budget&Position Count: Total Program Budget: $5,000 Total Program Position Count: 0 Total Agency Budget: $98,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil Fun Fest 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County grant $5,000 TOTAL: $5,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Any help we get from the County helps us not only with this project but it also helps us give more to the community projects that are not covered by any grant money.We are always seeking monetary and in-kind donations,and have scheduled regular fund raising(selling hot dogs and shave ice)at Punalu'u Black Sand Beach. 7. Program Objectives Using County Nonprofit Grant Program Funds: This is one of the few programs in Ka'u that provide a fun day for keiki,their families, and the kupuna.While celebrating our nation's birthday,we bring families together to participate in physical activities.The Ka'u kupuna always look forward to playing bingo and winning prizes. The project meets our Mission statement goal of supporting and promoting a healthy community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil Fun Fest 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 2016 served 559 hot dogs 600 hot dogs 2016 served 800 shave ice 850 shave ice 2016 had 93 bingo participants 95 bingo participants 2016 served 120 adult lunches 130 adult lunches 2016 had 60 volunteers 60 volunteers 2016 had 600 volunteer hours 600 volunteer hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees $135 $137 $140 Operations $2,492 $2,500 $2,000 Supplies $2,617 $2,663 $1,860 Equipment $1,687 $2,100 $1,000 Other: Other: Other: Other: Other: TOTAL $6,931 $5,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil 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. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. 1/28/2017 Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil Fun Fest 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil Fun Fest 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future fending requPct nnrl mny rptult in nrtinnc tnkPn to rrrnvPr thPcP funds, By signing below, you are acknowledging that you have read and understood these requirements. �� 1/28/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Famil Fun Fest 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result hot dogs served 600 hot dogs shave ice served 850 shave ice bingo participants 95 bingo participants adult lunches served 130adult lunches 60 volunteers volunteers volunteer hours 600 volunteer hours TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $140 Operations $2,000 Supplies $1,860 Equipment $1,000 Other: Other: Other: Other: Other: TOTAL $5,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 O Ka'u Kakou Ka'u Coffee Trail Run 126 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: 'O Ka'u Kakou Program Name: Ka'u Coffee Trail Run Agency Director: W.S. Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: PO Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop Road City,ST,Zip Pahala, HI 96777 Email Address: ebertn004@hawaii.rr.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $7,500 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Q 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: 'O Ka'u Kakou Program Name: Ka'u Coffee Trail Run 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $5,000 $3,750 2.Agency Mission Statement: '0 Ka'u Kakou was organized exclusively for charitable, educational,cultural,and economical support of the people of Kau. Operating income and assets are acquired entirely by donations,grants,and fundraisers. '0 Ka'u Kakou is a 100% volunteer-run community service organization that responds to a wide variety of needs,often partnering with other community groups to achieve its goals. The Mission Statement reads:To support and promote a healthy community through educational, cultural, and economic development opportunities that improve the quality of the life in rural Ka'u. 3. Program Description: This event is a scenic trail run consisting of a 5K,a 10K,and a half marathon. It is an international event,drawing runners from all over the United States as well as Europe and Asia. The event has been held on the slopes of Mauna Loa at the Ka'u Coffee Mill,thus promoting Ka'u as an international destination as well as promoting the coffee industry. Additionally,the event provides a day of outdoor physical activity for the whole family by encouraging family registration. 4.Total Budget&Position Count: Total Program Budget: $7,500 Total Program Position Count: 0 Total Agency Budget: $98,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: 'O Ka'u Kakou Program Name: Ka'u Coffee Trail Run 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County grant $7,500 TOTAL: $7,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to seek donations and,while the community supports the efforts of'0 Ka'u Kakou,we have used non-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: Our objective is to promote a healthy lifestyle through physical fitness by providing an opportunity for family participation. We also use this project to promote Ka'u coffee and to promote Ka'u as a vacation destination. Through this program,we are fulfulling our Mission of improving the quality of life in Ka'u. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 2016-198 runners 250 runners 2016-100 volunteers 100 volunteers 2016-1000 volunteer hours 1250 volunteer hours 2016-125 spectators(including family members) 150 spectators 2016-food for all racers and volunteers(298) food for 250 runners,100 volunteers Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees $206 $206 $200 Operations $1,300 $1,500 $1,500 Supplies $5,298 $5,300 $5,300 Equipment $500 $600 $500 Other: Other: Other: Other: Other: TOTAL $7,304 $7,606 $7,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. iZ,e .ylid..,:zi_ed44 Qp_e4A. 6, 1/28/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 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 aaency's future funding rpquact and mny rpcult in nrtinnc tnkan to rarnupr theca fundc, By signing below, you are acknowledging that you have read and understood these requirements. 4 V/4ze me,/ 1/28/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 250 runners 100 volunteers 1250 volunteer hours 150 spectators food for 250 runners,100 volunteers TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees $200 Operations $1,500 Supplies $5,300 Equipment $500 Other: Other: Other: Other: Other: TOTAL $7,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 O Ka'u Kakou Ka'u Sanitation Program 127 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitaiton Pros ram Agency Director: W.S. Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: PO Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop Road City,ST,Zip Pahala, HI 96777 Email Address: ebertn004©hawaii.rr.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $9,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo [' North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ® Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitaiton Pro.ram 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $00.00 $5,000 $5,500 2. Agency Mission Statement: 'O Ka'u Kakou was organized exclusively for charitable,educational,cultural, and economical support of the people of Ka'u. Operating income and assets are acquired entirely by donations, grants,and fundraisers. 'O Ka'u Kakou is a 100% volunteer-run community service organization that responds to a wide variety of needs, often partnering with other community groups to achieve its goals. The Mission Statement reads: To support and promote a healthy community through educational, cultural, and economic development opportunities that improve the quality of life in rural Ka'u. 3. Program Description: Currently'0 Ka'u Kakou provides and maintains two portable toilets at the South Point fishing and visitor area and two at the boat ramp at the Punalu'u Black Sand Beach. South Point is a culturally rich area that attracts many visitors and it is also popular for local fishermen. Lacking rest rooms at these well-visited sites, many people chose to pollute the natural environment and spoil their beauty for others. Providing portable toilets to minimize impacts on the environment at these two popular sites is one way that we carry forward our mission of promoting a healthy community. 4.Total Budget&Position Count: Total Program Budget: $9,000 Total Program Position Count: $0 Total Agency Budget: $98,000 Total Agency Position Count: $0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: 'O Ka'u Kakou Program Name: Ka'u Sanitaiton Pro•ram 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County grant $9,000 TOTAL: $9,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since we were unable to get our full amount of$9,000 requested from the County grant for FY16-17,we will continue to seek other opportunities for donations and grants. We were able to get a grant for$3,500 from the Hawaii Community Foundation. HCF is not offering their grant program for FY 17-18. While we feel this Sanitation Program is one of our more important programs,we find that it is hard to get additional support for this less glamorous project. 7. Program Objectives Using County Nonprofit Grant Program Funds: These funds will help'0 Ka'u Kakou continue this program of providing portable toilets at South Point and at the Punalu'u Black Sand Beach. While there are no studies done of the number of visitors to either of these two sites,the popularity of the portable toilets is measurable. All four portable toilets are serviced once a week.This weekly schedule was determined based on the need to empty the toilets.We know of no plans for anyone to install restroom facilities at these sites. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitaiton Pro.ram 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 2 portable toilets at South Point 2 portable toilets 2 portable toilets at Punalu'u boat ramp 2 portable toilets Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 1647 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations $9,295 $9,000 $9,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $9,295 $9,000 $9,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitaiton Pros ram 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council I I The Mayor The Managing Director The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: (71 If no conflicts exist, check here. -CY C %A/ 1/28/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitaiton Pro•ram ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitaiton Pros ram ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding rprqupct and mny rpccult in nrtinnc tnken to rprnvpr thpcP fundc. By signing below, you are acknowledging that you have read and understood these requirements. �.� ez /, ,_ 2c___ 1/28/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitaiton Pro.ram 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 2 portable toilets at South Point 2 portable toilets 2 portable toilets at Punalu'u boat ramp 2 portable toilets TABLE I1: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations $9,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $9,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 0 Ka`u Kakou Punalu'u Annual Fishing Tournament 128 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishin• Tournament Agency Director: W. S. Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: PO 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop Road City,ST,Zip Pahala, HI 96777 Email Address: ebertn004@hawaii.rr.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000 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 121 Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ®Youth 0 Victims of Crimes VICulture 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishin. Tournament 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0 $5,000 $2,125 2.Agency Mission Statement: '0 Ka'u Kakou was organized exclusively for charitable, educational,cultural, and economical support of the people of Ka'u. Operating income and assets are acquired entirely by donations, grants,and fundraisers. '0 Ka'u Kakou is a 100% volunteer-run community service organization that responds to a wide variety of needs, often partnering with other community groups to achieve its goals. The Mission Statement reads:To support and promote a healthy community through educational, cultural,and economic development opportunities that improve the quality of life in rural Ka'u. 3. Program Description: This is a catch-and-release fishing tournament for keiki ages 1 to 14 years of age and their families. Each child receives a prize,and then prizes are given for the biggest catch, most fish caught,etc. in each age group. Poles, bait, lunch, shave ice, and entertainment is provided free to everyone. 4.Total Budget&Position Count: Total Program Budget: $8,500 Total Program Position Count: 0 Total Agency Budget: $98,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: 'O Ka'u Kakou Program Name: Punalu'u Annual Fishin• Tournament 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County grant $5,000 Donations $3,500 TOTAL: $8,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are asking for grants for four programs, but we have many other programs that rely on non-specific donation for the many services we provide in the community. We have set up a regular schedule for selling hot dogs and shave ice at Punalu'u in 2017 to support this program. 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 has to be accompanied by parent or guardian in order to participate in the tournament. This event is one of'0 Ka'u Kakou's major family oriented projects, bringing together children of all ages. This event provides a way of meeting our Mission statement of promoting a healthy community through education. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishin• Tournament 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 2017-463 registered fishermen 500 registered fishermen 2017-1700 total breakfasts and lunches 1800 breakfasts and lunches 2017-133 volunteers 150 volunteers 2017-1174 volunteer hours 1200 volunteer hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations $560 $600 $600 Supplies $7,975 $8,000 $4,400 Equipment Other: Other: Other: Other: Other: TOTAL $8,535 $8,600 $5,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION P12017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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): fl Member or members of the Council U Staff appointed by a member of the Council ❑ The Mayor The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: V If no conflicts exist, check here. -14,4dit2gi.. e...k.A.,/, .„(i I,%4 1/28/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishin. Tournament i1. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishin• Tournament ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaency's future funding rPgIPct and mny rPcu►t in nrtinnc Minn, to rernvpr thPcP funds, By signing below, you are acknowledging that you have read and understood these requirements. '�� 4,-Le &,‘,414 1/28/2017 _ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishin• Tournament 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 500 registered fishermen 500 registered fishermen 1800 total breakfasts and lunches 1800 breakfasts and lunches 150 volunteers 150 volunteers 1200 volunteer hours 1200 volunteer hours TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations $600 Supplies $4,400 Equipment Other: Other: Other: Other: Other: TOTAL $5,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Pacific Tsunami Museum Tsunami Education: School Outreach; 4th Grade 129 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School Outreach; 4th Grade Agency Director: Marlene Murray Phone No.: (808 ) 935 — 0926 Contact Person: Marlene Murray Phone No.: (808 ) 935 — 0926 Mailing Address: Address: P.O. Box 806 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 130 Kamehameha Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: hitec@tsunami.org 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: 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School Outreach; 4th Grade 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 20,000 5,000 4,875 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 provide tsunami education presentations to 4th grade students at schools around the island. At the start of the performance period,the project coordinator will develop the presentation specific to the 4th grade level and include consultation with Department of Education teachers. (As this is a pilot project,we will focus on one grade level,and hope to develop this program to include other grades in the future.) Worksheets and handouts will also be created. The coordinator will then begin contacting schools to share information on the presentations being offered and then begin confirming dates and developing a schedule. Presentations will be offered to individual classes or an assembly of all students in the 4th grade level,depending on the number of students. Using exhibit materials purchased with generous funding from last year's County of Hawaii Non-Profit grant,the presenter will provide information on the causes of tsunamis,the history of tsunamis in Hawai'i,the differences between locally generated versus distant tsunamis(and the differences in responses),tsunami survivor stories and safety information. The students and teachers will also receive informational handouts. Students will be instructed to take the information home to share with their families. 4.Total Budget& Position Count: Total Program Budget: 11,494 Total Program Position Count: 2 Total Agency Budget: 230,000 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School Outreach 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate We currently do not have the revenue to support this program. TOTAL: 0 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since admissions,membership dues and donations only cover our year to year expenses,we continue to pursue grants and other fund raising opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: The threat of tsunamis is an ever-present reality to all who live in the Hawaiian Islands. Scientists and experts agree that it is not a matter of if,but when the next one will strike. The Pacific Tsunami Museum's mission is to save lives through education and awareness. The museum will extend its message beyond its walls by going into schools and sharing important tsunami lessons with our youth. Ideally,all of Hawaii's residents would visit the Pacific Tsunami Museum to learn about tsunamis. Since this is not possible,this project will aim to take tsunami education directly into the schools. Children will learn about tsunami science,history and important safety rules. The information learned will be reinforced with activities. They will also be given handouts that they will be asked to take home and share with their families. A possible challenge to the success of this program is that teachers have such a demand placed on them for high student achievement and therefore it may be difficult to give up a period for tsunami education. However,we are hoping that because the lesson will be developed with consultation with teachers, it will serve to not only teach them about tsunamis, but also achieve corresponding standards and benchmarks. The time to learn about tsunamis and how to prepare for one is now. An organized response begins with a community that is aware and educated about tsunami hazards and we believe that it starts with educating our children in our schools. If we believe that Hawai'i will be impacted by a future tsunami(and it will)the benefit to the commuinity is tangible and practical. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School Outreach 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of presentations to schools on Hawaii Island. 30 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 9360 Professional Fees 1134 Operations Supplies 250 Equipment Other: Printing 500 Other: Graphic Artist 250 Other: Other: Other: TOTAL 11494 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School Outreach 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. IOW 1/30/2017 Signature of Authorized Person (specifyt -) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School Outreach ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with 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 impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School 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 Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's fiiture funding rerpuect rind mny result in nrtinnc token to recover these firndc, By signing below, you are acknowledging that you have read and understood these requirements. 1 /30/2017 Signature of Authorized Person (speci le) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education: School Outreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Parents and Children Together Head Start 130 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start Agency Director: Ryan Kusumoto Phone No.: (808) 847 — 3285 Contact Person: Ben Naki Phone No.: (808) 842 — 5996 Mailing Address: Address: 1485 Linapuni St., Suite 105 Address: City,ST,Zip Honolulu, HI 96819 Facility Address: Address: 27 Waianuenue Ave. Address: City,ST,Zip Hilo, HI 96720 Email Address: rkusumoto@pacthawaii.org Fax No.: (808 ) 841 — 1485 Accountant/CPA: Karena Yee Phone No.: (808 ) 847 — 3285 Firm (if applicable): Mailing Address: Address: 1485 Linapuni St., Suite 105 Address: City,ST,Zip Honolulu, HI 96819 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $144,806 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 E 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $0.00 $0.00 $0.00 2. Agency Mission Statement: The mission of Parents And Children Together is to promote and support healthy individuals, families and communities by creating opportunities for them to identify and address their own strengths, needs, and concerns and successfully realize their potential. Since its founding in 1968, PACT has developed a comprehensive array of services to strengthen individuals, children,families and communities experiencing social, behavioral health, and economic needs. The agency is a leader in providing neighborhood-based services and forging community partnerships that support families. Known for prevention as well as treatment, PACT is recognized for its advocacy and continuum of inter-connected services in such areas as: •Early childhood education and support to families for children at risk; •Child abuse and neglect prevention and treatment; • Domestic violence prevention and treatment;shelter for women and children;accountability for offenders; • Behavioral health services to facilitate education for special needs children and youth; •Community building and community-based service centers for families and teens; and •Economic development and economic self-reliance education and training for the under-employed and unemployed. PACT's programs are community-based, culturally sensitive,family-centered and focused on family strengths. Over the years, PACT has developed strong community networks and effective working relationships with many service providers and community resources. PACT is active in advocating for children and families, and educating community leaders and elected officials about child and family welfare issues, needs and solutions. PACT has an established track record and organizational commitment to quality assurance and evaluation. 3. Program Description: Parents And Children Together(PACT)requests funding of$144,806 for Fiscal Year 2018 to supplement funding from the Office of Head Start and the State Department of Health and Human Services Childcare Subsidy program to cover a portion of childcare fees for children,ages 3 to 5,of needy families enrolled in the extended day program at the three PACT Head Start classrooms in Hilo. PACT operates three 8-hour classrooms in Hilo:two classes for a total of 34 children at Clem Akina Park and one classroom of 20 children at the Hilo Child Development Center(Piihonua).The first six hours of the day is funded through the federal Head Start grant while the remaining two hours are part of our extended day option for families that need the extra hours of care. The last two hours of the day are paid through child care subsidies parents receive through the state child care subsidy program and/or out of pocket. While the majority of our parents qualify for a state child care subsidy,the amount of subsidy ranges and often results in parents incurring an out-of-pocket cost. Our current rate for our 8-hour classes is $425/month. Out of the 54 full-day slots,we have only been able to fill 34 slots. We continue to have an influx of families inquiring about our full-day classrooms so that they can work or attend school full time; however, these families are not able to afford the$425/month cost associated with the extended day hours. In providing full-day services, PACT will utilize the federal Head Start grant and state child care subsidies in collaboration with the grant award from the County of Hawaii Non-profit Grant Program to provide financial assistance to needy families to afford a comprehensive, accessible, quality-driven early childhood education center. 4.Total Budget & Position Count: Total Program Budget: 11,132,943 Total Program Position Count: 119.4 Total Agency Budget: 23,414,982 Total Agency Position Count: 374 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Administration for Children & Family-Office of Head Start/Early Head Start $10,412,253 Power and Pleasure of Reading $25,000 Oscar& Rosetta Fish Speech Fund $40,000 USDA $435,690 Head Start/Early Head Start Wrap around Fee for service $220,000 TOTAL: 11,132,943 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: PACT offers a 6-hour day HS/EHS program on the Island of Hawaii funded by US Department of Human Services at three different sites.We also offer two, additional-hour supervised wraparound service to families who qualify for Federal Childcare subsidy. The extended hours of care to our students provide their parents the critical childcare service they need to pursue full-time work or schooling. While we have a total 162-slot capacity for the 8-hour program,we currently only offer the 8-hour program at one location. The participation rate at this location is currently at 63% (34 out of 54 slots filled)due to parents not being able to afford the full-day fee.While all of our students qualified for Federal Childcare subsidies,the amount they receive varies;which means the out-of-pocket cost for the family also varies. Our program currently charges$425 a month. This translates to$10.63/hr. (2 hrs./day for 20 days/month).The average out-of-pocket cost to the parents is$200.00. We also know that many families living in this underserved area where we offer our program often choose to keep their children at home because they cannot afford the out-of-pocket share. Funding of this request will enable many of these children to have the opportunity to participate in a"quality"childcare program their parents otherwise cannot afford. 7. Program Objectives Using County Nonprofit Grant Program Funds: Goal: Provide full-day(8hrs/day)quality comprehensive early childhood education services to low income families who are working or attending school full-time. Objective: 1. Fifty-four preschool children will receive early childhood development services through full-day(8-hours/day)center-based services. 2. Ninety percent of parents with children enrolled in Head Start full-day services will be working and/or attending school full-time. 3. Full-day Head Start classrooms will have an 85%average daily attendance rate. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of children being served using child care scholarships 54 children Percentage of parents working or attending school full-time 90% Average daily attendance of children 85% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 28,005 28,005 Professional Fees Operations 25 25 Supplies 1000 1000 Equipment Other: Beneficiary cost(snack @$.80 for 54 kids for 180 days) 7,776 7,776 Other: Beneficiary- subsidy @$200/family for 54 families for 10 months/yr 108,000 108,000 Other: Other: Other: TOTAL 144,806 144,806 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: (Not applicable) POSITION: (Not applicable) 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 n Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director H The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: (Not applicable) n If no conflicts exist, check here. 01 /20/2017 Signature of A horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start 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 June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futures funding rPquPct rind mny rPcutt in nrtinnc tnken to rernver these funric, By signing below, you are acknowledging that you have read and understood these requirements. ►,, 01 /20/2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Parents And Children Together Program Name: Head Start 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of children being served using child care scholarships 54 children Percentage of parents working or attending school full-time 90% Average daily attendance of children 85% TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 28,005 Professional Fees Operations 25 Supplies 1000 Equipment Other: Beneficiary cost(snack @$.80 for 54 kids for 180 days) 7,776 Other: Beneficiary-subsidy @$200/family for 54 families for 10 months/yr 108,000 Other: Other: Other: TOTAL 144,806 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 PFLAG Kona/Big Island One 'Ghana Youth and Family Services 131 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services Agency Director: Jefferson Gourley: President Phone No.: (808) 895 — 2803 Contact Person: Jefferson Gourley: President Phone No.: (808) 895 — 2803 Mailing Address: Address: C/O 73-4198 Holu Street Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Facility Address: Address: 73-4198 Holu Street Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Email Address: pflagkonabigisland@gmail.com Fax No.: ( ) — Accountant/CPA: Blake Kessner: Treasurer Phone No.: (808 ) 987 — 9295 Firm (if applicable): Mailing Address: Address: 75-6082 Alii Drive#8 Address: City,ST,Zip Kailua-Kona, Hawaii 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: $25,000 Geographical Areas To Be Served: (One or more can be checked) Puna [ I Hamakua [7 North Kona n South Hilo North Kohala [✓I South Kona North Hilo I✓I South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) [✓[ Educational concerns I✓)Youth [ [Victims of Crimes [✓� Culture and the arts Aged ✓ Victims of Health or Social Crises ✓ Needs of the poor I✓[ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 Not Applicable Not Applicable Not Applicable 2.Agency Mission Statement: The mission of PFLAG Kona/Big Island is to support LGBT, minority, and ally individuals in a sometimes adverse society, educate the community, and to advocate equality and an end to discrimination for all. Our programs focus on discrimination as a whole rather than on any single discrimination category or marginalized population. We believe that the only solution to end discrimination is the establishment of true equality in which all populations are recognized as equals. Our programs focus on building community leadership and in establishing leadership skills in young participants, as well as on the establishment of protective factors for youth and families while reducing risk factors. 3. Program Description: The"One Ohana"program of PFLAG Kona/Big Island is a family and youth program providing services both through the community resource center of PFLAG Kona/Big Island, as well as through our after school youth programs. The One Ohana community resource center is a central location for clients and members to receive services directly from PFLAG, as well as through other partner agencies which PFLAG staff assist with referrals and intake paperwork. It is also the home base for regular community educational programs and family strengthening activities. One Ohana also holds daily after school activities in the resource center, providing youth with leadership and personal development instruction and entrepreneurial skills. Programs are intended to build on the"40 Developmental Assets"of the Search Institute,which have been documented as significant protective factors in adolescent development. The One Ohana programs address various assets, including#7: Community Values Youth; Young person perceives that adults in the community value each of them.#9: Service to Others; young person serves the community.#35: Resistance Skills,#36: Peaceful Conflict Resolution, and#40 Positive View of Personal Future.Through peer led group activities utilizing curricula including"Making Proud Choices"(Comprehensive Reproductive Health and Pregnancy Prevention), "Why Try?"(Personal Development and Engagement), "Soar"(Multicultural Leadership and Awareness), as well as others, young people will learn to make positive choices, build positive self image, and learn to respect one another within the community. Additionally the One Ohana program includes family education and family strengthening activities which utilize the Family Strengthening Program curriculum available through the Family Strengthening Organization and developed with The National Institute on Drug Abuse(NIDA), SAMHSA and NREPP Center for Substance Abuse Prevention (CSAP),The Office of Juvenile Justice and Delinquency Prevention (OJJDP), The Administration for Children and Families, and the United States Department of Education. 4. Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 1 Total Agency Budget: $100,000 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii $25,000 Geist Foundation $6,000 Hawaiian Airlines Foundation $5,000 Matson Foundation $5,000 Third Wave Fund $4,000 TOTAL: $45,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: PFLAG Kona/Big Island has in place a comprehensive fund development policy which includes the solicitation of private and government grants, government service contracts, and private fundraising. Moving forward with the One Ohana program, PFLAG plans to continue to solicit grant funding from multiple grant resources, including the County of Hawaii as well as others. PFLAG Kona/Big Island also hopes to secure contract funding with the State of Hawaii Department of Human Services for youth and family programs. Regular organization fundraising will also be utilized to support and grow the One Ohana program, and as the program develops it will include entrepreneurial instruction which will involve youth learning business skills through the development and implementation of a business plan which will result in income.This income will be utilized to supplement available funding to further grow the program. 7. Program Objectives Using County Nonprofit Grant Program Funds: PFLAG Kona/Big Island utilizes the Search Institutes's 40 Developmental Assets as the primary marker for protective factors. These protective factors are measured utilizing the Developmental Asset Profile assessment,which measures the degree to which each factor is observed by the participant in their daily lives. Upon enrollment in the One Ohana program each youth will complete an initial baseline assessment.After six months of participation each youth will complete a follow-up assessment which will measure the change of presence of each asset as well as the change in each of eight asset groupings. It is the objective of PFLAG Kona/Big Island that of the youth who complete the six month follow-up assessment, 85%will show a measurable increase in at least two of the eight categories. Further it is our objective that of that of those youth reaching this goal, 60%will complete twelve months of program services, completing an additional follow-up assessment on which they have maintained the six month improvement and made a measurable improvement in at least an additional two asset groupings. Program objectives are based on comparable programs both within the State of Hawaii as well as in various regions in the United States which have showed a marked increase in student performance and a reduction in youth delinquency in regions where these programs were implemented well.Additionally these programs increase family cohesion and emotional health, resulting in stronger family relations, a reduction in youth run aways, and a community more accepting of those who are"different". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Youth enrolled in One Ohana and Complete initial DAP assessment 80 Youth participates in One Ohana program at least twice weekly for six months 68 Youth completes six month assessment increasing at least 2 asset areas 68 Youth participates in One Ohana program at least twice weekly for 12 months 40 Youth completes 12 month assessment increasing in at least 2 additional asset areas 40 Enrolled youth's family takes part in 4 of 6 family strengthening events in six months 40 Enrolled youth's family takes part in 8 of 12 family strengthening events in 12 months 25 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0.00 14,750.00 8,000.00 Professional Fees 0.00 0.00 0.00 Operations 0.00 19,750.00 14,000.00 Supplies 0.00 8,500.00 2,500.00 Equipment 0.00 0.00 0.00 Other: Vehicle Mileage 0.00 500.00 500.00 Other: Publicity & Outreach 0.00 750.00 0.00 Other: Training 0.00 750.00 0.00 Other: Other: TOTAL 0.00 $45,000 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance I 1 The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. �� 12-16-2016 /� '��CSit7rN � �• ign ture of Author' d Person (specify title) Date (--- EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 . Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding reryuect anti may rectilt in artinnc taken to rernver these funrlc. By signing below, you are acknowledging that you have read and understood these requirements. iJ eC $ , O (A1i 12-16-2016 ig#tatur of Authorized Person (specify title) Date r EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: PFLAG Kona/Big Island Program Name: One Ohana Youth and Family Services 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 80 68 68 40 40 40 25 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 8,000.00 Professional Fees 0.00 Operations 14,000.00 Supplies 2,500.00 Equipment 0.00 Other: Vehicle Mileage 500.00 Other: Publicity & Outreach 0.00 Other: Training 0.00 Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Project Vision Hawaii Health and Vision Services on Hawai'i Island 132 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island Agency Director: Elizabeth "Annie"Valentin Phone No.: (808) 282 — 2265 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: P.O. Box 23212 Address: City,ST,Zip Honolulu, HI 96823 Facility Address: Address: 1110 Nuuanu Avenue Address: City,ST,Zip Honolulu, HI 96817 Email Address: annie@projectvisionhawaii.org Fax No.: (808 ) 591 — 9909 Accountant/CPA: Greg Wong Phone No.: (808 ) 222 — 4848 Firm (if applicable): Hawaii Care Services Mailing Address: Address: 1288 Ala Moana Blvd.Suite 201 Address: City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ✓❑ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑r 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 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $32,500 $10,000 $7,625 2. Agency Mission Statement: Project Vision Hawaii (PVH) is a locally grown nonprofit organization that works in partnership with the people of Hawai'i to promote access to better healthcare. PVH brings to local communities three mobile screening units(soon to be four), which are literal and figurative vehicles for access to preventative health services. In 2016, PVH served a record number of 15,477 individuals across the state, including 8,433 children in public schools. Our success in reaching some of the most at-risk populations comes largely because of two unique components of PVH:(1)we bring health services directly to access-challenged communities via mobile screening units;and(2) services are always 100% free of charge to participants. In addition to providing vision and screening services throughout the state, PVH provides resources to supports rural and low-income areas. In 2016, PVH equipped its mobile health clinics to better respond to isolated, remote areas in case of disaster.Through public and private support, PVH equipped its three RVs with mobile medical tents, portable dialysis equipment,emergency medical supplies and power generators. Focusing on homeless populations, PVH is equipping mobile hygiene units in order to provide privacy, hot showers and to support outreach efforts across the state. 3. Program Description: PVH requests funding from the Hawai'i County to increase access to vision and health services to vulnerable populations living on Hawai'i Island. The activities to be supported through this grant will fall under three broad program headings: I. Better Vision for Keiki, which brings vision screenings,follow-up exams and glasses as needed to children in low-income schools. Our partners on Better Vision for Keiki are VisionQuest 20/20 and Vision to Learn. PVH brings to local schools EyeSpy 20/20, a video game by VisionQuest that detects vision disorders and preventable blindness in school age children. We work with the HIDOE and Vision to Learn to provide free eye exams and free glasses for children who need them. In 2016, PVH worked with 25 public schools to screen 1,241 students on Hawai'i Island. II. WE...a Hui for Health, bringing collaborative events with a variety of health care services and screenings into high-poverty communities in order to increase access to care. PVH is part of an extensive safety net that responds to and prevents diverse medical issues that are faced by poor, homeless and marginalized populations. In 2016, PVH provided on Hawaii Island free health screenings to 2,417 people, including 588 vision screenings, primarily to low-income and homeless people.Additionally, PVH was part of the Tropic Care health screening initiative and provided a variety of preventative and screening services to 2,307 individuals. III. Passport to Healthy Aging, a collaborative effort to address the pillars of fall prevention for seniors:vision problems, medication management, home safety and regular exercise. We had one event serving 22 seniors last year, and are developing relationship to expand service to kupuna on Hawai'i Island next year. 4. Total Budget & Position Count: Total Program Budget: $123,634 Total Program Position Count: 2 Total Agency Budget: $603,568 L Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Anonymous Donor for Showers for the People- secured 200,000 Kaiser Permanente- secured 35,000 GIFT Foundation - secured 90,000 Walmart Foundation - secured 25,000 Please Note: These grants are for statewide provision of service, with a percentage of each grant allocated to Hawaii Island for fiscal year 2018. TOTAL: 350,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: PVH continues to diversify its revenue plan toward sustainability. We pursue private and public grants and contracts, individual donations,corporate sponsorships, and will be launching an annual fundraiser in 2017. We are also working to establish earned income revenue streams. Project Vision Hawai'i has demonstrated its ability to provide screening and preventative services for a fraction of the cost that would be incurred by private and government agencies. We are pursuing relationships and developing fee-for-service income in areas that provide public health benefits. Working with community health clinics and public schools throughout Hawaii, we are pioneering new approaches to health services for vulnerable populations. Project Vision Hawaii is an integral part of the safety net supporting children and adults who lack adequate healthcare. Vision and health problems are acute for large swaths of geographic and socioeconomic groups, representing thousands of people in Hawaii. As long as there are disparities in access to care, PVH will continue to seek private and public funding toward health equity and better quality of life for all. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives related to this request align with the three program headings, as follows: I. Better Vision for Keiki brings vision screenings, follow-up exams and glasses as needed to children in low-income schools. -Objective 1:Deliver free, on-site vision screenings in about 20 low-income schools to 2,000 students on Hawaii Island. -Objective 2: Provide comprehensive exams and glasses as needed to 360 students. II. WE...a Hui for Health events, bringing health care services and screenings into high-poverty communities. -Objective 3: Participate in 25 health screening events enabling better vision and better health in general for 3,000 low-income/homeless individuals. -Objective 4:Participate in Tropic Care for the second year, and provide screenings to 2,000 Hawai'i County residents. III. Passport to Healthy Aging, a collaborative effort to prevent falls for seniors by addressing five factors that cause falls. -Objective 5: Provide vision screening and education to 200 seniors on Hawai'i Island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of school partners, including preschools, elementary, middle and high schools 20 Number of students vision screened on Hawaii Island 2,000 Number of comprehensive exams provided to children (and glasses as needed) 360 Number of individuals receiving vision and health screenings, including Tropic Care 5,000 Number of seniors receiving vision and health services to prevent falls 20o Number of health care events targeting underserved communities 25 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $5,956.96 $52,917 $11,500 Professional Fees 777.07 12,000 0 Operations 57.60 9,500 0 Supplies 257.89 21,717 5,500 Equipment 0 0 0 Other: RV Repairs and Maintenance 1,738.9 15,000 6,000 Other: Publications and Printing 0 2,500 0 Other: Mileage, Parking, Fuel 162.93 4,000 2,000 Other: Inter-island Travel 550.19 3,500 0 Other: IT Supplies 0 2,500 0 TOTAL I $9,501.54 $123,634 I $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ 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: Not applicable ❑✓ If no c icts exist, check here. Signature o Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, 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 (weLunderstand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding rerpiect rind may recult in nrtinnc taken to rernver theca fundc, By signing below, you are acknowledging that you have read and understood these requirements. 04 k;)-- u✓�✓ C17,t1 Sign re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 ANA County of Hawai`i Nonprofit Grant Application F; 017-18 Agency Name: Project Vision Hawaii Program Name: Health and Vision Services on Hawaii Island 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of school partners, including preschools, elementary, middle and high schools 20 Number of students vision screened on Hawaii Island 2,000 Number of comprehensive exams provided to children (and glasses as needed) 360 Number of individuals receiving vision and health screenings, including Tropic Care 5,000 Number of seniors receiving vision and health services to prevent falls 200 Number of health care events targeting underserved communities 25 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $11,500 Professional Fees 0 Operations 0 Supplies 5,500 Equipment 0 Other: RV Repairs and Maintenance 6,000 Other: Publications and Printing 0 Other: Mileage, Parking, Fuel 2,000 Other: Inter-island Travel p Other: IT Supplies 0 TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Salvation Army Family Intervention Services, The Independent Living Skills Program - West Hawai'i 133 r County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii Agency Director: Roxanne Costa, Executive Director Phone No.: (808) 959 - 5855 Contact Person: Annette Honda, Program Manager Phone No.: (808) 323 - 8081 Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Kona Civic Center Address: 82-6130 Mamalahoa Highway City,ST,Zip Captain Cook, Hawaii 96704 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808 ) 959 - 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808) 959 - 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, 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: $35,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona 9 South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged 9 Victims of Health or Social Crises 9 Needs of the poor 9 Physical/Emotional Disabilities 9 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $10,000 $16,250 2.Agency Mission Statement: The Salvation Army's Mission Statement: "To preach the gospel of Jesus Christ and to meet human needs in His name without discrimination." The Salvation Army-Family Intervention Services'Mission Statement: "To PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIVE 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 outreach programs are designed for foster youth and emancipated foster youth ages 12-26 prepare for and manage the transition to productive self-sufficiency in adulthood with a core base of independent living skills. The Goals of the program is to 1)provide a comprehensive life skills based curriculum,2)provide opportunities for foster youth to pursue higher education, vocational training,and/or employment and 3)provide linkages and resources to services in the community including:housing, health insurance and other vital needs,4)provide cultural based services for foster youth to connect with their communities and have a sense of belonging. For the 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,academic counseling and ongoing crisis and intervention services. For the foster youth over the age of 18 who choose to voluntarily remain under care of the State through the Imua Kakou,the program provides supportive services each month to ensure that each foster youth is meeting the criteria to continue to receive a monthly stipend. Our outreach programs is in line with national and local strategies to help mitigate the challenges faced by transitioning aged out foster youth. the proposed budget herein supports our operational cost for the programs. 4.Total Budget&Position Count: Total Program Budget: 126,038 Total Program Position Count: 8 Total Agency Budget: 3,000,000 _ Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii 35,000 Department of Human Services 91,038 TOTAL: 126,038 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services constantly explores new funding avenues in the private, Stare and Federal sectors to support and enhance program services. We annually seek grants and/or partnerships to build program services. In harmony with our mission statement and the services we provide,we still rely heavily on funding at all levels of government including the County of Hawaii. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 135 foster youth, ages 12-26 participating in the program, 100%will have at least one supportive adult in their lives who will always be there to support them. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - 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 (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide information&referral 30 Participate in individual sessions 30 Participate in group sessions 10 Make progress in independent living skills 30 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 25,692 90,510 25,205 Professional Fees 1,559 1,080 240 Operations 9,115 32,648 8,598 Supplies 545 1,800 957 Equipment Other: Other: Other: Other: Other: TOTAL 36,911 126,038 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I Member or members of the Council Staff appointed by a member of the Council I I The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: The Salvation Army had Code of Conduct and Conflict of interest Policies which out lines standard of professional behavior for all of its Officers,Employees and Agents. See Conflict of Interest and Code of Conduct polices included in attachments. 1✓1 If no conflicts exist, check here. JAN 2 4 2017 Signatu f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - 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, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and mny rPcult in nrtinnc tnkPn to rprnvpr thecP funds. By signing below, you are acknowledging that you have read and understood these requirements. — ° 2''''' JAN 2 4 2017 Signature ohorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army - Family Intervention Services Program Name: Independent Living Skills Program - West Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of youth provided information&referral 3° Number of youth provided individual sessions 30 Number of youth provided individual sessions 10 Number of youth to make progress in independent living skills 3° TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 25,205 Professional Fees 240 Operations 8,598 Supplies 957 Equipment Other: Other: Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Salvation Army Family Intervention Services, The Life Skills Program - Kea'au 134 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au Agency Director: Roxanne Costa Phone No.: (808) 959 — 5855 Contact Person: Same as Above Phone No.: ( ) – Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808 ) 959 — 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 — 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona n South Hilo ( ( North Kohala ❑ South Kona n North Hilo South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) Educational concerns III Youth Victims of Crimes ✓f Culture and the arts (— Aged n Victims of Health or Social Crises Needs of the poor I I Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $20,000 $10,000 $13,125 2. Agency Mission Statement: "To provide youth with skills for a healthy life, and instill purpose, hope, and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed, youth must feel a sense of belonging to their community, their culture,their peers, and within their families. 3. Program Description: The Salvation Army-Family Intervention Services-Life Skills Program provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth develoment for youth ages 7-21 residing in the Keaau communities. We utilize a prevention approach to decrease the use and abuse of alcohol, tobacco and other illicit drugs, involvement in gangs and violence, delinquent behaviors, early sexual behaviors, and to improve academic performance and school attendance. 4. Total Budget & Position Count: Total Program Budget: 110,000 Total Program Position Count: 8 Total Agency Budget: 3,000,000 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii $35,000 State of Hawaii - Office of Youth Services $75,000 TOTAL: $110,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continuously explores funding avenues in the private, State, and Federal sectors to continue and enhance program services. We annually seek grants and/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 for participation in the Life Skills Program, 85%will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum. Of that 40 youth, 50%will engage in Positive Youth Development activities including cultural awareness and community service learning projects. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of Botvin Life Skills Training 30 Cultural Awareness 20 Participation in Positive Alternative Activities 20 Follow up and Monitoring 40 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 30,994 81,970 27,241 Professional Fees 1,360 1,080 240 Operations 8,633 24,550 6,894 Supplies 3,933 2,400 625 Equipment Other. Other: Other: Other: Other: TOTAL 44,920 110,000 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): [' Member or members of the Council Staff appointed by a member of the Council I I The Mayor The Managing Director I I The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: VI If no conflicts exist, check here. $ Cf2it JAN 2 4 2017 Signat - •' Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requPct and mny recult in nrtinnc token to rPrnver thece funds, By signing below, you are acknowledging that you have read and understood these requirements. % 1(c),() ,.. t., JAN 2 4 2017 Signat - ,if Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Life Skills Program - Kea'au 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of Botvin Life Skills Training 30 Cultural Awareness 20 Participation in Positive Alternative Activities 20 Follow up and Monitoring 40 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 27,241 Professional Fees 240 Operations 6,894 Supplies 625 Equipment Other: Other: Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Salvation Army Family Intervention Services, The Project TLP Hilo 135 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo Agency Director: Roxanne Costa Phone No.: (sos) 959 — 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808 ) 959 — 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 — 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona 2 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2. Agency Mission Statement: "To provide youth with skills for a healthy life, and instill purpose, hope, and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed, youth must feel a sense of belonging to their community, their culture, their peers, and within their families. 3. Program Description: Research has shown that vulnerable young adults, youth transitioning from foster care, and those that are living in an unstable situation, comprise of one of the most fast growing groups of homeless individuals. Family Intervention Services is determined to help these young adults to overcome these various barriers. We believe with interventions to stabilize, house, educate, employ and empower these young adults we can help them to overcome these barriers and become self-sufficient. With the support and collaboration of our local programs, Agencies, Realtors, Rental Agents, Private landlords, and those of our community we will be able to help them get a fresh start in their lives. Project TLP will be the responsible agent for these young adults by subsidizing the rental-fee for those who are eligible for a six month period. Based on extenuating circumstances, rental periods may be extended as needed. With extra support they will learn simple strategies such as: balancing a check book, writing a resume, finding employment, time management, signing a rental agreement and setting and keeping realistic goals on a daily basis that will help with their transition to independence. Should issues arise participants will be referred to the appropriate resources/services and given opportunities to address issues and concerns as needed. Project TLP's main objective is to help these young adults achieve their short and long-term goals for sustainable housing. 4. Total Budget & Position Count: Total Program Budget: 110,000 Total Program Position Count: 8 Total Agency Budget: 3,000,000 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii $35,000 Victoria and Bradley Geist Foundation $75,000 TOTAL: $110,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continuously explores funding avenues in the private, State, and Federal sectors to continue and enhance program services. We annually seek grants and/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: 1) Be able to connect our Young Adults with the proper resources and services that they may need 2) Provide links to resources in the areas of Continuing Education and/or Employment 3) Provide our Young Adults with Employment Attire, food, hygiene products, and possibly a starter kit(ie. kitchen ware, towels, blankets, etc.)as needed 4)To promote awareness in the housing community of the struggles that former foster youth must go through in obtaining appropriate housing. 5) Establish collaborative relationships with realty companies and private landlords in the community to provide appropriate housing for participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of Financial Literacy Curriculum 4 young adults Participation in Weekly Individual Meetings with Case Worker 4 young adults Participate in Follow Up and Monitoring 4 young adults Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 47,477 23,741 Professional Fees 0 0 Operations 55,723 6,559 Supplies 6,800 4,700 Equipment Other: Other: Other: Other: Other: TOTAL 110,000 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I I Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director I J The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in 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 Q•sA, JAN B420 17 Signaill 4 Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPrquPst and may result in nrtinns taken to rernvPr these funds. By signing below, you are acknowledging that you have read and understood these requirements. I 624.4...4...„ JAN 242017 Signatur- . Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of Financial Literacy Curriculum 4 young adults Participation in Weekly Individual Meetings with Case Worker 4 young adults Participate in Follow Up and Monitoring 4 young adults TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 23,741 Professional Fees 0 Operations 6,559 Supplies 4,700 Equipment Other: Other: Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Salvation Army Family Intervention Services, The Substance Abuse Prevention Program - Pahoa 136 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Substance Abuse Prevention Program -Pahoa Agency Director: Roxanne Costa Phone No.: (808) 959 — 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,ST,Zip Hilo, HI, 96720 Email Address: roxanne.e.costa©usw.salvationarmy.org Fax No.: (808 ) 959 — 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 — 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) !✓I Puna Hamakua n North Kona n South Hilo ri North Kohala j I South Kona North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns n Youth n Victims of Crimes ✓ Culture and the arts I I Aged Victims of Health or Social Crises I I Needs of the poor n Physical/Emotional Disabilities j Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Substance Abuse Prevention Program -Pahoa 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $15,000 $10,000 $13,250 2. Agency Mission Statement: "To provide youth with skills for a healthy live, and instill purpose, hope, and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed, youth must feel a sense of belonging to their community, their culture, their peers, and within their families. 3. Program Description: TSA-FIS Substance Abuse Prevention Program-Pahoa provides a safe and nurturing environment along with access to opportunities, experiences, and services to support the prevention of alcohol,tobacco and other drug use among youth ages 7-17 residing in the Pahoa communities. We utilize a prevention approach to decrease the use and abuse of alcohol,tobacco and other illicit drugs, involvement in gangs and violence, delinquent behaviors, early sexual behaviors,family conflict and to improve academic performance and reduce truancy. 4. Total Budget& Position Count: Total Program Budget: 120,000 Total Program Position Count: 8 Total Agency Budget: 3,000,000 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Substance Abuse Prevention Program -Pahoa 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate County of Hawaii $35,000 Department of Health (ADAD) $85,000 TOTAL: $120,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continuously explores funding avenues in the private, State, and Federal sectors to continue and enhance program services. We annually seek grants and/or partnerships to build program services. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 40 youth targeted for participation in the Prevention Program, 85%will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum. Of that 40 youth, 50%will engage in Positive Youth Development activities including cultural awareness and community service learning projects. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services 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 Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of Botvin Lifeskills Training 40 Participation of in Positive Alternative Activities 40 Cultural Awareness and Identity 20 Participation in L.E.A.D. activities 40 Follow up and Monitoring 40 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 33,338 80,043 24,506 Professional Fees 1,145 1,320 300 Operations 10,769 35,037 8,933 Supplies 3,930 3,600 1,261 Equipment Other: Other: Other: Other: Other: TOTAL 49,182 120,000 35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Substance Abuse Prevention Program -Pahoa 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ( Member or members of the Council ( Staff appointed by a member of the Council ( The Mayor ( ( The Managing Director The Director of Finance ( The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: l"I If no conflicts exist, check here. \ ‘ a./..04,.. JAN 2 4 2017 Signatu4Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Substance Abuse Prevention Program -Pahoa ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Substance Abuse Prevention Program -Pahoa ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 mny recult in nrtinnc token to recover these funds, By signing below, you are acknowledging that you have read and understood these requirements. a7A•4 ^% JAN 242017 Signatu e of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: The Salvation Army Family Intervention Services Program Name: Substance Abuse Prevention Program -Pahoa 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of Botvin Lifeskills Training 40 Participation of in Positive Alternative Activities 40 Cultural Awareness and Identity 20 Participation in L.E.A.D. activities 40 Follow up and Monitoring 40 TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 24,506 Professional Fees 300 Operations 8,933 Supplies 1,261 Equipment Other: Other: Other: Other: Other: TOTAL 35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Self Discovery Through Art Recovery, Resiliance, ReCreation 137 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation Agency Director: Nidhi Chabora Phone No.: (808) 333 — 2642 Contact Person: Paula Vickery Phone No.: (808 ) 640 — 9016 Mailing Address: Address: 122 Haili Street, Suite#7 Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: 122 Haili Street, Suite#7 Address: City,ST,Zip Hilo, HI 96720 Email Address: Fax No.: (N/A ) — Accountant/CPA: Michele Slone, EA Phone No.: (808 ) 935 — 6545 Firm (if applicable): Hilo Income Tax Service Mailing Address: Address: 1028 Kinoole 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: $30,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua n North Kona n South Hilo n North Kohala n South Kona n North Hilo I I South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth n Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑ Needs of the poor ❑✓ Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017 -2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $5,375 2.-Agency Mission Statement: Self Discovery Through Art(SDTA)www.selfdiscoverythroughart.org is an art as therapy program to nurture and strengthen the mental health of all people using"Art as Medicine" (Shaun McNiff 1992). Our mission is to educate, enrich, and enlighten communities to the mental health benefits of understanding and correcting unhelpful thinking patterns using Cognitive Behavioral Therapy(CBT)concepts and the creative process. 3. Program Description: Self Discovery Through Art was established as a non-profit in June,2015 to build community resilience capacity in the Hilo and Puna districts of Hawaii County. SDTA has five Board members consisting of an internationally known artist;an art educator;a published author and art critic and two Advanced Practice Registered Nurses with Prescriptive Authority(APRN-Rx). We propose to engage community members to make art work depicting dimensions of Recovery, Resilience and ReCreation.We believe creativity is a resilience factor that can be cultivated by anyone in creating a meaningful life after trauma. SDTA references the Center for Disease Control's Adverse Childhood Experiences Study(ACE 2000) and the Hawaii Department of Health Foundations for Healthy Generations Initiative. http://hawaii.gov/doh.stratgicplan. In 2013 we exhibited educational art at the Wailoa Art and Cultural Center filling the entire gallery. Other success include: ongoing clinical practicum site for psychology students of the University of Hawaii, Hilo, and entries in juried art exhibitions. Since 2016,we have collaborated in partnership with The Boys&Girls Club, Hospice of Hilo, Kamana Senior Center, Circle of Life, and soon The Veterans Center. In June 2016, SDTA was invited and gave a presentation at the annual National Association of Mental Illness(NAMI)on Oahu.This coming March,2017 SDTA has been invited to present at the Hawaii Association of Professional Nurses. SDTA has acquired an office/studio/storage place where training sessions have already been held. During May, 2017,which is also Mental Health Awareness month,we have been invited back to the Wailoa Art and Cultural Center and will be displaying an exhibit on Recovery, Resilience, and ReCreation. 4.Total Budget& Position Count: Total Program Budget: 30,000 Total Program Position Count: 0 Total Agency Budget: 30,000 Total Agency Position Count: 5 volunteers EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii County Discretionary Funds (pending) 6000 Website Donations 8300 Hawaii County non-profit grant 30,000 Training for Trainers registration fee (pending) 2000 Sale of Manual as part of the training (Pending) 500 Conference with CE's for licensed professionals (pending) 1000 25% of all art sales remains with the program (pending) 500 TOTAL: 48300 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: All staff are volunteers and do not receive financial reimbursement for this program. Our plan is to continue to solicit additional funding after the grant period ends and continue to advertise our program to the community. We have made colorful, informational Recovery, Resilience and ReCreation brochures ready for advertising our program. A PayPal funding mechanism has been attached to our website. SDTA has developed a manualized"how to"session book for clinicians to use with their clients. Publishing a manual will help to generate future income back into our non-profit organization to perpetuate a Center for Resilience and continue the work for generations to come. SDTA plans on being a center for Resilience education and will train trainers to take this program with the manual to their perspective communities. SDTA will have Open House activities where the public can come and view and purchase art work. The proceeds will go to both the artists and SDTA. SDTA can offer art as therapy classes and charge a nominal fee, i.e. a co-pay when a person goes to see a therapist or their primary practitioner. The two APRNs can bill participants' health insurance. SDTA will schedule presentations to service clubs of East Hawaii. SDTA has partnered with The Boys and Girls Club, staff of Hospice, Kamana Senior Center,and Circle of Life and will continue to do so. SDTA has presented at NAMI conference on Oahu, at State of Hawaii nursing conferences and has future plans to become a credentialed site of education so that licensed professionals will be able to take a course and obtain continuing education (CE) credits. SDTA will continue to apply for appropriate grants 7. Program Objectives Using County Nonprofit Grant Program Funds: East Hawaii (defined as the districts of North and South Hilo and Puna)faces on-going and intermittent individual and community disasters that are straining the community's ability to bounce back. Besides universally recognized losses, Hawaii Island experiences outbreaks of diseases such as Leptospirosis, Rat Lung, and Dengue Fever. There are also lava flows,earthquakes, hurricanes and floods that sporadically ravage our communities. Many people react to such circumstances with an overwhelming sense of uncertainty.A current example is the fire in Pahoa which caused a tragic community loss of two long standing historic building/business sites. States and local agencies are hard pressed to provide emergency crisis/mental health rescue services and/or long term support, relying on the"kindness of strangers"to step up and often become first responders. SDTA offers a unique and initial response to raise community awareness and to build individual and community resilience capacity. SDTA believes that a community where art expression for recovery and healing from trauma is supported and encouraged,will be a resilient and thriving community. SDTA proposes to become a community resilience resource by building a sense of community that is characterized by high concern for community issues, respect for and service to others, sense of connection and needs fulfillment. SDTA aims to develop and establish partnerships to equip participants with knowledge, attitude and skills that can be used to recruit their own resilience. SDTA is working towards obtaining credentialing status to be able to offer licensed professionals continuing education (CE)credits. County funding is needed to publish the manual,train the trainers, put on the art exhibit at the Wailoa Art and Cultural Center during May to promote May is Mental Health Awareness Month in Hilo. Our long term objective is to create a community Center for Resilience Education. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 50 people participated in 10 art as therapy workshops on resiliency increase skills to cope with stress Art Exhibit: Recovery, Resilience, ReCreation at Wailoa Art&Cultural Center May 2017 community education on mental wellness SDTA evaluation form improvements from baseline status 3 volunteers facilitate each workshop. 1 University practicum student per semester attract community interest in taking courses Crisis Response and Resiliency Building in Pahoa after the fire,Jan 2017 (pending) deescalation&support for distressed commun Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages In Kind $ In Kind $ In Kind $ Professional Fees 400 Operations 8042 12600 9500 Supplies 637 1200 0 Equipment 3000 Other: Publish Manual, 2500 2500 Other: Independent contract with psychology student 6000 5000 Other: Paid time to offer CE offering to licensed MH professionals 5000 0 Other: Subsidized offerings to vulnerable communities for class sessions 10000 10000 Other: Art Exhibit on Mental Health Awareness at Wailoa Art& Cultural Cei 2000 3000 TOTAL 9079 42300 30000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 7 Member or members of the Council n Staff appointed by a member of the Council The Mayor n The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. January 24, 2017 Signature of Authorized Perso (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we)understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerluect nnrl mny recult in nrtinnc tnken to rarnvar theca fundc, By signing below, you are acknowledging that you have read and understood these requirements. Q0.,ut.J20, ;(. l< January 24 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SELF DISCOVERY THROUGH ART Program Name: Recovery, Resilience, ReCreation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result increase skills to cope with stress community education on mental wellness improvements from baseline sti attract community interest in taking courses deescalation 8 support for distressed commun TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages In Kind $ Professional Fees Operations 9500 Supplies 0 Equipment Other: Publish Manual, 2500 Other: Independent contract with psychology student 5000 Other: Paid time to offer CE offering to licensed MH professionals 0 Other: Subsidized offerings to vulnerable communities for class sessions 10000 Other: Art Exhibit on Mental Health Awareness at Wailoa Art& Cultural Center 3000 TOTAL 30000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Society for Kona's Education & Art Art Camps for Children &Teens 138 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children &Teens Agency Director: Susan B. Rice Phone No.: (808) 328 — 9561 Contact Person: Susan B.Rice Phone No.: (sos) 896 — 5858 Mailing Address: Address: PO Box 256 Address: City,ST,Zip Honaunau,Hawaii 96726 Facility Address: Address: 84-5191 Mamaiahoa Highway Address: City,ST,Zip Honaunau,Hawaii 96726 Email Address: susanrice@hawaii.rr.com Fax No.: (sos) 32s —9392 Accountant/CPA: Eric Curtis Phone No.: (808) 323 — 2939 Firm (if applicable): Mailing Address: Address: PO Box 230 Address: City,ST,Zip Kealakekua,Hawaii 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,750 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona ❑North Hilo 0 South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓0 Educational concerns 0 Youth 0 Victims of Crimes 0 Culture and the arts 0 Aged 0 Victims of Health or Social Crises Needs of the poor Q Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children &Teens 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 -- $4,000 $3,750 2.Agency Mission Statement: With a focus on South Kona,the Society for Kona's Education&Art (SKEA)servers the people of Hawaii Island by providing arts and educational opportunitie 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.Magic Camp will be a 4-day(20 hrs.)program focused on the techniques and performance of magic,for ages 10-18,an underserved group in our rural community.It is currently scheduled for the fall break in October,2017,but may be moved to the spring 2018,to coincide with the annual Magic Spectacular.Taught by professional magicians,the students will perform at the end of camp for the communty some of the things that they learned: Legerdemain-the skillful use of one's hands when performing tricks Prestidigitation-a show of ski or deceitful cleverness Prognostication-to foreshadow,portend Stagecraft-the art of performance,holding and keeping the attention of the audience Magic tricks-specific tricks using cards,ropes,scarves,boxes,hats,etc. The secret of making and using special magic props. Spring&Summer Art Camps(March 2018,and 2 weeks(in June,2018)provide a fun learning experience in the arts for children ages 6-11.Local teaching artists offer a activities such as painting&drawing,collage&mixed media projects,pottery, music,dance,theatre arts,&yard games.high school students are hired and trained to act as teaching assistants;the on-site supervisor is a DOE teacher;teaching artists are experienced as well.The quality of the instruction is high and the students are able to produce an excellent body of work that is on display at the end-of-camp performance. We are also planning a new program for the adolescent age group-a 3 day art camp that will focus on longer-term projects in the visual arts,and incorporating teaching basic concepts such as composft on,line,perspective,and color theory. 4.Total Budget&Position Count Total Program Budget: ,$42,225 Total Program Position Count: 12 part-time Total Agency Budget: $96,500 Total Agency Position Count: 18 part-time EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children &Teens 5.Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii State Foundation on Culture and the Arts 4,000,. .... Kukio Community Fund 2,000 Bill Healy Foundation(2018 Kona Brewers'Festival) 3,000 Rotary Club of Kona Mauka 1,000 Tuition Fees+scholarship donations 10,500 Hawaii Hotel Assoc.Charity Walk 1,000 Atherton Foundation 2,000 TOTAL: $23,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We wit continue to write aro lc to local foundations far support of the Art Camps program We will offer as many days of art camp that we have funding for.The funding sources listed above are sources that we have received in the past and are considered reliable,although he amounts vary from year to year.(an Atherton proposal is pending).The tuition for the camps is very reasonable,but it is still a hardship for many families in our community We solicit scholarship donations so that we are able to offer generous discounts. Additionally,our organization does a lot of fundraising each yar to support our programs,and we will continue to do so. 7. Program Objectives Using County Nonprofit Grant Program Funds: see attached page EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children &Teens 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc Describe,be specific) see attached page Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Awl' Total Budget Grant Req Salary and Wages 0 Professional Fees $19,000 $22,375 4,000 Operations 3,750 4,050 1,000 Supplies 2,225 2,800 2,000 Equipment 0 0 Other, marketing 2,000 2,700 2,000 Other: registrations,coordination of project,bookkeeping 3,000 3,300 1,750 Other• teen counselors(ages 16-19,local residents) 6400 6,750 5,000 Other- Other• (all numbers in 1st column are budget projections for current FY) _ TOTAL , $36,375 $41,975 $15,750 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 Society for Kona's Education&Art Art Camps for Children and Teens 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. 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 Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children &Teens sa. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose 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. January 28, 2017 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children & Teens 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 June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children &Teens 11.Certification of Understanding (tee 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to.and accepted by.the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2018 must be returned to the County of Hawai.'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rp/iupct and mny rpcudt in nrtinnc tnkpn to rprnupr thpcp fundc By signing below,you are acknowledging that you have read and understood these requirements. i i(av/ 1 Ce EXeCthNite:DUreacxpy January 28, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPUCATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children & Teens 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 4,000 Operations 1,000 Supplies 2,000 Equipment Other: marketing 2,000 Other: registrations,coordination of project,bookkeeping 1,750 Other: teen counselors(ages 16-19,local residents) 5,000 Other: Other: (all numbers in 1st column are budget projections for current FY) TOTAL $15,750 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Society for Kona's Education & Art South Kona Workshops & Events 139 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events Agency Director: Susan B. Rice Phone No.: (808) 328 - 9561 Contact Person: Susan B. Rice Phone No.: (808) 896 - 5858 Mailing Address: Address: PO Box 256 Address: City,ST,Zip Honaunau,Hawaii 96726 Facility Address: Address: 84-5191 Mamalahoa Highway Address: City,ST,Zip HOnaunau,Hawai 196726 Email Address: susanrice@hawaii.rr.com Fax No.: (808) 328 - 9392 Accountant/CPA: ERIC CURTIS Phone No.: (808) 323 - 2939 Firm (if applicable): Mailing Address: Address: PO Box 230 Address: City,ST,Zip Honaunau,Hawaii 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) El Puna ❑Hamakua ❑North Kona South Hilo ❑North Kohala Q South Kona El North Hilo ❑South Kohala ❑Ka`° Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns Q Youth 0 Victims of Crimes Culture and the arts Q Aged 0 Victims of Health or Social Crises Needs of the poor 0 Physical/Emotional Disabilities ❑Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 _._ ----. $2,250 2.Agency Mission Statement: With a focus on south Kona,the Society for Kona's Education&Art(SKEA)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: see attached sheet 4.Total Budget&Position Count 4(z Total Program Budget: - l l 5o, Total Program Position Count: 12 part-time Total Agency Budget: $96,500 Total Agency Position Count: 18 part-time EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 PROGRAM DESCRIPTION: South Kona Workshops&Events Through funding from the Atherton Foundation (2015-16 FY),and the County of Hawai'i (2016-17 FY), SKEA has offered a series of'Growing,Living,Creating' workshops.The response has been overwhelmingly positive, every workshop has been well attended (several to capacity,up to 30 people), and the community is asking for more.Activities offered so far have been gourd design, lei making, wreathmaking,tropical floral design,mushroom cultivation,and bookbinding.Coming up next month are Contour Leaf Drawing and Beginning Pastels,with more still to be scheduled. Participants have been mostly seniors (50+),but also some younger adults and children and adolescents,accompanied by a parent or grandparent.The workshop fees are VERY reasonable,and we feel this is a crucial element of success in this rural community. People are able to leave 3 hours later with a beautiful,handmade item, or new knowledge of a subject or art medium that is of interest. We propose to offer the most popular workshops again,and offer some new ones: Tropical flower arranging-August 2017 Gourd design- October 2017 Mushroom Cultivation- November,2017 Wreathmaking- December 2017 Coconut baskets-January 2018 Papermaking- February 2018 The Art of Storytelling- February 2018 Edible Landscaping- March 2018 Lei Making- May, 2018 We hire talented practioners in each field who also have good teaching skills. Marketing each workshop will be done through our newsletter,posters,press releases to newspapers and radio, email marketing, and social media. SKEA offers the community several free or very low-cost events throughout the year, that are attended by residents and also visitors. Music on the Lawn- September, 2017; Local musicians will play a variety of songs in different genres, with the last hour being kanikapila.$7 donation requested. Annual Membership Meeting-January,2018.An afternoon of live local music,pupus,and a showing of local art.The SKEA Board is introduced and we update guests on SKEA's programs at a short meeting. A kanikapila ends the afternoon. Free and open to the public. Quilt Show-Saturday&Sunday, February 10 &11, 2018. In association with the Aloha Quilters,a display of local quilts in a variety of styles. South Kona Studio Tour- in association with the South Kona Artists Cooperative, SKEA will host 3 or 4 South Kona artists at our site. Mauka Talent Show- Saturday, March 3, 2018. A family entertainment variety show of local performers of all ages, preschool to seniors.$7 donation. Artists, performers, and musicians donate their time for these events,and volunteers coordinate the activities.We are requesting funding for marketing expenses, (paid advertising, psoters,flyers, roadside signs,web calendars, email marketing, etc.) Outcomes: 1.we expect that a total of 2,000+ residents and visitors will attend the workshops and events. 2. Residents and visitors from around the island will visit South Kona and enjoy its scenic beauty, restaurants,and other cultural sites. 3. Local artists will be supported and recognized. 4. The SKEA organization will make new friends and supporters in the community and connect with old ones. County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events 5.Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Hawaii State Foundation on Culture and the Arts $3,500 Tuition and entry fees 2,500 TOTAL: $6,000 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: We will continue to work with community volunteers and partner with other organizations in bringing workshops and events to South Kona.We may also write proposals to local foundations that are interested in the arts.SKEA volunteers will continue with fundraising activities to help pay for site expenses and other program expenses. 7. Program Objectives Using County Nonprofit Grant Program Funds: Workshop objectives: *to give the opportunity for creative expression to people in our community,especially seniors. *to encourage the use of natural materials in making beautiful things. *to provide new knowledge in areas of agriculture and art. *to engage in social interaction_ *to educate participants in the names of plants,the history of their use,and the techniques of how to use them. *to educate particpants on environmental stewardship and responsibilities(e.g.the ban of transport of ohia in light of the rapid ohia virus that is affecting our forests). Event objectives: *to create and implement a comprehensive marketing plan for each event. *to showcase local art,artists,and performers and develop the community of South Kona as a destination for cultural events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific) attendance records-workshops 200 attendance records-events 2,000 #of events held- 5 #of workshops held 9 surveys from partcipants 50 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 1647 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 6,000 6,000 2,000 Professional Fees 500 500 500 Operations 500 500 500 Supplies 750 750 500 Equipment in kind in kind -- Other: marketing expenses 3,750 3,750 2,000 Other: coordination of events in-kind in-kind -- Other: Other• Other: TOTAL , 11,500 11,500 5,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events 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: Susan B. Rice POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council • The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist,check here. q\Aja-it- Q, -Xe_G U 61,1e-. January 28, 2017 Signature of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events 11.Certification of Understanding (Mage 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, 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.gov,complete the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I(we)understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of 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 30,2018 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your aaency's fl tt/lrp funding rpgllect and may rpcult in nrtinnc tnkan to rprauPr thpce funds, By signing below,you are acknowledging that you have read and understood these requirements. %/1/0„.(A_13 eLe_sz_2 i2Writ) JA-e..1,�. January 28, 2017 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops & Events 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result �+k-vtC10.4Ac-p- Ir`e.cs6v7-L — to x.Tr to% Ir, s 200 It u — e+t/‘e-vl'- zoo, of f�yeAks 4444, - 5 tt toc)CPALSiebe tt _ 5orvems Pian.,. e--100° 5, TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 2,000 Professional Fees 500 Operations 500 Supplies 500 Equipment --- Other: marketing expenses 2,000 Other: coordination of events --- Other: Other: Other: TOTAL 5,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Special Olympics Hawaii Special Olympics East Hawai'i 140 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: Special 01 m•ics East Hawaii Agency Director: Nancy Botello Phone No.: (808) 695 — 3522 Contact Person: JaNeal Stevens Phone No.: (360) 358 — 3783 Mailing Address: Address: PO Box 7265 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: N/A Address: City,ST,Zip Email Address: EastHawaiiAD@sohawaii.org Fax No.: (808 ) 943 — 8814 Accountant/CPA: Akamine,Oyadomari,Kosaki Phone No.: (808) 941 — 0500 Firm (if applicable): Akamine,Oyadomari,Kosaki Mailing Address: Address: 1440 Kapiolani Street#900 Address: City,ST,Zip Honolulu,HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Q Hamakua ❑ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑South Kona ✓❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged n Victims of Health or Social Crises ❑ Needs of the poor ❑✓ Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: S•ecial OI m•ics East Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $25,000 $20,500 $0 2.Agency Mission Statement: The mission of Special Olympics is to provide year-round sports training and athletic competition in a variety of Olympic-type sports for children and adults with intellectual disabilities,giving them continuing opportunities to develop physical fitness, demonstrate courage,experience joy and participate in sharing of gifts,skills and friendship with their families,other Special Olympic athletes and the community. 3. Program Description: see attached 4.Total Budget& Position Count: Total Program Budget: $134,348 Total Program Position Count: 1 Total Agency Budget: $2,141,162 Total Agency Position Count: 18 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: S•ecial 01 m•ics East Hawaii 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Fundraisers $69,148 Individual & Business Donations $15,500 Hawaii Island Visitor Industry Charity Walk $5,000 Walmart grant $1500 County of Hawaii $30,000 SOHI Airfare fund $3200 Iron Man Grant&Ross M Foundation Grant $10,000 TOTAL: $134,348 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: see Attached 7. Program Objectives Using County Nonprofit Grant Program Funds: see attached EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: S.ecial Olym•ics East 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 of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Applicant Projected Results #of athletes 215 #of special parnters and families 170 #of volunteers serving our program 720 #of coaching staff 47 #of delegations 7 #of competitions 10 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $6,688 $13,598 Professional Fees $0 $0 Operations $9000 $9000 $3600 Supplies $2075 $8479 Equipment $3000 $5166 Other: Airfare for Athletes competing at State level $67,820 $74,120 $43,400 Other: Airfare for Unified Champion Schools $11,120 $10,000 $10,000 Other: Coaches Clinic in Oahu _ $2986 $3000 $3000 Other: Area competitions $11,844 $10,985 Other: TOTAL $114,533 $134,348 $60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: S.ecial 01 m•ics East Hawaii 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor O The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: E✓j If no conflicts exist, check here. /1116. - tAr6fc-1 fte' r I - 1-q Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: Special Olym ics East Hawaii ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: Special Olympics East Hawaii 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's fiihire funding rPgluPct rind mny r ciiIt in nrtinnc tnkPn to rPr'nvpr thPCP flrnrIc. By signing below,you are acknowledging that you have read and understood these requirements. rp Af - ' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Special Olympics Hawaii Program Name: S ecial OI m ics East Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of athletes 21s #of special parnters and families no #of volunteers serving our program 720 #of coaches 47 #of delegations 7 #of competetions 10 TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies $3600 Equipment Other: Airfare for Athletes competing at State level $43,400 Other: Airfare for Unified Champion Schools $10,000 Other: Coaches Clinic in Oahu $3000 Other: Area competitions Other: TOTAL $60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii—East Hawaii Area 3. Program Description Began in 1970, Special Olympics East Hawaii, is a volunteer driven non-profit organization serving the East side of the Island of Hawaii, covering the areas from Honokaa to Volcano. Through the end of 2016, we have 193 registered athletes, who are supported by 150 volunteer special partners, 48 volunteer coaches and over 708 volunteers. Special Olympics East Hawaii offers Olympic-type sports training in Track and Field, Softball (Unified Softball, Coach Pitch Softball & T Ball softball), golf, soccer, bocce, swimming and basketball. Through our sports training programs, we provide each athlete with hands-on educational and life skills training experiences. Social skills, safety skills,health practices, language skills, transportation skills, communication skills, survival skills, and basic life skills are addressed and put into practical experiences through training, competition and travel. Unfortunately, appropriate physical education programs in the public schools and social programs that realistically address the special needs of this population are virtually non-existent. Special Olympics fulfills this need and provides the necessary skills for people to continue good health throughout their lives. The ultimate goal in this learning process is to have our athletes healthier, more physically fit and to become contributing members of our community. 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. They 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 708 community volunteers interact with individuals with special needs throughout the years, many of them being the youth of Hilo High, Waiakea High, Pahoa Intermediate and Keaau Middle schools. 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$134,348. Those funds will pay for all aspects of the Special Olympics program, which includes, equipment, uniforms, transportation costs, training of the coaching staff, family activities, our Unified Champion Schools, and training and professional development for our volunteers, unified partners and coaching staff. One of our programs is the After School All Star program. This program is targeting zone schools who are not meeting the Every Child Succeed Acts mandates. In our area, Keaau Intermediate and Pahoa Intermediate are the 2 schools in our After School All Star(ASAS) program. We provide the physical fitness aspect of the ASAS program. The ASAS program participates in unified softball, unified bocce and unified basketball. The program places equal number of non-disabled students on the same team as disabled students where they train and compete together. The transportation cost to get these teams to our State competitions during the school year is $14,000, we are requesting the County's assistance with this cost. Special Olympics Hawaii—East Hawaii has developed a very strong Unified Champion Schools presence here in Hilo which involves both Waiakea High and Hilo High Schools. Unified Champion Schools is a tremendous program that brings together students with and without an intellectual disability in inclusive environments not only on the field of play for Special Olympics but in their own school community. This program has increased the social and mental well being of not only the students with special needs but the regular education students that now interact on a daily basis with them. We are requesting $10,000 to help fund transportation costs to get these teams to area and state competitions. An additional cost for our program besides airfare is the cost to store our equipment for training and competitions. We would like assistance of$3,600 to help us cover those costs. Professional development and leadership training for all coaches remain a top priority in our program. Airfare of$3000 will be needed to send 10 coaches to the certification clinic in Oahu in this upcoming year. 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 training's and development opportunities. As always, Special Olympics East Hawaii's largest expense for 2017-2018 will be transportation. It is an essential part of our program that Special Olympics athletes are provided an opportunity to interact and compete against people of 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 that are held on Oahu 3 times per year provide many activities that our athletes never have a chance to experience. Some of the activities that our athletes look forward to include dances, Opening and Closing Ceremonies, entertainment and games, and exposure to a Healthy Athlete Program. The Healthy Athlete Program provides free dental, vision, hearing, nutrition and podiatry screening for our athletes. These services, which are often not available to individuals with disabilities due to 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.As our Area continues to grow, we strive to allow as many athletes as possible the experience of competing at the State level. We are asking for $29,400 from the County of Hawaii to help make this happen. Special Olympics Hawaii-East Hawaii Area is requesting $60,000 from the County of Hawaii to help fund our Special Olympics East Hawaii program activities and events for the FY 2017-2018. 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 o four 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 $10,000 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 filed and in life are that much more important and requires us to be steadfast an focused on our plans to increase revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds 1. To provide quality sports training and Olympic-type competitions in our area for 215 athletes and 165 Unified Partners by June 2017. 2. To provide sport-specific coaches training and re-certification opportunities for 10 coaches by June 2017. 3. To provide airfare transportation for 35 middle schools students to our State competitions 4. To safely secure all Special Olympics equipment and supplies 5. To provide airfare transportation for 28 students participating in our Unified Champion Schools 6. To provide airfare for our 280 adult athletes and partners by June 2017. 7. To provide an opportunity for 725 community volunteers to interact with our program athletes through June 2017. 8. 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. Special Olympics Hawai`I - West Hawaii General Fund 141 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SPECIAL OLYMPICS HAWAII-WEST HAWAII Program Name: GENERAL FUND Agency Director: NANCY BOTTEI"O Phone No.: (806) s43 — woe Contact Person: DENISE LINDSEY Phone No.: (eos) 345 — 0433 Mailing Address: Address: P.O.BOX 330358 Address: City,ST,ZIP KEAUHOU-KONA,HAWAII 96739 Facility Address: Address: P.O.BOX 3295 Address: City,ST,Tap HONOLULL,HI 96801 Email Address: denise@bigislandtv.com Fax No.: ( ) — Accountant/CPA: Akamine,Oyadomari&Kosaki Phone No.: (eoe) 941 — 0500 Firm (if applicable): Akamine,Oyadomari&Kosakl,CPA's,Inc. Mailing Address: Address: 1440 Kapiolani Blvd. Address: City,ST,Zip Honolulu,HI 96814 YOU ARE RESPONSIBLE TO KEEP ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE p PARTMENT,AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑Hamakua ©North Kona ❑South Hilo Q North Kohala 0 South Kona 0 North Hilo Q South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓Q Educational concerns Q Youth 0 Victims of Crimes ❑Culture and the arts ©Aged', 0 Victims of Health or Social Crises ❑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 2017-2018 Page 1 of 8 c County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: SPECIAL OLYMPICS HAWAII-WEST HAWAII Program Name: GENERAL FUNQ 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 15,000.00 15,000.00 0.00 2.Agency Mission Statement: The mission of Special Olympics is to provide year-round sports raining and athletic competition in a variety of Olympio-type sports for children and adults with intellectual disab lilies,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 working to position people with intellectual disabilities as leaders in engendering and sustaining acceptance and respect within schools and communities throug i inclusive sports,fitness and youth activation programming. Special Olympics has a vision of a world where people;with Intellectual disabilities lead healthy,vibrant lives grounded in ongoing sports and physical activity,sound nutrition and a deeply held conviction to improve,compete,achieve and demonstrate their personal best to themselves and their community. 4.Total Budget&Position Count: Total Program Budget: 102,250 Total Program Position Count: 295 Total Agency Budget: 2123829.00 Total Agency Position Count: 5094 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SPECIAL OLYMPICS HAWAII-WEST HAWAII Program Name: GENERAL FUND S.Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate VISITOR INDUSTRY CHARITY WALK 5,000 WALMART FOUNDATION 2,500 YOUNG BROTHERS GRANT 1,000 KONA BREWERS FEST 7,500 COP ON TOP 16,000 UNDERPANTS RUN 5,000 COUNTY OF HAWAII GRANT 30,000 TOTAL: 67,000 *Attach additional pages,if needed. s�,c_ 14-771,4 ,4.4,r" 6. Explain what plans your agency or program has to increase revenues to support this program: We plan to have some new fundraisers like ICON sales at KTA Supermarkets,a Rodeo and another Fishing Tournament With that being said,we can estimate an additional income of$7,000.00 for 2017. 7. Program Objectives Using County Nonprofit Grant Program Funds: These grant funds will kick in July of 2017,so that means we can utilize some of the funds to help with our July Area Games in Kona,plus travel to State Games in August of 2017 and help host our Area Games for Bowling in October of 2017. EXHIBIT A NONPROFIT GRANT APPUCATION FY 2017-2018 Page 3 of 8 'rah C � �� Se*eG 1144 0 t J/Z-S tAiteJr 4-t1 SPECIAL EVENTS/FUNDRAISERS a-€.44 r }--✓�cl ZUMBA Thon $ 2,200.00 Golf Tournament $ 4,000.00 Concert $ 3,000.00 Cross Fit $ 3,000.00 Roller Dereby Fundraiser $ 350.00 Kona Marathon $ 600.00 Paniolo Police Plunge&Torch $ 3,600.00 Lavaman Aide Station (2 event $ 750.00 Torch Run tshirt sales $ 3,450.00 Roberts Hawaii Bus Pull $ 3,500.00 Fishing Tournament $2,700.00 Mauna Lani Charity of Trees $300.00 KTA Icon Fundraiser $4,000.00 Waimea Rodeo $1,500.00 Kawaihae Fishing Tourament $1,500.00 Sake&Sushi Fundraiser $1,500.00 Sub Total $35,950.00 I-0141 re-01,1", ?j '42 f- 67; 000 set �� L -CCA v AI N( �l �c = `fl /�Z ?Sip County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: SPECIAL OLYMPICS HAWAII-WEST HAWAII Program Name: GENERAL FUND 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE!MEASURES Applicant Projected Results (i.e.:Number of dients served,workshops or events held,volunteer hours,etc Describe,be specific) 60 Special Olympics Athletes to State Games in August 2017 12,000 Bocce&Soccer Area Games meals,awards for 12E people 1,500 Bowling Area Games for 2 days covering bowling fees,;lunch,refreshments&awards 2,500 70 Special Olympics Athletes to State Games in November 2017 14,000 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-IS Actual Total Budget Grant Rea Salary and Wages 14,303 14,303 14,303 Professional FAAS 0.00 0.00 0.00 Operations 62,660 62,660 62,660 Supplies 12,000 12,000 12,000 Equipment 10,000 10,000 10,000 other. Bus,Van,Cargo transportation for annual events 4,000 4,000 4,000 Other: Other: Other: Other. TOTAL 102,963 102,963 102,963 *if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonp •fit Grant Application FY2016-17 Agency Name: et-%c-‘ ��h� �► ICC, 46°4I �._ 9% N1c� ; Program Name: GonerDA c:Am 10. ORGANIZATION CONFLI DISCLOSURE FORM Please disclose any conflicts or potential c•nflicts of interest that any board member,officer,director, or administrator of your organization may ave with the County of Hawaii. Only those listed below need to be disclosed.One form per person ith a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exi t' option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of nterest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the ouncil ❑ Staff appointed by a membe of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,th- Assistant Corporation Counsel,or a Deputy Corporation Counsel conflict of Interest is defined as:a substantial prob,bllity that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to be fits accruing in general to an Industry. Please specify any and all mitigation measu es to avoid, in fact or appearance, any conflicts or potential conflicts of interest: gi If no conflicts exist,check here. Signature of Authorized Person (specify titl ) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2016-2017 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: SPECIAL OLYMPICS HAWAII-WEST HAWAII Program Name: GENERAL FUND 11.Certification of Understanding(Page 1 of 2) I (we)have read and understood all of the eligibility requirements;grant conditions;award procedures; and records,reporting,and fiscal accountability requirements as mandated in Article 25,Sections 2- 135—2-142.1,Hawaii County Code,relating to Appropriation of Funds to Nonprofit Organizations. I(we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equip trent,property,or records pertinent to the grant,contract,or program for which funds were used. I(we).hereby certify that information supplied herein,including all supporting documents,is correct and that I(we)have the authority and ability 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. 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 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.eov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii,I(we)understand and will comply with the reouirement to submit a vear-end report to the County Cpuncil within 60 days mer June 3Q9f the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived limn 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 submi cl.timely; complete,and a juste veer-end report usina the template DANfirigft will impact the evaluation of your prooram's or miency's future fundina requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai'i Nonp +fit Grant Application FY2016-17 Agency Name: Program Name: 11. Certificatio of Understanding (Page 2 of 2) If awarded a grant from the County of Haw:i'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each •ccurrence) must be provided to the County of Hawai'i Finance Department,which specifically an. explicitly indicates that the County of Hawaii is an additional insured prior to receiving any pa rent(s). I (we) understand that failure to submit th: final report within 60 days of June 30th shall result in loss of all grant funds received during the gran period(must be refunded to County)and exclusion from future grant participation for a minimum $f one year or until a written report is submitted to,and accepted by.the council. I (we)understand there is no provision fo further notification to submit the final report. Information and instructions are available at tt // ` 1;; a, ,urty ov/fr-n r°p fit tram f r si on or about May 30 of the year the final report is due. As part of this application,you acknowledg- that any funds awarded will be restricted for the purposes stated in the application,except for a maxi um ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2015 ut be returned to the County of Hawaii with the final report. Failure to return these funds in a ti efr manner will impact the evaluation of your agency's future funding request and may result in a ions taken to recover these funds. By signing below,you are acknowledging t atyou have read and understood these requirements. Signature of Ar4thorized Person (specify titl:) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2016-2017 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: SPECIAL OLYMPICS HAWAII-WEST HAWAII Program Name: GENERAL FUND 12.COUNCIL AWARD WORKSHEET TABLE is PROGRAM PERFORMANCE MEASURES Applicant Council Prosed Projected Results. Prod Result 60 Special Olympics Athletes to StaleGsmes in.Amelia.2017 Isz000 Bocce&Soccer Area Games meals,awards for 125 people saw Bowling Area Games for two days covering bowling fees,iunchs,refreshments,awards 2.500 70.Special.Olympics.Athletes.to State Games in Novethber 2017. s'000 I1I TABLE PROGRAM EXPENDITURES I FY 17-18 I Council I Grant Request Award Salary and.Wages. 14,303 Professional fees 0.00 Operations 62,660 Supplies 12,000 Equipment 10,000 Other: Bus,Van,Cargo transportation tar transportation forannUalevents r ,000 Other: Other: Other: Other: TOTAL 102,993 Additional Council directives resat ting award: EXHIBIT B NONPROFIT RANT APPLICATION FY 2017-2018 Page 8 of Three Ring Ranch Internships, Externships and Mentoring 142 (Pope County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Three Ring Ranch Program Name: Internships, Externships and Mentoring Agency Director: Ann Goody Phone No.: (808 ) 331 - 8778 Contact Person: Ann Goody Phone No.: (808 ) 895 - 2313 Mailing Address: Address: 75-809 Keaolani Dr Address: City,ST,Zip Kailua-Kona HI 96740 Facility Address: Address: 75-809 Keaolani Dr Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address: animals@threeringranch.org866 Fax No.: (866 ) 365 - 5097 Accountant/CPA: Bill Houser Phone No.: (702 ) 952 - 2814 Firm (if applicable): The Taxman Mailing Address: Address:871 Coronado Center Dr.Ste 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: 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name rre__Qv‘ ! - v\e / Program Name: Internships, Externships and Mentoring 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 10,000 6500 2.Agency Mission Statement: Our mission is to positively impact the environment while educating Hawaii's children about thier place in the natural world.We assist in the development of an environmentally responsible generation of youth while caring for our exotic animal residents. Through education we teach animal communication and behavior to our children,students,visitors and professionals creating positive change. 3. Program Description: A. Residential Internships for pre-vet and veterinary students at 3RR.These are held in summer breaks.2 rounds of students with three students per session.Acceptance preference always given to Hawaii students(we have 2 pre-vets pending for 2017 from BI). B.Externships x 2 for forth year vet students.Acceptance preference to Hawaii born/residents or those who plan on practicing in the islands. C. High School Residential Internships.Three week long program for High school seniors who live in or are from Hawaii with BI students recieving the highest prefference. D.Mentoring,Afterschool mentoring program for BI youth ages 11 and up.4 hour sessions two times a week. 2017 budget figures quoted below 3RR continues to be 100%volunteer staff. Positions for these four programs 8 total. For entire 3RR facility 40+ 4.Total Budget.& Position Count: Total Program Budget: 38,000 Total Program Position Count: 0 Total Agency Budget: 99,900 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: r�,e., ,,x vtc_lc\ Program Name: iiClu, ,i- /e4t- _ 5/t1-1- ' ►'� 5. Program Funding Sources(identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Kukio Fund-confirmed 5000 Hawaii Island United Way-confirmed 4500 3RR Curator In-Kind donation of time-confirmed 9500 Hawaii County Non-profit Grant funds-pending 15000 Private donor-in memory of a BOD member-confirmed 2,000 3RR cash funds to make up difference 2,000 TOTAL: 38000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As the cost has gone up for us to run this program we have scrambled to share the information about it with our patrons,grant souces and our donor base.We were told just this week that we will recieve support for the next season of internship programs in memory of one of our BOD.We have increased our email marketing and visitor toursbut we need to focus on keeping the hours required to run our educational programs free of our tours.The tours fund the sanctuary but we need those tour free times to run all of these programs.To meet our facility Mission we must teach and serve our community.We have been talking up this program to our tour visitors and one of them liked the idea so much he wrote a$2,000 check on the spot in memory of our BOD President who died this year and specifically said it was to fund our next round of vet and pre-vet internships. 7. Program Objectives Using County Nonprofit Grant Program Funds: Goal is to maintain all 4 parts of our educational programs at the current levels.We have shifted a bit of our focus to the older (high school)age students and are building a solid relationship with Konawaena HS(new for us).This has a direct impact on the number of students we can mentor who will go on to higher education in many fields.These students become teachers, nurses, doctors, business leaders and of course veterinarians.Our programs are like no other in Hawaii by giving the students a hands • on science program we can make them think outside the box.Then they leave to college and hopefully will return to careers here on the BI.To keep doing this we need your support. EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: TLY'.e-c_ -"1‘;.S f� Ct-\ Program Name: / tt, i v 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Residential Internships(vet and Pre-vet) 6 students,(4 weeks x 2 rotations) Externships(4th year vet student) 2 students,(4-6 weeks per student) High School residential internships 7 students,(4 week program x 2) Afterschool Mentorships(ages 11 and up) 25-30 students,held 32 weeks per year Attach additional pages as necessary. • 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 4500 4500 0 Supplies 0 0 0 • Equipment 2500 2500 0 Other: Food, utilities, car, insurance 16,800 18,500 7500 • Other: Surgery, mobile vet van, spay and neuter clinics 2700 3000 7500 Other: Loss of Three Ring Ranch tour income 9500 9500 0 Other: Other: TOTAL 36,000 38,000 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: rem 2v 2-c":v'c:�t Program Name: ;ft ,,v �',..stki Vr144. 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor . ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ,rCk-ln , Program Name: -kti,t,;M1.,, 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 June 30 of the contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: ' hr S- v'3Rc,L,Ack I Program Name: A "'` is. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. • I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's flltllrP funding rPrpiect rind mny rPsflit in nrtinns tnken to rernvPr thPc fl/ndc. By signing below,you are acknowledging that you have read and understood these requirements. JZ/e/-7/,‘,/4 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: '"_ Program Name:- .0--, 5 Kt/A.v,rI 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 Volunteer Legal Services Hawaii Hawai'i County Pop-Up Legal Clinics 143 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics Agency Director: Michelle D Acosta Phone No.: (808) 522 — 0678 Contact Person: Michelle D Acosta Phone No.: (808) 528 — 7050 Mailing Address: Address: 545 Queen Street Address: Suite 100 City,ST,Zip Honolulu, Hawaii 96813 Facility Address: Address: 545 Queen Street Address: Suite 100 City,ST,Zip Honolulu, Hawaii 96813 Email Address: michelle@vlsh.org Fax No.: (808 ) 521 — 2147 Accountant/CPA: Joseph Evans/Michelle Gray Phone No.: (808 ) 763 — 8723 Firm (if applicable): Mailing Address: Address: 545 Queen Street Address: Suite 100 City,ST,Zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) n Puna ✓ Hamakua I✓I North Kona 1i1South Hilo n North Kohala ✓ South Kona ✓ North Hilo n South Kohala ✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ri Youth I I Victims of Crimes Culture and the arts I I Aged I 'Victims of Health or Social Crises ✓I Needs of the poor Physical/Emotional Disabilities U Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 15000 10000 7500 2.Agency Mission Statement: Volunteer Legal's mission is to mobilize the legal community to address the unmet legal needs of the indigent and disenfranchised members of our community. Established in 1981 by the Young Lawyers Division of the Hawaii State Bar Association,Volunteer Legal continues to be a community based organization with a goal of serving the needs of our community in a responsive and meaningful way. Over 55%of those serviced by Volunteer Legal have incomes at or below 125%of the federal poverty guideline for Hawaii.This equates to$35,800 gross annual income for a family of four.Volunteer Legal also provides services to those whose incomes are just above the income cut off for traditional legal aid services,but do not make enough money to be able to afford a full market rate attorney. In 2016,Volunteer Legal qualified over,2,100 individivals and provided over 2,600 civil legal services ranging from legal advice and counsel,limited scope assistance,and referrals to volunteer attorneys for pro bono direct representation. Approximately, 23%of those servived in 2016 were residents of Hawaii County. In October 2016,Volunteer Legal launched the Hawaii Online Pro bono(HOP)portal which allows income qualified individuals to post legal questions and receive legal advice from volunteer attorneys through the confidential portal.This tool provides access anytime and anywhere internet is available. However, knowing that an in-person contact is much more effective, Volunteer Legal is proposing 8 Pop-Up Legal Clinics for Hawaii County residents under this proposal to allow for the individualized and in-person contact with volunteer attorneys. 3. Program Description: Funding will support a series of 8 Pop-Up Legal Advice Clinics in Hawaii County that will provide low-and moderate-income resident to the opportunity to meet with volunteer attorneys on an individual and in person basis for legal advice and limited legal assistance.The Pop-Up Legal Clinic model is based on Volunteer Legal's Neighborhood Legal Clinic model in which pre-screened individuals are matched with volunteer attorneys for counseling. Participants undergo an intake process which includes the collection of information regarding household income,and legal issue.Additionally, Intake staff collect pertinent facts and documents regarding the specific legal issue to relay to the volunteer attorney with whom the participant is matched with.This in-depth screening process enables volunteers to focus on providing actual legal advice at the clinics and guidance for next steps. Volunteer attorneys are recruited by Volunteer Legal and are expected to provide services in the following civil legal areas: family law(adoption,guardianship, divorce,child custody,visitation and support);estate planning; probate and trusts; Chapter 7 bankruptcy and consumer debt collections; private residential tenant issues; and VA benefits.Volunteer Legal staff will be on-site at each event to oversee logistics and follow-up services for participants in need of further assistance. The Pop-Up Legal Clinics will take place in rural districts with high poverty legals. Volunteer Legal will work with local service providers and agencies to identify accessible locations and community appropriate venues. In addition,Volunteer Legal will engage in public awareness efforts to ensure that the community receives timely notice of each Clinic. Participant surveys will be collected at each Clinic for purposes of quality assurance and project effectiveness. 4.Total Budget& Position Count: Total Program Budget: 35000 Total Program Position Count: 1 Total Agency Budget: 975000 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate The Hawaii State Judiciary- Purchase of Service Contract 20,000 TOTAL: 20,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Volunteer Legal actively pursues grants both private and public to support services to residents throughout the state.This includes services offered in Hawaii County. Volunteer Legal currently leverages funds via a purchase of service contract with the State of Hawaii Judiciary for the delivery of core services statewide to include Hawaii County residents.Such funds are currently funding to Pop-Up Legal Clinics in Hawaii County for FY 2016-2017 which are aimed to build the model for the proposed Clinics under this proposal.Volunteer Legal has requested State funding to provide the bulk of funding for statewide funding via three(3)alternative funding vehicles: 1)continued funding through the Judiciary purchase of services contract;2) state appropriations via two companion bills, SB329 and HB853;and 3)a State Grant-in-Aid request. Volunteer Legal has secured funds from the Hawaii Justice Foundation to support civil legal assistance for the homeless population in Hawaii County for Calendar Year 2017. Should state funding fall short for the proposed Pop-Up Clinics,Volunteer Legal will seek additional funding from the Hawaii Justice Foundation to support services to low and moderate income persons in Hawaii County for Calendar Year 2018. 7. Program Objectives Using County Nonprofit Grant Program Funds: By the end of the grant period,Volunteer Legal will have completed 8 Pop-Up Legal Advice Clinics in Hawaii County,serving at least 100 individuals in total. Of the 100 served at the Clinics,an estimated 40 will be provided additional legal assistance by way of limited scope services(drafting letters to creditors or landlords, or completion of court forms),and referrals to volunteer attorney for direct services(negotiating with opposing party,attending court hearings,and full representation). The Pop-Up Legal Clinics will be held in rural districts with high poverty rates. The proposed Pop-Up Legal Clinics will enhance current services offered to Hawaii County Residents through Volunteer Legal's core services and the Hawaii Online Pro bono (HOP)legal advice portal. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) At least 100 individuals will be provided legal advice at the 8 Pop-Up Clinics 100 Clinic Participants Of the estimated 100 clinic participants,40 will be provided further assistance 40 Additional Services Beyond Clinic Services 8 Pop-Up Legal Clinics will be presented in Hawaii County without fee to the public 8 Total Pop-Up Legal Clinics Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages 7000 Professional Fees 0 Operations 500 2000 Supplies Equipment 1500 Other: Mileage and Parking 1000 Other: Venue Rental Fees 1000 Other: General Liability and Professional Liability Insurance 500 Other: Event Refreshments for Volunteers and Participants 1000 Other: Volunteer Appreciation 500 TOTAL 15000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Michelle D Acosta 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. 1604-1/;: _ Jan. 27. 2017 e of Authorized P rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, 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 Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, 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 2017-2018 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai`i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in nrtinns taken to rernver these fiends. By signing below, you are acknowledging that you have read and understood these requirements. (,,,i‘e/h h/,/..: 0 `- Jan. 27, 2017 Sigature of Authorized Person specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 100 Clinic Participants 40 Additional Services Beyond Clinic Services 8 Total Pop-Up Legal Clinics TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages 7000 Professional Fees 0 Operations 500 Supplies 2000 Equipment 1500 Other: Mileage and Parking 1000 Other: Venue Rental Fees 1000 Other: General Liability and Professional Liability Insurance 500 Other: Event Refreshments for Volunteers and Participants 1000 Other: Volunteer Appreciation 500 TOTAL 15000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 West Hawai'i Community Health Center Inc. WHCHC Community Outreach to Vulnerable Populations 144 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations Agency Director: Richard Taaffe Phone No.: (808) 326 — 3878 Contact Person: Natasha Ala Phone No.: (808) 331 — 6472 Mailing Address: Address: Address: 75-5751 Kuakin Hwy., Ste 203 City,ST,Zip Kailua Kona, HI 96740 Facility Address: Address: Address: 75-5751 Kuakin Hwy., Ste 203 City,ST,Zip Kailua Kona, HI 96740 Email Address: nala@westhawaiichc.org Fax No.: (808 ) 327 — 0804 Accountant/CPA: Diane Pautz, CFO Phone No.: (808 ) 326 — 3883 Firm (if applicable): Mailing Address: Address: Address: 75-5751 Kuakini Hwy.,Ste 203 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: $9,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua [' North Kona ❑South Hilo ❑ North Kohala ❑✓ South Kona ❑ North Hilo ✓❑South Kohala ✓❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ✓❑Youth ❑Victims of Crimes ❑Culture and the arts ✓❑Aged ✓❑Victims of Health or Social Crises ✓❑ Needs of the poor ✓❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $10,000 $25,000 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. Since 2006,WHCHC has improved the health of the people living on Hawaii Island by making primary health care services accessible to people of all ages,cultures, and income levels We have achieved this by offering comprehensive medical,dental, and behavioral health services as well as enabling services.Over the years our enabling services have expanded to include: eligibility and enrollment support for the uninsured, under-insured,and low income people;referral services to specialists; assistance with prescription medications; language interpretation and translation services;care coordination for patients with chronic illnesses;and health education and community outreach programs. 3. Program Description: Through our Health Education and Outreach program,WHCHC supports under-served and vulnerable populations such as the Marshallese,the Micronesians, Native Hawaiians,the Spanish speaking community,and disadvantaged youth groups by connecting them to resources and opportunities that will result in strengthening their community ties and promote community wellness in the spirit of malama pono. By addressing upstream issues and working to improve social determinants facing the most under-served populations West Hawaii,WHCHC improves community well-being and decreases health disparities among minority populations. The Health Education and Outreach program provides the following services to the community: 1.WHCHC staff members participate regularly at community health fairs and events to promote and inform the public about personal health and disease prevention. Educational materials and fliers are made available in English as well as other languages,e.g., Spanish, Marshallese, Ilocano or Tagalog,and Hawaiian. 2.WHCHC staff provide health education and training classes at public housing facilities,senior day care centers,at homeless shelters, at public schools, at churches, at night clubs,and many other community partner organization locations. 3.WHCHC staff collaborates with community leaders from the Marshallese community, Micronesian community,the Spanish speaking community,the farm workers community,and leaders from many other community groups to develop trusted relationships and work to become their partner in supporting and promoting the health and well-being of each community. Through these valued partnerships we better understanding the individual needs of each community and then work to develop and support programs that can meet these needs. 4.Total Budget& Position Count: Total Program Budget: $12,500 Total Program Position Count: 3 Total Agency Budget: $16,433,884 Total Agency Position Count: 152.10 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate WHCHC General Fund $4,500 Hawaii County Nonprofit Grant $9,000 TOTAL: $12,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: WHCHC will continue to develop diverse sources of revenue to fund and support outreach education efforts. Currently the services provided through our Health Education and Outreach program are not billable services and thus WHCHC must rely on private foundation grants,government support, and donor contributions to fund these valuable public services. 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be used for the printing and purchase of health educational materials(in multiple languages)to be distributed at health fairs and health education training classes. The West Hawaii Community Health Center service area extends from Kawaihae to Ocean View,an area of roughly 80 miles-funds will be used to pay for staff to travel to locations through out this vast services area where health education opportunities are available.Funds well also be used to purchase medical supplies to be used for health screenings at public health fairs and other community events. Through the support of Hawaii County,the WHCHC Health Education and Outreach program will work to reduce the social determinants that contribute to the disparities facing many of the under-served populations,thereby creating more productive and rewarding lives of our minority and youth populations in West Hawaii. Studies suggest that health does not occur in a vacuum. Instead,health status is embedded in larger living and working conditions. There is strong,suggestive evidence that viewing an individual as more than just a system of organs,and taking into account the social context in the delivery of healthcare services can have an important impact on improving health.There is growing evidence that the social determinants that negatively impact these under-served populations are costly to society in multiple ways.Through this generous County Nonprofit grant,WHCHC will support under-served populations in West Hawaii by helping them become proactive in promoting their own health and wellbeing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) WHCHC Outreach staff will attend 15 Health Fairs per year 2,500+people will receive health screenings WHCHC Outreach staff will provide health education training to community groups 250+people will receive in-depth training WHCHC Outreach staff will partner with organzations on public health issues Strengthen public health network for patients Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $6,500 $5,000 Equipment $2,500 $1,000 Other: mileage reimbursement $3,500 $3,000 Other: Other: Other: Other: TOTAL $12,500 $9,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council I 1 Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ,I\ .cam- 12t cl"Vac.f -�a:fo o F:a /V/1 ignature of Au orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements;grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's futures funding requect rind may recult in nrtinnc taken to recover thece fundc. By signing below, you are acknowledging that you have read and understood these requirements. t -61(4(42 //31 / Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 2,500+people will receive health screenings 250+people will receive in-depth training Strengthen public health netytp, TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies $5,000 Equipment $1,000 Other: mileage reimbursement $3,000 Other: Other: Other: Other: TOTAL $9,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 West Hawai'i Community Health Center Inc. WHCHC Honaunau School Based Health Center 145 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center Agency Director: Richard Taaffe Phone No.: (808) 326 - 3878 Contact Person: Natasha Ala Phone No.: (808) 331 - 6472 Mailing Address: Address: Address: 75-5751 Kuakini Hwy.,Ste 203 City,ST,Zip Kailua Kona, HI 96740 Facility Address: Address: Address: 75-5751 Kuakini Hwy., Ste 203 City,ST,Zip Kailua Kona, HO 96740 Email Address: natashaala@westhawaiichc.org Fax No.: (808 ) 327 - 0804 Accountant/CPA: Diane Pautz, CFO Phone No.: (808) 326 - 3883 Firm (if applicable): Mailing Address: Address: Address: 75-5751 Kuakini Hwy.,Ste 203 City,ST,Zip Kailua Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ['South Hilo ❑ North Kohala ['South Kona ❑ North Hilo ❑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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $10,000 $25,000 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. Since 2006,WHCHC has improved the health of the people living on Hawaii Island by making primary health care services accessible to people of all ages,cultures,and income levels We have achieved this by offering comprehensive medical,dental, and behavioral health services as well as enabling services.Over the years our enabling services have expanded to include: eligibility and enrollment support for the uninsured, under-insured, and low income people;referral services to specialists; assistance with prescription medications; language interpretation and translation services;care coordination for patients with chronic illnesses; and health education and community outreach programs. 3. Program Description: West Hawaii Community Health Center Inc.(WHCHC), in partnership with the Hawaii DOE,and Honaunau Elementary School is opening a school based health center on the campus of Honaunau Elementary School. WHCHC Honaunau will begin operation by providing primary medical services 1 day per week and will expand and grow service to become a full-time(140 hours per week)operational health center. Services offered will include primary and preventative medical care, health screenings, behavioral health services,care and management of chronic medical conditions, immunizations,TB testing, physicals for employment and sports,women's health and family planning,smoking cessation, referral to specialists,care coordination and case management.Services will be available to all residents of the area,children and adults,although special attention will be given to students attending Honaunau Elementary. WHCHC expects to reach out into the agriculture community by going into the coffee fields and mac nut plantations to address the healthcare needs of these farm workers, many of whom are migrant and seasonal farm workers. When initially open,WHCHC expects to provide primary health care services 1 day per week. The initial staff will include 1 family physician, 1 medical assistant, 1 patient service representative,and 1 community health worker.As we grow our patient population at WHCHC Honaunau,we will begin to expand days of operation as well as services provided to the community at the Honaunau Elementary campus. 4.Total Budget& Position Count: Total Program Budget: $106,400 Total Program Position Count: 1 FTE Total Agency Budget: $16,433,884 Total Agency Position Count: 152.10 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Billable Revenue-(480 annual office visits) $86,400 Hawaii County Nonprofit Grant $20,000 TOTAL: $106,400 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: West Hawaii Community Health Center will slowly grow the Honaunua School Based Health Center program and gradually increase the number of billable patient visits each quarter.Thanks to our partnership with the Hawaii DOE, and Honaunau Elementary,we will initially be able to use space on campus that is currently vacant and will require minimal renovation to become a fully operational health care center. Usage of the vacant space will keep initial overhead costs low. Once we have expanded our patient capacity we will then renovate a vacant building,on campus,to accommodate our growing need for space. 7. Program Objectives Using County Nonprofit Grant Program Funds: By providing primary medical care, behavioral health,outreach health education,and eligibility and insurance enrollment assistance to one of the most under-served communities in Hawaii County,WHCHC Honaunau will improve public health outcomes for people in South Kona, and improve the health and safety of migrant&seasonal farm workers. By making primary care accessible and available to the people of South Kona,WHCHC Honaunau will: •reduce costs associated with ER visits for preventable health and safety problems; •decrease work/school absenteeism due to illness and injury; •improved quality and wellbeing of life; •improve chronic health conditions; •reduce infection rates of epidemic outbreaks such as dengue fever and possible zika virus; •reduce population anxiety over epidemic outbreaks; •promote community wellness and pride. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) WHCHC will initially provide primary health care services 1 day per week WHCHC will build capacity manageably WHCHC will provide 1 DR., 1 MA,and 1 Patient Service Representative WHCHC will serve 10 patients per day WHCHC will provide services 48 weeks per year WHCHC will annual provide 480 pt visits WHCHC will attend 3 school/community open house events at Honaunau Elementary WHCHC will integrate into the community WHCHC will conduct community surveys and focus groups at Honaunau Elementary WHCHC will develop programs based on need Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $56,213 $10,000 Professional Fees Operations $10,687 Supplies $4,500 Equipment $35,000 $10,000 Other: _Other: Other: Other: Other: TOTAL $106,400 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): H Member or members of the Council H Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. (ka-- _ I ( Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to 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 program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding requect rind mny racult in nrtinnc tnkan to rarnvar thecp funds, By signing below, you are acknowledging that you have read and understood these requirements. // v„AG-' (AAcC <3 I l'st \ / Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Honaunau School Based Health Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result WHCHC will build capacity manageably WHCHC will serve 10 patients per day WHCHC will annual provide 6 WHCHC will integrate into the community WHCHC will develop programs based on need TABLE II: PROGRAM EXPENDITURES FY 17-18 Council Grant Request Award Salary and Wages $10,000 Professional Fees Operations Supplies Equipment $10,000 Other: Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 West Hawai'i County Band Friends Music and Equipment Fund 146 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund Agency Director: Larry Boucher Phone No.: (808 ) 345 — 2859 Contact Person: Larry Boucher Phone No.: (808 ) 345 — 2859 Mailing Address: Address: WHCB Friends Address: P.O. Box 5058 City,ST,Zip Kailua Kona, HI 96745 Facility Address: Address: Address: City,ST,Zip Email Address: konalarry@gmail.com Fax No.: ( ) — Accountant/CPA: Meleana Smith Phone No.: (808 ) 929 — 8000 Firm (if applicable): Kau Business Services Mailing Address: Address: P.O. Box 6239 Address: City,ST,Zip Ocean View, HI 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑ North Kohala ✓J 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 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 5000 5000 3125 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: The program will help to purchase sheet music sets with instrument parts and conductor score to assist the Band in its compliance with the Parks and Recreation's goal of sight-reading 20 new compositions a year. The purchase of an electric piano will enhance the sound of the"jazz band"subset of the main band. The purchase of monthly color programs will support audience enrichment, marketing of the non-profit's request for donations and the encouragement of the County's committment to promotion culture and the arts. 4.Total Budget& Position Count: Total Program Budget: 4000 Total Program Position Count: 0 Total Agency Budget: 12000 Total Agency Position Count: 9 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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): FY17-18 Revenue Source Estimate Private Individuals 1000 TOTAL: 1000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The agency plans to apply for more grants and to market private individual's 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 a piano will enhance the jazz band subset within the Band and the purchase of concert programs with enhance the appreciation for the music and the composers. All these help to create a professional and enriching experience for the audience. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Band will be able to sight read aat least 20 new compositions. Diverse audiences. Compliance with County goals Enhance the"jazz band"subset to reach more diverse audiences by providing an electric Audience enrichment with more authentic jazz piano to a musician who will play it. performance. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees 400 400 Operations 500 500 Supplies 500 500 Equipment Other: Electric piano 2700 1700 Other: Sheet music 1000 1000 Other: Insurance 675 675 Other: Marching lyres and concert mutes 225 225 Other: TOTAL 6000 5000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. PREC406,v7 /— 7e2 -2e'/7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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, 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding requect rind mny rpcult in nrtinnc tnken to rprnvpr thecp flinch By signing below, you are acknowledging that you have read and understood these requirements. PR 6s h eAi 7 — 2 0 2 �/ Signature o Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Diverse audiences. Compliance with County goals Audience enrichment with more performance. TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees 400 Operations 500 Supplies 500 Equipment Other: Electric piano 1700 Other: Sheet music 1000 Other: Insurance 675 Other: Marching lyres and concert mutes 225 Other: TOTAL 5000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 West Hawai'i County Band Friends Volunteer Musicians Fund 147 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians Fund Agency Director: Larry Boucher Phone No.: (808 ) 345 — 2859 Contact Person: Larry Boucher Phone No.: (808 ) 345 — 2859 Mailing Address: Address: West Hawaii County Band Friends Address: P.O. Box 5058 City,ST,Zip Kailua Kona HI 96745 Facility Address: Address: Address: City,ST,Zip Email Address: konalarry@gmail.com Fax No.: ( ) — Accountant/CPA: Meleana Smith Phone No.: (808 ) 929 — 8000 Firm (if applicable): Kau Business Center Mailing Address: Address: P.O. Box 6239 Address: City,ST,Zip Ocean View, HI 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala ❑✓ Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑✓ Culture and the arts Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians Fund 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 I 15000 5000 3625 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 8 member County-paid group and sometimes ask for financial assistance for travel. 4.Total Budget & Position Count: Total Program Budget: 6000 Total Program Position Count: Total Agency Budget: 12,000 Total Agency Position Count: 9 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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): FY17-18 Revenue Source Estimate Hawaii International Billfish Tournament 400 Ironman Foundation 150 Private Individuals 450 TOTAL: 1000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The WHCB Friends plans to continue to apply for grants and to market to private individuals the opportunity to make a non-profit tax deductible contribution to this program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program will provide the eight member County paid musicians an opportunity for more complete coverage of music parts and a bigger, more professional sound. The progrdam will encourage more musicians from the community 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 enhance culture and arts enrichment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 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 Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) The Band will be able to perform every month at its free concert series at Hale Halawai. At least one community concert every month. The program will increase the number of musicians available to perform. The Band fully staffed at 30 musicians. At The Band will be able to increase the number of music events requested by the community. least 2 additional events can be added. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Honorarium 3625 6000 5000 Other: Other: Other: Other: TOTAL *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians Fund 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): H Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. 6t5U1itCA-tom F aiDCSe/ f - 2a - z �`i Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians 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 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians Fund 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 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 retried-rind mny recult in nrtinnc tnken to rernver thecc fnnric, By signing below, you are acknowledging that you have read and understood these requirements. lig PR E SI,D #V 7 / — 2, — 2 a( Signature of Au orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: West Hawaii County Band Friends Program Name: Volunteer Musicians Fund 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result At least one community concert every month. The Band fully staffed at 30 musicians. At least 2 additional events can be added on per year. TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Honorarium 5000 Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 YWCA of Hawaii Island SANE 148 F" cCiOPvYi Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE Agency Director: Kathleen McGilvray Phone No.: (808) 935 — 7141 Contact Person: Lorraine Davis Phone No.: ( 808) 961 — 3877 Mailing Address: Address: YWCA of Hawaii Island Address: 1382 Kilauea Avenue City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1382 Kilauea Avenue, Hilo, HI 96720 Address: 75-5706 Hanama Place,#202, Kailua-Kona, HI 96740 City,ST,Zip Email Address: Idavis@ywcahawaiiisland.org Fax No.: (808 ) 961 — 9140 Accountant/CPA: Phone No.: (808 ) 935 — 5404 Firm (if applicable): Taketa, Iwata, Hara and Associates, LLC Mailing Address: Address: 101 Aupuni Street Address: Suite 139 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua n North Kona VI South Hilo ✓ North Kohala ✓ South Kona ✓ North Hilo ✓ South Kohala ✓ Ka`u • Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns Ill Youth ❑✓ Victims of Crimes I I Culture and the arts n Aged n Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 0 0 0 2.Agency Mission Statement: YWCA of Hawai'i Island is dedicated to eliminating racism,empowering women,and promoting peace,justice,freedom and dignity for all. The YWCA of Hawai'i Island(YWCA),first organized in Hilo in 1919, has offered valuable programs and activities for the benefit of women,children,and their families. the YWCA was established as a 501(c)(3)non-profit organization in 1965,and has been a partner agency of the Hawaii Island United Way(HIUW)since 1979. It belongs to a national organzation consisting of 300 YWCA Associations across the United States with 2.6 million members. Employing over 50 full-and part-time staff,the YWCA offers a variety of services to people of all ages,from newborns to senior citizens in their 80's through the island of Hawai'i. Current programs in place include: Healthy Start,a child abuse and neglect prevention program;Teen Court,a diversion program for first time,teen offenders; Developmental Preschool,a NAEYC accredited preschool serving 2-5 year olds; Sexual Assault Support Services,a program operating a 24/7 rape crisis line and providing therapy to victims of sexual violence and their families;Sex Assault Nurse Examiners Program,a program to provide specially trained nurses to provide medical assessments and sex assault forensic examinations to victims of crime. 3. Program Description: The Sex Assault Nurse Examiner is a specially trained nurse to examine victims of violence,specifically sexual violence,for trauma injuries,collect forensic evidence for police and prosecution and provide medical referrals for treatment. These nurses are specially trained to perform the Sexual Assault Forensic Examination(SAFE)which entails 40 hours of didactic training and an approximate 40-50 more hours in a preceptorship/clinical environment to examine adults and adolescents and to provide care to children, must complete an additional 40 hours of didactic training and more clinical work. On the island of Hawaii,there are 3 fully trained nurses providing SAFE services for both the adult and pediatric population,and one nurse who is able to provide SAFE services for adults and is in training for pediatrics. All of the nurses have full time jobs elsewhere,and are not available on a 24/7 basis to provide services. Additional nurses are needed for the island. To provide for approximately 60 SAFEs and 40 medical assessments,there is a need for at least 6 more trained nurses to provide the care needed and full coverage. To assist nurses in getting the basic training,on-going training and access to training to current best practices,the SANE program is requesting assistance from the County of Hawaii. These funds will be used to provide tuition assistance for the didactic courses,membership to IAFN for professional development and peer review activities both locally and with national leaders,and support with certification. 4.Total Budget&Position Count: Total Program Budget: $102,887 Total Program Position Count: 5 Total Agency Budget: $2,854,191 Total Agency Position Count: 54 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Violence Against Women Act $106,324 County of Hawaii $4053 TOTAL: $110,377 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program has a variety of funding streams because sexual violence is something that few want to talk about. That being said,this agency is taking the following steps to keep this program funded: -- Partnering with the community for support either in-kind or monetary help to support the program. -- Collaborate with community programs to enhance support,provide referrals and not duplicate services. -- Applications to other funding sources. 7. Program Objectives Using County Nonprofit Grant Program Funds: Recruit and train 3 to 5 nurses for adult and pediatric SAFEs,and pediatric medical assessments. Keep the current nurses up to date in best practices,new procedures and peer review through professional membership to the International Association of Forensic Nurses. Support nurses in obtaining certification in both Adult/Adolescent and Pediatric Certifications. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Recruit and train 3-5 registered nurses in SAFE procedures. 6 courses of training will be completed. Provide membership to IAFN for best practices, peer review and procedures 8 professionals will be members of IAFN Support nurses in getting certification in Adult/Adolescent and Pediatric SAFEs 1 nurse will become certified in one area Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $22,615 $23,231 $615 Professional Fees $75,321 $76,000 Operations $1,882 $1,900 $0 Supplies $1,022 $1,100 Equipment $0 $0 Other: Training/membership $2,047 $5,000 $3438 Other: Other. Other: Other. TOTAL $102,887 $107,231 $4,053 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n T- he Mayor n T- he Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. 12/ CtO /)27/ 7 Signat e of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE 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 agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rPrgvPct and may rasiilt in artinnc taken to rprnvar thacP fiinrlc. By signing below,you are acknowledging that you have read and understood these requirements. (LC) /A-7/7 Signature f Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: SANE 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 6 courses of training will be completed. 8 professionals will be members of IAFN 1 nurse will become certified in TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $615 Professional Fees Operations $0 Supplies Equipment $0 Other: Training/membership $3438 Other: Other: Other: Other: TOTAL $4,053 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 YWCA of Hawaii Island Sexual Assault Support Services - Prevention Education 149 CI+ D . Ha ai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education Agency Director: Kathleen McGilvray Phone No.: ( 808) 935 — 7141 Contact Person: Lorraine Davis Phone No.: (808) 961 — 3877 Mailing Address: Address: YWCA of Hawaii Island Address: 1382 Kilauea Avenue City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1382 Kilauea Avenue, Hilo, HI 96720 Address: 75-5706 Hanama Place,#202, Kailua-Kona, HI 96740 City,ST,Zip Email Address: Idavis©ywcahawaiiisland.org Fax No.: (808 ) 961 — 9140 Accountant/CPA: Phone No.: (808 ) 935 — 5404 Firm (if applicable): Taketa, Iwata, Hara and Associates, LLC Mailing Address: Address: 101 Aupuni Street Address: Suite 139 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) I Puna Hamakua ✓ North Kona V South Hilo V North Kohala IVI South Kona Ill North Hilo IV South Kohala ✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns III Youth V Victims of Crimes Culture and the arts Aged I I Victims of Health or Social Crises Needs of the poor I I Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 $30,000 $10,000 $20,000 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 Hawaii Island(YWCA),first organized in Hilo in 1919, has offered valuable programs and activities for the benefit of women, children, and their families. the YWCA was established as a 501(c)(3)non-profit organization in 1965,and has been a partner agency of the Hawaii Island United Way(HIUW)since 1979. It belongs to a national organzation consisting of 300 YWCA Associations across the United States with 2.6 million members. Employing over 50 full-and part-time staff,the YWCA offers a variety of services to people of all ages,from newborns to senior citizens in their 80's through the island of Hawaii. Current programs in place include: Healthy Start,a child abuse and neglect prevention program;Teen Court, a diversion program for first time,teen offenders; Developmental Preschool,a NAEYC accredited preschool serving 2-5 year olds;Sexual Assault Support Services,a program operating a 24/7 rape crisis line and providing therapy to victims of sexual violence and their families; Sex Assault Nurse Examiners Program,a program to provide specially trained nurses to provide medical assessments and sex assault forensic examinations to victims of crime. 3. Program Description: SASS provides services for the healing of sexual violence. Sexual violence is an equal opportunity crime that crosses the boundaries of age, race, religion and gender equally. Sexual violence is pervasive on our island. In the last 6 months,the SASS program has opened 177 new cases of victims seeking services. To compare, 168 cases were opened during the same time frame last year. Our numbers are increasing and we expect to open 354+cases by June 30. Of the 177 cases that we opened,85%of the victims were female;73.6%were under the age of 17 and 96%of the victims knew their attacker. The cases that we opened constitute 30-40%of the total number of victims of sexual violence. Sexual violence is an underreported crime. While the program's primary goal is to respond to victims and their families and help them through the healing process of trauma,the SASS program believes in educational activities that give our community a voice BEFORE the crime occurs. Utilizing a Hawaii State DOE approved curriculum,the SASS program is requesting assistance to visit preschool,K-6 classrooms,youth groups and community organizations to talk about body safety, body respect and healthy relationships. We anticipate being able to reach 5,000 children in the classroom setting and 4,800 community members through community health and awareness events. Prevention educational activities are crucial to giving our keiki a voice and for adults to recognize signs of sexual abuse. Our primary funding through Sex Abuse Treatment Center and VOCA are for direct services only,and nothing for Prevention Education/Community Awareness.. Should the County decide favorably to the SASS program,it would be the only funding that would support the education and awareness building in the community. The funding requested would supply a 0.5FTE employee to provide prevention education and awareness services to the entire island. 4.Total Budget& Position Count: Total Program Budget: $626,974 Total Program Position Count: 15 Total Agency Budget: $2,854,191 Total Agency Position Count: 54 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Sex Abuse Treatment Center(Statewide Contractor) $431,638 Victims of Crime Act(Direct Services to Victims only) $44,917 Fundraising Event(Walk a Mile in Her Shoes) $8,000 County of Hawaii Non-Profit Grant $30,000 Other grants will be applied for to provide funding to keep the program intact. TOTAL: $514,555 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program has a variety of funding streams because sexual violence is something that few want to talk about. This agency is taking the following steps to keep the SASS program funded: -- Direct fundraising. In the past seven years,the YWCA has sponsored"Walk a Mile"and"Y-Walk"where the program was recipient of all the funds raised. The Board of Director's is planning this event for Hilo to be held in October 2017. -- Continuous grant writing to foundations,granting agencies,and response to request for proposal that would support the efforts in alignment with the program services. -- Working within the program to increase the infrastructure to provide more services to the under-served populations like trafficking victims,the LGBTQI community, isolated communities on the island,elderly and limited English speaking population. As the program is developed to provide services,additional grant monies through the State of Hawaii and Federal Office of Victims will be applied for through their RFP process. -- Partnering with the community for support either in-kind or monetary help to support the program. -- Collaborate with community programs to enhance support, provide referrals and not duplicate services. -- Third party billing with licensed therapists. -- As a last resort,we have considered but have avoided,requesting payments for services from victims. 7. Program Objectives Using County Nonprofit Grant Program Funds: The SASS program can maintain core services by providing services through the 24/7 crisis line,crisis intervention,face-to-face support in forensic exams and interviews and for therapy serving the same number of victims as in previous fiscal years. Moreover, because SASS is aware of the percentage of under-reported crimes with children, it is the goal of the program to provide additional training to the current staff who had been specifically trained to provide prevention educational activities in the schools and in the community. We want to work with our keiki to give them a voice;to help them stop something from happening and to get help,if something does happen. We expect to receive funding from SATC and VOCA to provide a majority of the core services and are requesting that appoximately 5 percent of our total budget be used to provide prevention education services to the entire island. In FY 2017,the program objectives for using County Nonprofit Grant Program Funds would support the following efforts: --Provide the necessary training and infrastructure to the program to support prevention education in our community,which will include preschools,grades K-12,college age and adults. The training will include training in the DOE accepted statewide curriculum and providing support in the community around the evidence based curriculum. --Provide prevention education and community awareness activities to Hawaii Island communities. --Maintain core services of a 24/7 crisis line,victim advocacy,crisis intervention and therapeutic services at no cost to the victim for increased disclosures as a result of education/awareness activities. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide evidence based curriculum prevention education to schools and youth groups. 5,000 children will have participate in a class. Provide community awareness activities at community health fairs and events. 4,800 people will receive information. Continue core services on the 24/7 crisis hot line. 350 victims will receive services. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $396,975 $400,000 $20,280 Professional Fees $106,153 $106,153 $3,000 Operations $74,237 $76,000 $0 Supplies $20,793 $22,000 $4,380 Equipment $3,950 $0 $0 Other: Staff Training $3,500 $3,500 $0 Other: Mileage $11,123 $3,000 $2,340 Other: Other: Other: TOTAL $616,731 $610,653 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council The Mayor The Managing Director I I The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. C_EC) ///),-.0 7 Signat re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding requect nnrl mny recult in nrtinnc token to rernver thecP fundc. By signing below, you are acknowledging that you have read and understood these requirements. //).,/-72,720 c_ 60 //2-7//7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services - Prevention Education 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 5,000 children will have participate in a class. 4,800 people will receive information. 350 victims will receive service: TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages $20,280 Professional Fees $3,000 Operations $0 Supplies $4,380 Equipment $0 Other: Staff Training $0 Other: Mileage $2,340 Other: Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8 YWCA of Hawai'i Island YWCA Developmental Preschool 150 Erav in I a .i`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool Agency Director: Kathleen McGilvray Phone No.: (808) 935 — 6067 Contact Person: Lissa Van Kralingen, MEd. Phone No.: (808) 935 — 7141 Mailing Address: Address: YWCA Address: 1382 Kilauea Ave. City,ST,Zip Hilo, HI 96720 Facility Address: Address: YWCA Address: 145 Ululani Street City,ST,Zip Hilo, HI 96720 Email Address: Ivankralingen@ywcahawaiiisland.org Fax No.: (808 ) 935 — 5150 Accountant/CPA: Phone No.: (808 ) 935 — 5404 Firm (if applicable): Taketa, Iwata, Hara&Associates Mailing Address: Address: Hilo Lagoon Center Association Address: 101 Aupuni Street,#139 City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) ✓ Puna Hamakua North Kona ✓I South Hilo North Kohala n South Kona ✓I North Hilo I I South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns Ill Youth I I Victims of Crimes Li Culture and the arts Aged n Victims of Health or Social Crises I Needs of the poor Physical/Emotional Disabilities VI Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 14-15 FY 15-16 FY 16-17 8000 10000 0 2.Agency Mission Statement: YWCA Hawaii Island is dedicated to eliminating racism, empowering women and promoting peace,justice,freedom and dignity for all. In 1919,visionary Hilo women responded to the need for safe housing for young women,founding the YWCA Hawai'i Island as part of a national and world-wide women's movement. Over the years,the needs of women and their families have shaped the programs and services provided by the YWCA.Today,we remain an advocate for women and children, ready as ever to respond to the needs and desires of women to make their place in the world. In keeping with our mission statement,the preschool empowers women through providing a healthy,safe, learning environment in which to place their child when they are in school to better their family's future or so they can be gainfully employed without having to worry about their child. The preschool also works toward eliminating racism,and promoting peace,justice,freedom and dignity for all through our curriculum which provides for character and values education as well as teaching tolerance and cooperation through mentoring, modeling and being a caregiver(Lickona, 1992). Reference Lickona, T.(1992). Educating for Character: How our Schools can Teach Respect and Responsibility. New York. Bantam Book 3. Program Description: YWCA Developmental Preschool focuses on the whole child...socially,cognitively,emotionally and physically. Our program is Licensed by the State of Hawai'i Department of Human Serves(DHS)and we are actively seeking re-accreditation through the National Association for the Education of Young Children(NAEYC). YWCA Developmental Preschool is unique because we expose children to the academic world in a nurturing,safe and secure environment that is catered to each individual child. We are able to accomplish this through the curriculum we use, Teaching Strategies Creative Curriculum. In our classrooms,the children get a balance of a structured learning environment as well as time to learn through their own self-initiated discovery. Our indoor and outdoor school environment offer the opportunities for children to make choices that will enhance their naturally emerging skills. Our belief is that children don't need to be forced to learn,they want to learn and they will. "The demand for early childhood care and education programs continues to increase not only in response to the growing demand for out-of-home child care but also in recognition of the critical importance of educational experiences during the early years. Several decades of research clearly demonstrate that high-quality,developmentally appropriate early childhood programs produce short-and long-term positive effects on children's cognitive and social development." (http://www.naeyc.org/ policy/excellence). 4.Total Budget& Position Count: Total Program Budget: 972,159.30 Total Program Position Count: 19 Total Agency Budget: 3,258,916.75 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 5. Program Funding Sources (identify all sources of funding applied to this program): FY17-18 Revenue Source Estimate Castle low-income tuition assistance 20,000 Castle Expansion Grant 17,000 Weinberg low-income tuition assistance 30,000 Program Fees 827,293.00 Central Pacific Bank professional development grant 12,000 Wal-Mart State Giving Grant 30,000 Hawaii Island United Way 16,500 TOTAL: additional page Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The program has, and will continue to seek grants to support the preschool. The program holds an annual fundraiser to help support the program needs. This past November,with the help of staff and families,the preschool raised $5000. The program has also planned to increase tuition as expenses, like minimum wage and cost for goods and supplies, increases. The program and agency actively seeks additional funding for equipment and participation in enrichment activities. The Agency and the program actively seek funding streams that benefit the program and the families we serve. Our goal is to enroll a minimum of 105 full time students to meet budget requirements. We had 103 children enrolled and due to inability to pay tuition 7 children were recently withdrawn from school. Depending on available tuition assistance and the parents ability to pay tuition,each month enrollment numbers change. We exhausted all possible funding streams for these families and were unable to secure tuition assistance for them. This funding may have kept the students in school,giving them much needed stability. The agency also conducts an annual fundraiser to raise needed funds, used for the physical plant and for projects which are unable to be funded from other means. 7. Program Objectives Using County Nonprofit Grant Program Funds: The YWCA Developmental Preschool works to; 1) To provide an environment which is safe,secure and is respectful of each child. 2) To promote growth for each child socially, emotionally, cognitively and physically. 3) To promote creative expression through art, music,dance,story-telling and cooking. 4) To promote awareness of our community and environment 5) To provide an Early Childhood Education opportunity for children who are outside of the Department of Education service priorities and those who the DOE are not able to serve due to classroom constraints. This would be the 2 and 3 year olds without special needs or challenges and the 4 and 5 year olds whose receiving school for Kindergarten is unable to accommodate them in a preschool setting. These Nonprofit grant funds, if obtained, provide tuition assistance for families who have more than one child enrolled in our program,short term tuition assistance for families who want to enroll their child but need financial assistance while they wait for a decision on their pending application with other agencies, and short term tuition assistance for families who are experiencing a financial hardship and need the financial help to keep their child enrolled. Families will be counseled on seeking other means of financial support and assistance in finding available sources will be provided by the child care director.A smaller portion of this grant request is to provide the children with enrichment activities such as ukulele lessons, music&dance performances, and cooking activities. These activities enhance children's learning and exposes them to activities outside of the classroom. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 3 of 8 Revenue Source continued USDA Child and Adult Care Food Program $85,300.00 Total $1,038,093.00 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of clients served with an average of$800 short term(2 to 3 months)assistance 16 students Provide 100 hours of support in art, music,cooking and dance projects for the children 100 hours of specialty instruction Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 16-17 FY 17-18 FY 17-18 Actual* Total Budget Grant Req Salary and Wages $452,173.31 $474,781.97 Professional Fees $17,847.74 $18,383.17 Operations $219,071.06 $232,389.69 $13,000.00 Supplies $9,200.00 $6,901.00 Equipment $3126.79 $3,169.09 Other: Direct $91,500.00 $33,000.00 Other: Art, Music, Dance and Cooking classes 0 $2000.00 $2000.00 Other: Occupancy $13,618.80 $87,550.00 Other: Benefits&taxes $150,584.18 $99,815.71 Other: TOTAL $957,121.88 $954,821.54 $15,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): 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. _ (70 ///30// Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with 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 2017-2018 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in nrtinnc taken to rernver thPcP funds, By signing below, you are acknowledging that you have read and understood these requirements. //3017ll Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2017-2018 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2017-18 Agency Name: YWCA of Hawaii Island Program Name: YWCA Developmental Preschool 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 16 students 100 hours of specialty instruction TABLE II: FY 17-18 Council PROGRAM EXPENDITURES Grant Request Award Salary and Wages Professional Fees Operations $13,000.00 Supplies Equipment Other: Direct Other: Art, Music, Dance and Cooking classes $2000.00 Other: Occupancy Other: Benefits&taxes Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2017-2018 Page 8 of 8