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2004-229I
jo i vN Indian River County Grant Contract This Grant Contract ("Contract") entered into effective this 1st day of October 2004 by and between Indian River County, a political subdivision of the State of Florida , 1840 25th Street, Vero 32960 ("County") and Center for Emotional & Behavioral Health , ( Recipient) , of: 710037 th Street Vero Beach , Florida 32960 MU Background Recitals A. The County has determined that it is in the public interest to promote healthy children in a healthy community. B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance") and established the Children 's Services Advisory Committee to promote healthy children in a healthy community and to provide a unified system of planning and delivery within which children 's needs can be identified , targeted , evaluated and addressed . C . The Children 's Services Advisory Committee has issued a request for proposals from individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling its purpose . D . The proposals submitted to the Children 's Services Advisory Committee and the recommendation of the Children 's Services Advisory Committee have been reviewed by the County. E . The Recipient, by submitting a proposal to the Children 's Services Advisory Committee , has applied for a grant of money ("Grant" ) for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged , the parties agree as follows : 1 . Background Recitals The background recitals are true and correct and form a material part of this Contract. 2 . Purpose of Grant The Grant shall be used only for the purposes set forth in the complete proposal submitted by the Recipient attached hereto as Exhibit "A" and incorporated herein by this reference (such purposes hereinafter referenced as "Grant Purposes") . 3 . Term The Recipient acknowledges and agrees that the Grant is limited to the fiscal year 2004/2005 ("Grant Period") . The Grant Period commences on October 1 , 2004 and ends on September 30 , 2005 . - 1 - 4 . Grant Funds and Payment The approved Grant for the Grant Period is Twenty Thousand Dollars ($20 , 000 ) . The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for Grant Purposes provided in accordance with this Contract . Reimbursement requests may be made no more frequently than monthly. Each reimbursement request shall contain the information , at a minimum , that is set forth in Exhibit " B" attached hereto and incorporated herein by this reference . All reimbursement requests are subject to audit by the County . In addition , the County may require additional documentation of expenditures , as it deems appropriate . 5 . Additional Obligations of Recipient . 5 . 1 Records . The Recipient shall maintain adequate internal controls in order to safeguard the Grant . In addition , the Recipient shall maintain adequate records fully to document the use of the Grant funds for at least three (3 ) years after the expiration of the Grant Period . The County shall have access to all books , records , and documents as required in this Section for the purpose of inspection or audit during normal business hours at the County's expense , upon five ( 5) days prior written notice . 5 . 2 Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws , rules , and regulations . 5 . 3 Quarterly Performance Reports . The Recipient shall submit Quarterly Performance Reports to the Human Services Department of the County within fifteen ( 15) business days following : December 31 , March 31 , June 30 , and September 30 . 5 .4 Audit Requirements , If Recipient receives $25 , 000 or more in the aggregate from all Indian River County government funding sources , the Recipient is required to have an audit completed by an independent certified public accountant at the end of the Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the Recipient shall submit the audit to the Indian River County Office of Management and . Budget . The fiscal year will be as reported on the application for funding , and the Recipient agrees to notify the County prior to any change in the fiscal period of Recipient . The Recipient acknowledges that the County may deny funding to any Recipient if an audit required by this Contract for a prior fiscal year is past due and has not been submitted by May 1 . 5 .4 . 1 The Recipient further acknowledges that, promptly upon receipt of a qualified opinion from it's independent auditor, such qualified opinion shall immediately be provided to the Indian River County Office of Management and Budget. The qualified opinion shall thereupon be reported to the Board of Commissioners and funding under this Contract will cease immediately. The foregoing termination right is in addition to any other right of the County to terminate this Contract. 5 .4 . 2 The Indian River County Office of Management and Budget reserves the right at any time to send a letter to the Recipient requesting clarification if there are any questions regarding a part of the financial statements , audit comments , or notes . 5 . 5 Insurance Requirements . Recipient shall , no later than September 21 , 2004 , provide to the Indian River County Risk Management Division a certificate or certificates issued by an insurer or insurers authorized to conduct business in Florida that is rated not less than category A- : VII by A. M . Best, subject to approval by Indian River County's risk manager, of the following types and amounts of insurance : - 2 - (i ) Commercial General Liability Insurance in an amount not less than $ 1 , 000 ,000 combined single limit for bodily injury and property damage , including coverage for premises/operations , products/completed operations , contractual liability, and independent contractors ; ( ii ) Business Auto Liability Insurance in an amount not less than $ 1 ,000 , 000 per occurrence combined single limit for bodily injury and property damage , including coverage for owned autos and other vehicles , hired autos and other vehicles , non-owned autos and other vehicles ; and ( iii ) Workers ' Compensation and Employer's Liability (current Florida statutory limit) 5 . 6 Insurance Administration . The insurance certificates , evidencing all required insurance coverages shall be fully acceptable to County in both form and content, and shall provide and specify that the related insurance coverage shall not be cancelled without at least thirty (30 ) calendar days prior written notice having been given to the County. In addition , the County may request such other proofs and assurances as it may reasonably require that the insurance is and at all times remains in full force and effect. Recipient agrees that it is the Recipient's sole responsibility to coordinate activities among itself, the County, and the Recipient's insurer(s ) so that the insurance certificates are acceptable to and accepted by County within the time limits set forth in this Contract . The County shall be listed as an additional insured on all insurance coverage required by this Contract, except Workers' Compensation insurance . The Recipient shall , upon ten ( 10 ) days' prior written request from the County, deliver copies to the County, or make copies available for the County's inspection at Recipient's place of business , of any and all insurance policies that are required in this Contract . If the Recipient fails to deliver or make copies of the policies available to the County; fails to obtain replacement insurance or have previous insurance policies reinstated or renewed upon termination or cancellation of existing required coverages ; or fails in any other regard to obtain coverages sufficient to meet the terms and conditions of this Contract, then the County may, at its sole option , terminate this Contract. 5 . 7 Indemnification , The Recipient shall indemnify and save harmless the County, its agents , officials , and employees from and against any and all claims , liabilities , losses , damage , or causes of action which may arise from any misconduct , negligent act, or omissions of the Recipient, its agents , officers , or employees in connection with the performance of this Contract . 5 . 8 Public Records . The Recipient agrees to comply with the provisions of Chapter 119 , Florida Statutes ( Public Records Law) in connection with this Contract . 6 . Termination . This Contract may be terminated by either party, without cause , upon thirty (30 ) days prior written notice to the other party. In addition , the County may terminate this Contract for convenience upon ten ( 10 ) days prior written notice to the Recipient if the County determines that such termination is in the public interest . 7 . Availability of Funds . The obligations of the County under this Contract are subject to the availability of funds lawfully appropriated for its purpose by the Board of County Commissioners of Indian River County. 8 . Standard Terms , This Contract is subject to the standard terms attached hereto as Exhibit C and incorporated herein in its entirety by this reference . - 3 - IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS By: Caroline D . Ginn , Chairmaf BCC Approved : 1 Attest: J . K . Barton, Clerk 40 By. D'e'pu., ietk , :. M Approve . Jos ph A:Bardu County Ar Appr and iency: ar' n E . a I , Assiorne RECIPIENT: By: Ce r f Em onal & Behavioral Health 4 - y EXHIBIT A [Copy of complete proposal/application] - 1 - The 'enter for Emotional and Behavioral Health AIRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional and Behavioral Health @ IRMH Executive Director : Dr. Raymond Dean MD E-mail : raymond . dean@irmh . org Address : 1190 37°i Street Telephone : 772- 563 -4666 ext 1809 Vero Beach, FL 32960 Fax : 772-770-2025 Program Director : Mariamma Pyngolil RN E-mail : mariamma. pyngolil@irmh . org Address : 1190 37thStreet Telephone : 772- 5634666 ext 1838 Vero Beach FL 32960 Fax : 772-770-2025 Program Title : Camp Manatee Therapeutic Summer Camp Priority Need Area Addressed: Therapeutic, intervention and educational program for children diagnosed with ADHD and other more severe emotional problems in Indian River County Brief Description of the Program : P1 -640 . 150-85 Therapeutic Camps-Day camp facility that is appropriately staffed and equipped to provide an opportunity for children who have developmental disabilities. emotional disturbances and/or health impairments who have other limitations or problems which require special facilities or projuamming, to enjoy a cooperative living experience in the out of doors. SUMMARY REPORT — (Enter Information In The Black Cells Only) Amount Requested from Funder for 2004 /05 : $ 20 , 000 . 00 Total Proposed Program Budget for 2004 / 05 : $ 52 , 564 . 25 Percent of Total Program Budget : 38 . 0 % Current Program Funding ( 2003 /04 ) : $ 20 , 000 Dollar increase/ ( decrease ) in request : $ _ Percent increase / ( decrease ) in request * * : 0 . 0 % . Unduplicated Number of Children to be served Individually : 35 Unduplicated Number of Adults to be served Individually : _ Unduplicated Number to be served via Group settings :mmmmmmm� 2 Total Program Cost mmm-mmmmWper Client : 1420 . 66 * * If request increased 5 % or more, briefly explain why : If these funds are being used to match another source, name the source and the $ amount : The Organization 's Board of Directors sl approved-this applicatio:?1100 � (o Char 1 eS V. Shc �hct t'1 Name of President/Chair of the Board Signature Te kr Sus ; Name of Executive Director/CEO 91 3 ' The Center for Emotional and Behavioral Health @UZMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROPOSAL NARRATIVE Please respond to each question in the allotted space for each section. In responding to each section of the proposal narrative, please retain the section-label and/or question that you are addressing. Type using 12 pt. font on 8 %" X 11 " paper and number each page. These directions and the graphic boxes may be deleted if space is needed. A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization. _ .. IndiauRiver .Memorial Hospital strives to be the finest community based health care organization anywhere. Our values are compassion, respect, and teamwork. The Center for Emotional and Behavioral Health @ IRMH is committed to provide excellence in Mental Health Care to the individual and families while responding to the needs of the changing community. Our patients can expect quality care with dignity and professionalism through the collaborative efforts of the multidisciplinary team. We will continue to support the Quality First process while working together as a team. Camp Manatee Therapeutic Summer Camp is committed to improving the lives of children and their families who are challenged with ADHD disorder with or without more severe emotional problems and who are at risk for alcohol/drug abuse, crime and school dro ut 2. Provide a brief summary of your organization including areas of expertise, accomplishments, and population served. CEBH provides Mental Health services to children, adolescents and adults . Psychiatric clinicians are located in the Emergency Department of IRMH and provide a comprehensive psychiatric assessment to determine level of care for the community. In patient services are provided on a voluntary or involuntary basis to all three age groups. The facility also provides out-patient therapy for children/adolescents and their families, parenting classes, EAP services, urine drug screens/drug free workplace services, a summer camp (Camp Manatee Therapeutic Summer Camp) for ADHD children and Experiential (ROPES teambuilding) services to the community. Camp Manatee Therapeutic Summer Camp is a structured and closely supervised program focused on the goals of increased self esteem, socialization, appropriate coping skills development, problem solving, creativity, play and communication skill building. These goals are achieved through a variety of carefully planned structured activities utilizing a behavior management feedback and reward program to teach specific skills. 4 ` y r The Center for Emotional and Behavioral Health @IRIM- Camp Manatee Therapeutic Summer Camp — IRC- CSAC Be PROGRAM NEED STATEMENT (Entire Section B not to exceed one page) 1 . a) What is the unacceptable condition requiring change? b) Who has the need ? c) Where do they live? d) Provide local, state, or national trend data, with reference source, that corroborates that this is an area of need. Children diagnosed with the psychiatric disorder, ADHD, are lacking a comprehensive day camp in the summer designed to meet their special needs and dispense medications . The children are ages 5 though 14 with the last two years designed as leadership skill and work skill development for previously enrolled campers who reside in Indian River county. _ According to http ://www.mentalhealth.org/features/surgeonggngralrepordchapterYsec2 .asp ADHD, which is the most commonly diagnosed behavioral disorder of childhood, occurs in 3 to 5 percent of school-age children in a 6-month period (Anderson et al., 1987; Bird et al. , 1988; Esser et al., 1990; Pelham et al. , 1992; Shaffer et al ., 1996c; Wolraich et al., 1996). Pediatricians report that approximately 4 percent of their patients have ADHD (Wolraich et al., 1990), but in practice the diagnosis is often made in children who meet some, but not all, of the criteria recommended in DSM-IV (Wolraich et al., 1990) (see also Treatment later in this section). Boys are four times more likely to have the illness than girls are (Ross & Ross, 1982). The disorder is found in all cultures, although prevalences differ; differences are thought to stem more from differences in diagnostic criteria than from differences in presentation (DSM-IV). 2. a) Identify similar programs that are currently serving the needs of your targeted population ; b) Explain how these ezisting programs are under-serving the targeted population of your program. -Sandy Pines ADHD Summer Program — Jensen Beach, Fl — closed program due to for-profit business and could not meet financials. No outcome data available. -Milestone Charter School, Brevard County Public Schools — In the years past, had a summer camp for ADHD, which modeled the program after Camp Manatee Therapeutic Summer Camp. School principal collaborated with Camp Manatee Manager to institute program in Brevard due to success of their children attending Camp Manatee. No outcome data available due to closing of the camp No other program like this currently exists in FL; however, several programs throughout the USA exist and are ` sleep-over' camps . 5 / The Center for Emotional and Behavioral Health @UZMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC C. PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two pages) 1 . List Priority Needs area addressed. It will increase recreation opportunities for children with special needs . Camp Manatee Therapeutic Summer camp offers age appropriate recreational activities to enhance social skills, coping skills, leisure and recreation skill development, and education about their disease. It is also a recreational program that allows ADHD to take their medications. Camp Manatee provides quality childcare before and after camp at an affordable price for working parents to help reduce the amount of juvenile crime. 2. Briefly describe program activities including location of services. -A written structured, age appropriate schedule of recreational activities to enhance social skills, coping skills, leisure, recreation skill development, and education about their disease. -Written Positive Behavior Management Program with immediate feedback in the form of verbal praise, tokens and skill development. Medication times to ensure continuity of care for ADHD children. -Parents of children enrolled are mandated to attend parenting classes specifically designed for parenting the ADHD child.-Experiential Team building Activities to learn & experience growth in self-esteem, making choices, supporting others, communication and developing trust. wSemior Campers 13 years old, community service education & project. -Camp Manatee Therapeutic Summer Camp is located at the CEBH, but utilizes the recreation and leisure resources within Indian River County to provide optimum services for these children 3. Briefly describe how your program addresses the stated need/problem. Describe how your program follows a recognized "best practice" (see, definition on page 12 of the Instructions) and provide evidence that indicates proposed strategies are effective with target population. The issues and problems ADHD with more severe emotional behavioral problem child face are: * Due to an ADHD child' s lack of impulse control, decreased self-esteem, poor social and problem solving skills these children are usually unsuccessful in regular camp and recreational settings. There is a lack of recreational opportunities and community service experiences available to ADHD children in general, and no other programs that specifically addresses targeted areas of concern. Research indicates that ADHD children are at a higher risk for drug & alcohol use. Research also indicates that with preventive education such as development of coping skills, better level of understanding of the disorder, parenting education classes, along with social skill development that the incident of substance abuse and delinquency will be decreased. * Pre & post camp childcare hours, at affordable prices, are difficult for working parents to find, Camp Manatee provides quality childcare before and after camp at an affordable price for working parents. * Recreational Activities program that allows ADHD to take their medication. 4 . List staffing needed for your program, including required experience and estimated hours per week in program for each staff member and/or volunteers (this section should conform with the information in the Position Listing on the Budget Narrative Worksheet). Camp Manatee Therapeutic Summer Camp Program Staffing: List of staff follows : ( I )Director of Patient Care Services — Advanced Registered Nurse Practitioner in child & adolescent 6 The Center for Emotional and Behavioral Health QIRMI I- Camp Manatee Therapeutic Summer Camp.- IRC- CSAC psychiatric nursing- 5 % time of full time position; . 05 position, 20 years experience with children & adolescents mental health programs. Assist with critical incidents and behavior interventions. (2) Psychological Services — Doctoral Level Clinical Psychologist; 5% time of full time position; .05 position. Provides clinical supervision to behavior program content, revisions, clinical standards and parenting education classes . Assist with more serious behavior problems with children & their families when they occur. (3 ) Manager of Activity Therapy — Bachelor degree, certified by National Therapeutic Recreation Society. 10% time of full time position; . 1 position. 15 years experience in Therapeutic Recreation services with children & teenagers; 10 years experience with Camp Manatee Program. (4) Supervisor of Camp Manatee — Certified Special Education Teacher. 25% of a full time position; .25 position. Many years of experience in services with children & teenagers. (5) Camp Counselor — High school diploma plus 2 year experience working with children and entering or enrolled in college with a major in mental health related field. 32 hours training on ADHD (provided by CEBH), behavior programming and skills competencies completed and passed. 100% time; 6 positions; 7 weeks; 35 hour week; summer only. (6) Assistant Camp Counselor — High school student who has ADHD and will be helping with various aspects of camp. He will report directly to the camp supervisor. Camp Manatee in the past has recruited volunteers through IlWH teenage auxilian volunteer (TAV) program, IRMH Auxilian/Volunteer Services, Volunteer Action Center YVC — Youth Volunteer Program, St. Edward' s Upper School - Community Volunteer Program. Due to IRMH' s policy on client confidentiality, Camp Manatee must use discretion on selecting volunteers and limit the number of volunteers. 5. How will the target population be made aware of the program? Camp Manatee Therapeutic Summer Camp reaches clients it intends to help by providing literature to schools, medical doctors, therapist, parents, at health fair in Indian River County, to patients treated at CEBH. Camp Manatee Therapeutic Summer Camp staff welcomes all opportunities to speak at organizations, TV, radio, specialty articles in newspaper, etc CEBH provides collaboration with the community through: ( 1 )Vero Beach Press Journal Ads "IRMH Community Calendar and Special Summer Camp Section in Lifestyles (2) Camp Manatee Open House each April to welcome all community members. (3)IRMH Annual Health Fair — distribute flyer & provide educational information for prevention & treatment of ADHD.(4) Vero Beach Health Fair Booth — distribute flyer & provide educational information for prevention & treatment of ADHD.(5)Women' s Health Fair — distribute flyers & provide educational information for prevention & treatment of ADHD " 6. How will the program be accessible to target population (i.e., location, transportation, hours of operation)? Camp Manatee Therapeutic Summer Camp is located at CEBH across the street from IRMH and easily accessible from US 1 or Indian River Boulevard. The hours of operation are 9 : 00am- 3 : OOPM, with the option of before care from 8 : 00AM-9 : 00AM and after care from 3 : OOPM- 4 :OOPM. Transportation is provided by Camp Manatee for field trips, but parents/guardians must provide own transportation to get child to and from camp. 7 • Tkw Center for Emotional and Behavioral Health @U MI i- Camp Manatee Therapeutic Summer Camp — IRC- CSAC D. MEASURABLE OUTCOMES (Description of Intent) Use the Measurable Outcomes orm. This description pagre does not need to be included in the proposaL In order to show the impact that your program is having on the target population and the community, the funders are requiring measurable outcomes. Please review the examples and summaries below to insure your understanding of what is expected. OUTCOMES : Describes what you want to achieve with the target population. Indicates the results of the services you provide, not the services you provide. Outcomes utilize action words such as maintain, increase, decrease, reduce, improve, raise and lower. - ACTMTEPS : Describes the tasks that will be accomplished in the program to achieve the results stated in the outcomes. Activities utilize action words such as complete, establish, create, provide, operate, and develop. The activities should reflect the services described in the PROGRAM DESCRIPTION (C2). Use the following elements to develop your outcomes. All elements must be included.- • Direction of change • Timeframe • Area of change • As measured by • Target population Baseline: The number that you will be • Degree of chane measuring against Example I (Outcome) . To decrease (direction of change) number of unexcused absences (area of change) of enrolled boys and girls (target population) by 75% (degree of change) in one year (time frame) as reported by the 2003 School Board attendance records (as measured by). Baseline: 2003 School Board attendance records for enrolled boys and girls . Example 1 (Activity) . To provide anger management classes to enrolled boys and girls 2 times a week for 12 weeks . Example 2 (Outcome) : 75 % (degree of change) of youth (target population) who have participated in the academic enrichment activities (as measured by) for 6 months or more (time frame), will improve (direction of change) their scores in one or more subject area (area of change) . 25% of participants in academic enrichment activities will maintain the initial level of performance assessed at entry. Baseline: Pre-test scores from the academic enrichment test. Example 2 (Activity) : 1 ) Provide pre and post-test exercises on the Advanced Learning System software; 2) Participants will go through the one lesson per week and be graded for 10 weeks. IMPORTANT NOTE : Keep in mind when developing your PROGRAM OUTCOMES , that if funded, this will be what you are held accountable to accomplish. Also, the PROGRAM OUTCOMES should reflect the information described in the PROGRAM NEED STATEMENT (B 1 ). All Program Need Statements should flow from the Mission & Vision. Measurable Outcomes should be based on and measure program needs . Activities are the tasks you do that are going to influence the outcome and impact the unacceptable condition in your Program Need Statement. 8 • Thi Center for Emotional and Behavioral Health @MIA I- Camp Manatee Therapeutic Summer Camp — IRC- CSAC D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all o the elements or the Measurable Outcomes Add the tasks to accomplish the Outcome(s) 1 . To decrease the number of missed 1 . Provide camper' s prescribed medications medications of enrolled ADHD campers by under the direction of a qualified professional 100% as reported by the 2004 medication (RN) and counselor to manage the medical chart records: Baseline: Medication chart on needs of each child daily each child 2 . To increase the ability to utilize coping skills 2 . Instruct & provide written feedback of enrolled ADHD campers to 100% as regarding camper' s coping strategies each day reported by daily feedback report by to parents. Parents respond on sheet and return counselors and returned next camp day with with signature parental signature. Baseline: Daily feedback report 3 . To increase the overall parental 3 . Instruct & provide 4 — 1 . 5 hour of education understanding of strategies on how to cope regarding strategies so that the parents can with their children' s maladaptive ADHD better manage the maladaptive behaviors of the behaviors by 100% as reported by parent post ADHD child education evaluation form . Baseline: Pre-class evaluation assessment. 4. To increase the ability to demonstrate, attend 4. Sr. Campers and Jr. Counselors will receive to and organize daily tasks assigned to Sr. up to three tokens, per hour for completion of Campers and Junior Counselors, to 80% of the organized daily tasks. time as reported by the behavior management system and daily feedback sheets. Baseline : Daily feedback sheets 9 ' The Center for Emotional and Behavioral Health CIRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC E. COLLABORATION (Entire Section E not to exceed one page) L List your program 's collaborative partners and the resources thata they are providing to the program beyond referrals and support. (See individual funder requirements for inclusion of collaborative agreement letters.) Collaborative Agency Resources provided to the program Camp Manatee Jeff Home Memorial Foundation funds donated to assist lower income Fund families with Camp Manatee fees The Skate Factory Discounted rate for campers to skate. Rate is good for all six weeks of camp. Barefoot Bay Homemakers $200.00 donation to assist children' s fees in North Indian River County IRMH Auxiliary Supplying volunteer to help with marketing materials Florida Institute of Technology (F.I.T) Allowing psychology resident students to assist with ADHD parenting classes Indian River County Schools Student Support Services by supplying educational laws for children with disabilities. Also co-facilitating parenting classes for parents of children receiving scholarship to camp Indian River Memorial Allowing us to utilize the facilities of CEBH (pool, Hospital/CEBH existing play equipment, ROPES course, playground, gymnasium, art room, van, cafeteria, and lounge) and supplies (postage, phones, electricity, copy machines, and existing arts and craft supplies) to run Camp Manatee for 6 weeks during the summer. Dr. Judy Linger is providing support for parenting classes, medication education, and critical incident counseling. Ercildoune Bowling Center Discounted rate for campers to bowl . Rate is good for all six weeks of camp , 10 I I , The Center for Emotional and Behavioral Health @a IRMI I- Camp Manatee Therapeutic Summer Camp= IRC- CSAC F. PROGRAM EVALUATION (Entire Section F not to exceed two pages) 1 . DEMOGRAPHICS : What information (data elements) will you need to collect in order to accurately describe your target population including demographics (age, gender, and ethnic background) required by the funder in Section H? What are the pieces of information that qualify them for your target population? How do you document their need for services or their "unacceptable condition requiring change" from Section Bl ? We have created a camper database in Microsoft Access that will allow us to track the following demographics as provided by the parents via the registration form. ❖ Age ❖ Gender ❖ Ethnic Background •'• Family income ❖ School attending •'• Medications •'• Zip code 2. MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D ? What tools or items are you using as measures (grades, survey scores, attendance, absences, skill levels) for your program? Are you getting baseline information from a source on your Collaboration List in Section E? Are there results from your Activities in Section D that need to be documented? How often do you need to collect or follow-up on this data? We have developed a point system (based on the behavior of the camper) and feedback sheet (a written synopsis of the day for each camper given to his/her parent(s)) to track our outcomes and record the statistics. We also have evaluation forms filled pre and post parenting classes to accurately measure goals and outcomes of our interventions and education. The Feedback sheets and point sheets are filled out on a daily basis by the camp counselors assigned to each group. The numbers will be complied on a weekly basis and entered in to a database accordingly. From the database we will be able to chart our outcomes 3. REPORTING : What will you do with this information to show that change has occurred ? How will you use or present these results to the consumer, the funder, the program , and the community? How will you use this information to improve your program? The numbers for the point system will be complied on a weekly basis and entered in to a database accordingly. From the database we will be able to chart our outcomes to see when improvements in behaviors are being made . We will be keeping all the returned feedback sheets for one year, to reference as needed. Information collected for pre and post parenting classes is complied and then entered in to a database. We will be able to chart the results and accurately measure outcomes . The information is shared with the counselors and parents of the child in camp, with a signed release of information form . It may also be shared with educators and therapists, to help better serve the child' s needs . Il ' Thi Center for Emotional and Behavioral Health @1RMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC R G . TIMETABLE (Section G not to exceed one page) 1 . List the major action steps, activities, or cycles of events that will occur within the program year. New programs should include any start-up planning that may occur outside the funding year. In completing the timetable, review information detailed in prior sections. Month/Period Activities January 2005 Confirm dates of camp and open house, contact marketing to update flyers for open house, call HR department to advertise for 6 counselor positions, review criteria February 2005 Review, update and print all camp forms (registration, releases, medications), update file systems, review budget March 2005 Mail open -house flyers, order behavior/reward system items, list and compose letter to potential field trip sites, set up interviews for counselor positions April 2005 Host open house (call employees to attend open house), send memo to food service requesting daily snacks for camp, secure rental vans for field trips, inventory and order art supplies, gym equipment, pool supplies, and games, order camp shirts for counselors, review registration forms, send out follow up letter to parents, set scholarship committee meeting to review and reward scholarships to applicants May 2005 Develop and finalize camp schedules, review and update 5 -day counselor training, review and update counselors schedule, research new ADHD information, secure dates and speakers for parenting classes, sort and stock point store, finalize camp registration forms, secure field trips by completing check requests June- July 2005 Week 1 Counselor training and Week 2 Camp begins, complete and distribute pre-evaluation for parenting classes, hold parenting sessions, continue to compile goals and outcomes, as well as charting information, hold daily pre and post counselor meetings of August 2005 Use feedback from counselors for planning and implementing (changes in the program and brainstorm new ideas for next year), complete counselor termination form, wrap up grant information (employee paycheck, cancelled checks, finance department) . 12 The Center for Emotional and Behavioral Health QIRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC H. PROJECTIONS FOR UNDUPLICATED CLIENTS Number of Unduplicated Clients by Location 2 „`, " sa"Yk »y r 1. ,.Z ' n 3.;'ta"Yk4' MMt�f Irt ` Current Fiscal Year ri y° Tete 'isca . `,f� a ;� .[ <e%• �i1 Wei S+C.�iSf'! Mirf 4j ryl'F' �Z• ;:.a`�Ty }•YLf a� . Location a -Am m"4 ' Budget 2003/04 F " + Unduplicated Clients Unduplicated Clients Unduplicated Clients N. Indian River County 10 10 13 S. Indian River County 33 19 22 - Indian River CWTotal 43 29 35 Greater Stuart Hobe Sound Indiantovm Jensen Beach Palm City Martin County Total Fort Pierce Port Saint Lucie St. Lucie Co. Total 1 1 - Other Locations TOTAL SERVED 44 301 35 Number of Unduplicated. Clients by Age gs izi .ry�yf ,c? i .' V :sem rY'i tw-c +(k'a�dT' s0r, Current Fiscal Year41 Location Budget 2003/04 ' < NOW I o 2 Ind ividuals Group I . wo - tlfYa d r, km.. ..-:•�Y ""R; . 'z ,y !:" .:NzB(E' t r. ♦ a"' 0 to 4 - (Pre-school) - - - - - 5 to 10 - (Elementary) 26 2 18 2 18 2 11 to 14 - (Middle) 18 2 12 2 17 2 15 to 18 - (High School) - - - - - - Total Children 44 4 30 4 35 4 19 to 59 - (Adults) - - - - - - 60 + (Seniors) - - - - - - Total Adults - - - - - - TOTAL SERVED 1 44 4 30 4 35 4 13 ' The tenter for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below. " Core Budget Forms " 14 CEBH@IRMH/ Camp Manatee Therapeutic Summer Camp UNIFORM GRANT APPLICATION BUDGET NARRATIVE WORKSHEET IMPORTANT: The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder Specific Budget Forms. AGENCY/ PROGRAM NAME : CEBH a@IRMH/ Camp Manatee Therapeutic Summer Camp FUNDER : IRC -CSAC I CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should I 'tbe used for calculations and to write information onl . - - - - - - - - - - - - - 1 Children's Services Council-St. Lucie 2 Children's Services Council-Martin 3 Advisory Committee-indlan River 20,000.00 209000.00 152,605.07 4 United Way-St. Lucie County 5 United Way-Martin County 6 United Way4ndian River County 7 Department of Children & Families 8 County Funds 9 Contributions-Cash 200 00 200 00 10 Program Fees 10,000,00 697009000.00 11 Fund Raising Events-Net 12 Sales to Public - Net 13 Membership Dues 14 Investment Income 15 Miscellaneous 16 Legacies & Bequests 2 ,000.00 2 ,000.00 17 Funds from Other Sources 18 Reserve Funds Used for Operating 19 In-Kind Donations- IRMH 20,364.25 20 TOTAL (doesn't Include line 191 $32,200.00 $20,000.001 $6,854 ,805.07 :?: : . .�'NA. ::.:::. . . ... . . . . . . . . . . . . . . . . :::::::::::.: . :::::::;:::;:: . .: . . . . . . . . . . . . . . . ;:::.::::,. :.: . . . . . . . . . . . # ;::::.... .. Firncfer. .5 . f✓Il •; .; .;:.;;:. ;.> .:;> : . _:::::,::;.;:.;:.;:;.::.;;:.;:;.;::.;;;:<:::::::._::.�.�::::::::.�:;:.::.;:.;:.:.:.;:.:.;:.;•;.;;;;•::.:::. :.. � �. �,a. : . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . .: . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . ::. . . . . . . . . . . . . . . . . 1�'. . . . . . . . . . . . . . . . . . . . . . :. . .ataf. %A .enc . . . . . <. . . . . . . . . .: . . ;:::<;:.::;.;r:.;>:.>::>: »:: :::�»»::> . . . .; .; 21 Salaries - (must complete chart on next page) 34,272.50 18,578.73 3551 ,4,47.21 V4 a I . . . . . . . . . . . 22 FICA - Total salaries x 0.0765 : > 1-144va 21621 .85 11421 .27 271 ,685.71 23 Retirement - Annual pension for qualified staff ` ? „ ? I $ , ' 813.42 0.00 170,824.61 24 Life/Health - Medical/Dental/Short-term Disab. 2,748.04 0,00 577, 110. 17 25 Workers Compensation - # employees x rate '> " '•.:`•. > 3 ? 1 : ' 299.32 0.00 62 ,860.62 t- londa unemployment - # projected 26 employees x $7,000 x UCT-6 rate 81 . 17 0.00 17 ,046.65 05/24/2004 B-t CEBHQIRMH/ Camp Manatee Therapeutic Summer Camp /� . . .: : '2 ::::: : ...iso:: :: > :>::>::::: :> : ::::: :: <::«>'s.>:::>:; > .�.�:::: . {::>::::>;::;<<:;::»::>:««.<.;:::::>::::;>:<>;:«<:::>::: :::>::>: " . ;:a:»>::>::::»::: » : »::::»::>:::<:::»:::::. . . ..::::. .:::: «::<::« ;t:> :: . . . . . :. . ::::, . . . . . . . . . . . . . . . , . . . . . . . . :. . . . . , . . . . .: . . . . . ., . . : ::.:: � fu»der. :: ;::::.;:.: :.::::::: .:::::: .:.;.:.; .;:. . . . . .� ::.:: .:nttty Pf?�Sf �L31 :L1.s� .TINC ::::::. .: . . . . . . . . . . :. :.::. :.::.:::::::::! ! .::::, tq . . . . . . . . . . . . :::: ::. :::::.: . . .: .: . :. : :::::::::::: .:::: .. ::. :.:.:::.:: . 96. .af.Grass:ltn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sala : . : : :, .:;: ;:.;;:;:.;:.::.>;;;:;:.;:.>;:: �.;;:.;:;:;;:.;:..;;::.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :;.;:.;: ;:.;:.: :::::::: . . . . . . . . . . . . . . . . . . . . . nit . .:c�st��rr .�. . . . . .��'QST:�t�VxK;.;:.:;.::-;:;;.::.:..::: .::.::;:.;:.;:::.:< .;:.>;:: :.;<:;.: ;::.;:.:.;;;:<.:;.;:;;;.;;::<::;:. .: : . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f . <R� r. r." '. . . . . . . . . . . . . .:: . . . . . . . . .: .: . .:: .:1!t�,fJ!f1U:iJtt : ;;.;:;.:: ;:;•;:;.: ;:•:.:;;:;.; <;•;::;:.;:.>:;;:.: S;SOU:;i�: :::;:;:::::;;:.;::;::;:.;:<;::;:;:<;;:;:<;:7. �¢,1; Director of Patient Care Services/40 hrs 90,280.74 40514 .04 0.00 0.00% Psychology Fellow/40 hrs 449133.44 2,206.67 0. 00 0.00% Manager of Activity Therapy/40 hrs 49,917.92 41991 .79 0.00 0.00°� Camp Manatee Supervisor/40 hrs 41200.00 41200.00 41200.00 100.00°.G Counselor - A group/40 hrs 21800.00 2 ,800.00 2 800 00 100.00% Counselor - A group/40 hrs 21800.00 2,800.00 21800.00 100.00 Counselor - B group/40 hrs 21800,00 2 ,800.00 21800.00 100.00% Counselor - B group/40 hrs 21800.00 29800.00 20800.00 100.00% Jr. Counselor - Camp Assistant/40 hrs 1 ,960.00 1 960 00 11960.00 100 00% Registered Nurse/40 hrs - 521000.00 5,200.00 11218.73 2.34% #DIV/O1 #DIV/01 #DIV/0! #DIV/01 #DIV/Ol #DIV/O1 #DIV/01 #DIV/O1 #DIV/O1 #DIV101 Remaining positions throughout the agency 31297,755. 11 Total Salaries $3,551 ,447.21 S34,272.50 $18957;8.7730410.52% ..•., . . . ::� .:::::: �;>��R2;Y:;;: ::; rs :���:?:;::_:: . �:: � ' ' ' � . .. . ;;:.;:.:::.:: ::. ::::: .: . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . .F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . : . -: .: .;. . . .,. .,.: . . . . . .,. . <; ;;:�. ::•.�:. :. . .411:> :# ;s•:>: �>- : >� �` '�:�>: >:� : tltk . : . :: : :-: ;•::::. ::. :::::: . . .Ctfl .;: ;: 7 ;::;::•:::::::•:::::::::,. ,::;: h/:.Yr7t.::. : # PI.F#l! S:Ft!?tlf�l :.: : ;.c�!#,[ttfi::�:• <> _ : . . . . . . :.�. . . :::._ .: a�e. . . . . . . . . . . . . . < Ftr1l.:::�.66�'►.- :;:::>:::.::>-><;•.>":<:::�:: .:#fBattfia ::.Ease M a??a9r'. . . . . : ?!s :::•: xx r. :.f10 0 00 3D Director of Patient Care Services/40 hrs 0.00 0,00 0.00 Psychology Fellow/40 hrs 0.00 0.00 0. 00 Manager of Activity Therapy/40 hrs 0.00 0.00 0 .00 Camp Manatee Supe nrisor/40 hrs 4,200.00 321 .30 321 . 30 Counselor - A group/40 hrs 2 ,800.00 214,20 214.20 Counselor - A group/40 hrs 26800.00 214.20 12144...2 Counselor - B group/40 hrs 2 ,800.00 214.20 Counselor - B group/40 hrs 2,800.00 214.20 Jr. Counselor - Camp Assistant/40 hrs 1 ,960.00 149.94 Registered Nurse/40 hrs 1 ,218.73 93.23 93.23 0 0.00 0.00 0. 00 0 0.00 0.00 0. 00 0 0.00 0.00 0.00 0 0.00 0.00 0.0 0 0.00 0.00 0. 00 0 0.00 0.00 0. 00 0 0.00 0.00 0.00 0 0.00 0.00 0.00 0 0.00 0.00 0. 00 0 0.00 0.001 O.nno Total Funder Request Fringe Benents $18,578.73 $ 10421 .27 $0.00 $0.00 $0.001 $0.00 $ 1 ,421 .27 05/24/2004 B-1 • CEBH©IRMH/ Camp Manatee Therapeutic Summer Camp • • :: :::::.:::::::::..: ::::.. ::::::::.:::::::.:::. ::::::. :.:::.::::::.:>::.:::::::::. >;>:.: ::.::.:: : :::.::. 11� jy: :: ::: :. .. . . :: :. ......:. ::: :::iiWNE .:..-.:::: : :::: '.: < :. •... .. ...: ; ::: : ::: :: :: : ::::; :2 :; '.`i:4:: :::::i:: ::> : :> ...: :;:::i : »:::::i: -:5eM... �::•/.�� > /;y:• : �:y .: ::i1i»: ::iii::>::>:: ; : M.:404:#00. . . :::i ;::<::;::> . . . .MON . . . . . . . I . . . : , . ::: .: . . . . . . . . . . . ta! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . .:: . . . . . .� : :::: :: :::: . ., .XCENCYUSE.ONl,Y.iG :::.::,. . . . . . . . . . . . . . . . . . . : :.. ::: . .::::.:::.�::::::.:: . . . . . . . . . . . . . . . . . . . . :::::::•:; .>:.;:.;: :1..'.".','..::: . . :. . . . . ::. . ::: . . . . . . .�. . . . . /4 G/'� . . . . . . . . .:�.�.�:.� :: : : ;:.::.:.;:.;;:,• .;::::::::::::,:.::: ::.,::.; :.;:;,: .>;;:::: :. .: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . fit` 27 Travel-Daily :>::::i: :i:::::»::.=:: ::<:::::::::::::::::::::::::::iii:::ffc 324.00 0.00 2 ,635.77 e of miles /wk Staffx avers # I # of /wk x 50 wks x 9 $ Estimated Daily Trave l/Milea 9 e Reim!) erencesM-House _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Travel/Conf Training :: <.... : :. ...„. : v.v...::::. 0,00 0.00 50,035.54 • National Conference cost per staff)a Training/Seminar• (cost per staff) • Other Trainings (cost of travel , lodging, registration , food) 29 Office Supplies ffic PP . . . . . .. . . . . . . . . . . . . . . . . . . . . . :::::::::::::: < :: : : > :::}: :;>:: 0.00 0.00 48,249.00 • ie o : :•:•:> ::> ::: : : : : ....:. ....:. .....: .. ... ..... z«<:::::........:.::::...... ::: :::.. .. :.: ......:::.::. ... ..:.;:•i .... . . ... . . .. . . :•: : ::;. .x.:.:.:..z.:::: . . :. . . . . . . . :. . . . .. .. . . . . . .. . .. . : Office suppl s (m nth& average x 12 months : : :.:_:::. e..... . ...... . ... :..smiiii::::• isKi: ::..... iii ii ... . . . :.: :: : i: : :. .... . .:,: .� . . :. :. ::: .... *Kt :::i*i:i:::::.. . . :. .... ::::. .....� .... :::::: . . : . 9 estimated cosot f office supplies sba sed on Pe res nt history:- • 30 Telephone E::::::."•:::.M ::.: 258.75 0.00 44,805.00 oeli • # Phone nes x average cos vera 9 tPe r month 12 months = localho P necost • Average long distance calls x 12 months the — o Estimated c st of long distance nce os 31 P to e/Shi in 9 PP 996.20 0.00 1 ,638.00 ;:::::::?:::::::::::::::::::?:::;::?:::::: • Quarterly Mailing Of Newsletter er < M:::: :W::::::::: :: CEBHQIRMW Camp Manatee Therapeutic Summer Camp • Com uteri onito P m r # x • ae L s r Printer 7 . ::::40 Professional Fees ( Legal, : :::: :. : 0.00 0.00 303 653.00 timated • Legaladvice es #h s r x i • ( C n ult nt o s a fees • Other 41 Books/Educational Materials ::::•::::::::::::.�::::.:::: 1 ,300.00 0.00 28,657.00 • Books/videos • Materials x sta ( ffl 42 Food Nutrition F 12050.00 1129720.00 • Meals # meals x clients x 5daY s x 50 wks :;::4`i :_ 'i:•isiii:�i:i•:+.is•:•i:-ii:Lii:•iY•iii::`iiii: �• Snacks e Costs d inistrativ 43 A m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :.:::.:::.:::::.::::::.::::::;:.;:;<::.;; • : <::< :: ?:s`:> <:: :: 3,010.00 •:::•::::::::::• :•. :0:•:.00. .. .. :. . . . . . . . . . . . . . . 567,617.55 ::::•:::Admin. Cost (% of total budget : : o>: : : zi :::: :::: « . 44 Audit Expense : 0.00 0.00 Independent Audit Review 45 Specific Ass o t Assistance Individuals Is . .. . .. . . . .. . . . . .. . . . .. . • 0.00 Medical assistance :.:.; o::..00: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Meals/Food : ::::Y::;:;:;�:}'•:•::�i: is � :i:ii:'v:Ctt:C : : :>.':{iii is �'+-ilei?'i:i:::: • ... """"<''"""'�•i';i:tivtiti:•ii:;i::tititi4i:C:r:;:•i:•ii:• •: • Rent Assistance .... : ::::::»::» »»::>::»::»»::»:: :;:;;;.;:; : : : '.>::>:'•: ::'•>::::> <:::> :< :> :: :> :> :>? : ;,.._ . Other 6 4 Other/Miscellaneous »:::r 360.00 0.00 11575.00 Background check/drug Backg h ec < ' < »>`': > z3 ' ?>< :»:<:;:::<::;:»>:<: :;:: ::>:<:»:::>: ::»>::»::>::>:::» ;:•;::•;:.:.;;:;•;::•:.;;:;. •: •;:.;:;.;:.;:•;:.;:.;:::... :::. :::::::::::::::::. ::::::::. : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 test • Other hr C 47 Other/ ontract 0.00 • : : : 0. :.:00. . ::. . :::: . . . . . . . . . 7. .4. .0. . ,. 000.00Sub-contractfor program services .... ... . ....... » : :: woo 0 " 48 TOTAL EXPENSES $52,564.25 $20,000.001 $8, 138,3o1 .5s 05/24/2004 B4 w CEBH@IRMW Camp Manatee Therapeutic Summer Camp from MCR MCR $63'25per MA MCR Ancillary 05!24/2004 B-I CEEIMiDIRMY fgrrp MOMM iMapM°t :vrtm5r l op " UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME :CEBH IRMH/ Camp Manatee Therapeutic Summer Cam FY 02103 FY 03/04 FY 04105 % INCREASE FYE_913012003 FYE_9/30/2004 FYE 9/3012005_ CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (coL PcoL Bucol B REVENUES BUDGETED BUDGETED 1 Children's Services CouncilSt. Lucie "0.00 #DIV/01 2 Children's Services Council-Martin #DIV/O! 3 AdvisoryCommittee-Indian River 20 000.00 24445 524.28% 4 United Way-St Lucie County #DIV/0! 5 United Way-Martin County #DN/OI 6 United Way-Indian River County #DN/Ol 7 Department of Children & Families 0.00 #D1V/0! s County Funds 0.00 #DN/O! 9 Contributions-Cash 200.00 #DN/0! io Program Fees 69931 ,136,001 6 900 000.00 61700,000,00 -2.90% 11 Fund Raising Events-Net 0.00 #DN/01 12 Sales to Public-Net 0.00 #DN/Ol 13 Membership Dues 0.00 #DN/OI 14 Investment Income 0.00 #D1V(0I 15 Miscellaneous 0.00 #D1V/0l 16 Legacies & Bequests 21000,00 #DN/01 17 Funds from Other Sources 0.00 #DN/01 is Reserve Funds Used for Operating 0.00 #DN/0! is In-Kind Donations pwkmkxmdintow) 0.00 #DIV/O! 20 TOTAL 6 951 136.00 692444500 6 854 805.07xwo EXPENDITURES 21 Salaries 31446,298,001 31448,007,001 3 651 447.21 3.00% 22 FICA 240 456.001 a 263 902.0011 271 685.71 2.95% 23 Retirement 165 766.93 165 849.14 170 824.61 3.00% 24 Life/Health 560 023.431 a 560 301 .14 577110.17 3.00% 25 Workers Compensation 60 999.47 6102972 62,860.62 3.00% 26 Florida Unemployment 16 542.23 16,550.43 17 046.95 3.00% 27 Travel-Daify 21389.00 21559.00 2,635.77 3.00% 2e Travel/Conferences/Training 49 549.00 49 649.00 50 ,035.64 0.98% 29 Office Supplies 47 051 .00 4824900 48 ,249.00 0.00% 3o Telephone 42,157.021 43 460.85 44,805.00 3.09% 31 Postage/Shipping 19547.00 11638,00 1 t638.00 0.00% 32 Utilities 66182.00 6170000 66 636.00 8.00% 33 Occupancy (Building & Grounds 111361B99.00 1 119,712.00 1 121 909.12 0.20% 34 Printing & Publications 31145.00 31331 ,00 31464.24 4.00% 35 Subscription/Dues/Memberships 1 ,705.00 11524,00 11524.00 0.00% 36 Insurance 390,200.00 355 200.00 360 000.00 1 .35% 37 Equipment: Rental & Maintenance 81614.00 966000 91650,00 0.00% 3e Advertising 4 996.00 61000.00 5 000.00 0.00% 39 Equipment Purchases:Ca ital Expense 13 115.00 17 557.00 177657.00' 0.00% 40 Professional Fees (Legal, Consulting) 303I850,00 303,850.00 303 653.001 EEINEHEEEEEEEJ� -0.06% 41 Books/Educational Materials 24,349.00 28 657.00 28,657.00 0.00% 42 Food & Nutrition 117 636.00 110 880.00 112 720.00 1 .66% 43 Administrative Costs 551 085.00 559 351 .28 567v617.65 1 .48% 44 Audit Expense 0.00 0.00 0.00 #DIV/O! 45 Specific Assistance to Individuals 0.00 0.00 0.00 #DIV/O ! 46 Other/Miscellaneous 800.00 800.00 11575.00 96.88% 47 Other/Contract 739,421 .00 740 000.00 740 ,000.00 0.00% 4s TOTAL 7993676 01 7 978 367.56 8138 301 .59 2.01 49 REVENUES OVER/ UNDER EXPENDITURES -1 042,540.09 al 1063,862. 61 -1 ,2839496.52 21 .79% osrzu2oa u CEHHO*Y " ( °Ir I S UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAM E : CEBH IRMH/ Cam Manatee Thera eutic Summer Cam FY 02103 FY 03/04 FY 04/05 % INCREASE FYE_913012003 FYE_9130WN FYE 9!30/2005 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (coL Geos. BNcoL B REVENUES BUDGETED BUDGETED 1 Children's Services CouncilSt Lucie 0.00 #DIV/01 2 Children's Services Council-Martin 0.00 #DIV/0! 3 Advisory Committee-Indian River 20 000.00 2000000 2000000 0.00% Way- St United Lucie County 0.00 #DIV/01 5 United Way-Martin County0.00 #DIV/0l 6 United Wa Indian River County0.00 #DIV/0! 7 Department of Children & Families 0.00 #DIV/01 s CountyFunds 0.FO' #DIV/Ol e Contributions-Cash 200.00 200.00 0.00°k 10 Program Fees 51669.00 10 000,00 10 000.00 0,00% 11 Fund Raising Events-Net 0,00 #DIV/01 12 Sales to Public-Net 0.00 #DIV/01 13 Membership Dues 0.00 #DIV/01 14 Investment Income 0.00 #DIV/01 15 Miscellaneous 0.00 #DIV/01 16 Legacies & Bequests 2 000.00 27000,00 0.00% 17 Funds from Other Sources 0.00 #DIV/O! 18 Reserve Funds Used for O eratin 0.00 #DIV/O! 19 In-Kind Donations - IRMH 24 222,35 1882082 20 364.25 8.20% 20 TOTAL 25,559.00 3220000 32 200.00 0.00% EXPENDITURES 21 Salaries 32 247,00 33 244.33 34 272.50 3,09% 22 FICA 21466.90 254319 2 621 .85 3.09°k 23 Retirement 765.03 788.94 813,42 3.10% 24 LifelHealth 21584,56 266533 274804 3.10% 25 Workers Compensation 281 .52 290.32 299.32 3,10% 26 Florida Unemployment 76,34 78.73 81 .17 3.10% 27 Travel-Daily 300 .00 300.00 324:00 8.00% 2e Travel/Conferences/Training 0 .00 #DIV/01 29 Office Supplies 0.00 #DIV/O! 30 Telephone 250.00 250.00 258.75 3.50% 31 Postage/Shipping 95.00 95.00 96.20 1 .26% 32 Utilities 775.00 775.00 828.00 6.84% 33 Occupancy (Building & Grounds 31900.00 37900,00 41021 .00 ' 3.10% 34 Printing & Publications 180.00 180,00 180.00 0.00% 35 Subscription/Dues/Memberships 100.00 100.00 100.00 0.00% 36 Insurance 0.00 #DIV/O! 37 E ui ment:Rental & Maintenance 0.00 #DIV/01 38 Advertising 200.00 200.00 , 200. 0.00% 39 Equipment Purchases :Ca ital Expense 0.00 #DIV/01 40 Professional Fees (Legal, Consulting) 0.00 #DIV/O! 41 Books/Educational Materials 1 200.00 11250.00 11300.00 4.00 /7. 42 Food & Nutrition 1 VOOO.00 11000.00 105000 5.00% 43 Administrative Costs 37000.00 300000 39010.00 0.33% 44 Audit Expense OAO #DIV/O! 45 Specific, Assistance to Individuals 0.00 #DIV/01 46 Other/Miscellaneous 360.00 360.00 360.00 0.00% 47 Other/Contract 0.00 49 TOTAL 49,781 .35F 51 020.82 52 564.25 3 .03% 49 REVENUES OVER/ UNDER EXPENDITURES1 -0 -24,222.35 -18,820.82 -20,364.25 8.20% OVNR04 ea t • CEBHQIRMW Camp Manatee Therapeutic Summer Camp UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : CEBH@IRMH/ Camp Manatee Therapeutic Summer Camp FUNDER : IRC = CSAC A B C FY 04/05 FY 04/05 % OF TOTAL FUNDER TOTAL VS, PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET (col. B/col. A) - EXPENDITURES 21 Salaries 349272.50 189578.73 54 .21 % 22 FICA 29621 .85 19421 .27 54.21 % 23 Retirement 813 .42 0.00 0 .00% 24 Life/Health 21748 .04 0.00 0 .00% 25 Workers Compensation 299 .32 0 .00 0 .00% 26 Florida Unemployment 81 .17 0 .00 0 .00% 27 Travel-Daily324.00 0.00 0 .00% 28 Travel/Conferences/Training 0.00 0 .00 #DIV/01 29 Office Supplies 0.00 0.00 #DN/O ! 30 Telephone 258 .75 0.00 0 .00% 31 Posta e/Sh 1p ping96 .20 0 .00 0 .00% 32 Utilities 828 .00 0 .00 0 .00% 33 Occupancy( ( Building & Grounds) 4 ,021 .00 0 .00 0 .00% 34 Printing & Publications 180 .00 0.00 0 .00% 35 Subscription/Dues/Memberships 100 .00 0 .00 0 .00% 361nsurance 0.00 0 .00 # DIV/01 37 E ui ment : Rental & Maintenance 0 .00 0.00 #DIV/01 38 Advertising 200.00 0 .00 0 .00% 39 Equipment Purchases : Ca ital Expense 0.00 0 .00 # DIV/01 40 Professional Fees ( Legal , Consulting 0 .00 0 .00 # DIV/01 41 Books/Educational Materials 11300 . 00 0 .00 0 . 00% 42 Food & Nutrition 19050 .00 0 .00 0 .00% 43 Administrative Costs 39010 .00 0 .00 0 . 00% 44 Audit Expense 0 .00 0 .00 #DIV/01 45 Specific Assistance to Individuals 0 .00 0.00 # DIV/01 46 Other/Miscellaneous 360 .00 0 .00 0 . 00% 47 Other/Contract 0.00 0 .00 # DIV/01 48 TOTAL $ 52 , 564.25 $ 205000 .00 38 .05% wwwwwwwwoommma 05242004 B-4 CEBN®IRMW Camp M"" iMnpeulk Sunman Camp . UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME : CEBH@IRMHl Camp Manatee Therapeutic Summer Camp FUNDER: IRC - CSAC #DIVI01 #DNlO! #DIVlO! #DIV/O! #DIV/O! #DMO! #DIVro! #DNro! #DIVIO! #DIVIOf #Dwro1 #DIV/O! #DIV/OI #DIVro! #DNro! #DIV/0! #DIV/0! #DIV/O! #DIV/0! #DIV/O! #DIV/01 #DIV/O! o UIM ra S CESHORMW Camp MWW" TMroI Summa CaW UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE FUNDER SPECIFIC BUDGET AGENCYIPROGRAM NAME: FUNDER: ��i::4}}}} ::� .isk; ::}i::.{i:}�'�iii'ri:� ':ii:•iL •i ij•:Yi•:i+.:.:i•}}:uti•}:•}}?:-:i.}:i4}:.}:iii.}} 'i:: • :: •.�: :: • :: . .: . ..::.�: }}}} �,inv}}v}> }''::.:.vvv:. :#i'L'/@tiv+.}::.::•.+•:i}}:i?:}::+::: •}. vL}}}:\v}}:.yv.:.vv::::x:::::::•:.x..v.::.n�v:<.`, }{.�}::+5;:}}:w. .; .;• . . . . . . : . . . .. : x . . . . . . . . .. r. . . . :::::. . ::::::+:.::}:::::. :?}+.-.}:•??:i•}}:.}:•?}?}:i}:•}%i.,v' � }}tv,. }}i}div ' � ., L� :?Yf�l!F :ai:•:.v}:n::. . . . . . . . .:. }?:}::?::}:::.}:}..: . .:..�.v::.::::.:. .. :.�:•._:?. Salaries Requested funds is 54. 21 % less than Program Budget FICA Requested funds is 54. 21 % less than Program Budget #DIV/01 #DIV/01 #DIV101 #DN/01 #DN/01 #DN/01 #DIV/01 #DIV/01 #DIV/01 0saum04 e-s EXHIBIT B [From policy adopted by Indian River County Board Of County Commissioners on February 19 , 2002] " D . Nonprofit Agency Responsibilities After Award of Funding Indian River County provides funding to all nonprofit agencies on a reimbursement basis only. All reimbursable expenses must be documented by an invoice and/or a copy of the canceled check . Any expense not documented properly to the satisfaction of the Office of Management & Budget and/or the County Administrator may not be reimbursed . If an agency repeatedly fails to provide adequate documentation , this may be reported to the Board of Commissioners . In the event an agency provides inadequate documentation on a consistent basis , funding may be discontinued immediately . Additionally, this may adversely affect future funding requests . Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For example , no expenditures prior to October 1St may be reimbursed with funds from the following year. Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not carried over to the next year unless expressly authorized by the Board of Commissioners . All requests for reimbursement at fiscal year end (September 30th) must be submitted on a timely basis . Each year, the Office of Management & Budget will send a letter to all nonprofit agencies advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early to mid October, since the Finance Department does not process checks for the prior fiscal year beyond that point . Each reimbursement request must include a summary of expenses by type . These summaries should be broken down into salaries , benefits , supplies , contractual services , etc . If Indian River County is reimbursing an agency for only a portion of an expense (e . g . salary of an employee) , then the method for this portion should be disclosed on the summary. The Office of Management & Budget has summary forms available . Indian River County will not reimburse certain types of expenditures . These expenditure types are listed below. a . Travel expenses for travel outside the County including but not limited to ; mileage reimbursement, hotel rooms , meals , meal allowances , per Diem , and tolls . Mileage reimbursement for local travel (within Indian River County) is allowable . b . Sick or Vacation payments for employees . Since agencies may have various sick and vacation pay policies , these must be provided from other sources . c. Any expenses not associated with the provision of the program for which the County has awarded funding . d . Any expense not outlined in the agency's funding application . The County reserves the right to decline reimbursement for any expense as deemed necessary." - 1 - • 1 EXHIBIT C STANDARD TERMS FOR GRANT CONTRACT 1 . Notices : Any notice , request, demand , consent , approval or other communication required or permitted by this Contract shall be given or made in writing , by any of the following methods : facsimile transmission ; hand delivery to the other party; delivery by commercial overnight courier service ; or mailed by registered or certified mail ( postage prepaid ) , return receipt requested at the addresses of the parties shown below: County: Joyce Johnston-Carlson , Director Indian River County Human Services 184025 th Street Vero Beach , Florida 32960-3365 Recipient : Mariamma Pyngolil , RN , Program Director Center for Emotional & Behavioral Health 119037 th Street Vero Beach , Florida 32960 2 . Venue : Choice of Law : The validity, interpretation , construction , and effect of this Contract shall be in accordance with and governed by the laws of the State of Florida , only. The location for settlement of any and all claims , controversies , or disputes , arising out of or relating to any part of this Contract, or any breach hereof, as well as any litigation between the parties , shall be Indian River County, Florida for claims brought in state court, and the Southern District of Florida for those claims justifiable in federal court . 3 . Entirety of Agreement: This Contract incorporates and includes all prior and contemporaneous negotiations , correspondence , conversations , agreements , and understandings applicable to the matters contained herein and the parties agree that there are no commitments , agreements , or understandings concerning the subject matter of this Contract that are not contained herein . Accordingly, it is agreed that no deviation from the terms hereof shall be predicated upon any prior representations or agreements , whether oral or written . It is further agreed that no modification , amendment or alteration in the terms and conditions contained herein shall be effective unless contained in a written document signed by both parties . 4 . Severability: In the event any provision of this Contract is determined to be unenforceable or invalid , such unenforceability or invalidity shall not affect the remaining provisions of this Contract, and every other term and provision of this Contract shall be deemed valid and enforceable to the extent permitted by law. To that extent, this Contract is deemed severable . 5 . Captions and Interpretations : Captions in this Contract are included for convenience only and are not to be considered in any construction or interpretation of this Contract or any of its provisions . Unless the context indicates otherwise , words importing the singular number include the plural number, and vice versa . Words of any gender include the correlative words of the other genders , unless the sense indicates otherwise . 6 . Independent Contractor. The Recipient is and shall be an independent contractor for all purposes under this Contract. The Recipient is not an agent or employee of the County, and any and all persons engaged in any of the services or activities funded in whole or in part performed pursuant to this Contract shall at all times and in all places be subject to the Recipient's sole direction , supervision , and control . 7 . Assignment. This Contract may not be assigned by the Recipient without the prior written consent of the County. - 1 - r "y ACORD� CERTIFICATE OF LIABILITY INSURANCE OP ID E DATE (MMIDD/YYYY) INDIA - 1 11 / 04 / 04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Assoc Ins Svc HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1675 Terrell Mill Rd . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Marietta GA 30067 Phone : 800 - 476 - 7601 Fax : 770 - 850 - 0988 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Admiral Insurance Co . INSURER B: American autrmobllu Ins . Co , Indian River Memorial Hospital Greg Morgan INSURER C: 1000 36tH Street INSURER D: Vero Beach FL 32960 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR INSR TYPE OF INSURANCE POLICYNUMJBER DATE MMI DATE IMMID LIMITS GENERAL LIABILITY EACH OCCURRENCE S $ 5 , 0 0 0 , 0 0 0 X X COMMERCIAL GENERALLIABILrrY CAPTIVE SIR 10 / 01 / 04 10 / 01 / 05 PREMISES Eaoccurenoe S X CLAIMS MADE OCCUR MED EXP (Any one person) S PERSONAL & ADV INJURY $ $ 5 , 0 0 0 , O O O GENERAL AGGREGATE $ $ 15F0001000 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S $ 510001000 POLICY JPPCT El LOC AUTOMOBILE LIABILITY COMBINED SINGLE X ANYAUTO ( cdM $ $ 2 , 000 , OOO ALL OWNED AUTOS BODILY INJURY B X SCHEDULED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 (Per person) $ B X HIRED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 BODILY INJURY B X NON-OWNED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 (Peraclderd) $ PROPERTYDAMAGE $ (Per sodden!) TANYAUTO LIAZLITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESSRIMBRELLA LIABILITY EACH OCCURRENCE x $ 2 0 , 0 0 0 , 0 0 0 A IOCCUR K CLAIMSMADE CRL - FLm10013 - 1002 - 0 10/ 12 / 04 11 / 01/ 05 AGGREGATE S $ 2049000 , 000 Excess s DEDUCTIBLE Above SIR $ RETENTION S $ 5M/ $ 15M $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABIIJTY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? H Yes, describe under E.L. DISEASE - EA EMPLOYEE S SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT s OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate Holder is added as Additional Insured with respect to their interest in contract with the Named Insured . CERTIFICATE HOLDER CANCELLATION INDIANC, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1840 25th Street REPRE TATIXES. _ Vero Beach FL 32960 AUT DED REPRE TA VE ACORD 25 (2001108) © ACORD CORPORATION 1988 s ACORD. CERTIFICATE OF LIABILITY INSURANCEoP ro DATE (MM/DiArr ) INDIA - 1 11 / 04 / 04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF IN FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Assoc Ins Svc HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1675 Terrell Mill Rd . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Marietta GA 30067 Phone * 800 - 476 - 7601 Fax : 770 - 850 - 0988 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: coatinmta2 Casualty Company INSURER B: Indian River Memorial Hospital INSURER c: Greg Morgan 1000 36th Street INSURER Vero Beach FL 32960 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR INSRN TYPE OF INSURANCE POLICY NUMBERDATE EWY POLICY EXPIRATION DATE? (MWRM LIMBS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL. GENERAL LIABILITY PREMISES Ea oocurence S CLAIMS MADE F�] OCCUR MED EXP (Any one person) S PERSONAL d ADV INJURY S GENERAL AGGREGATE $ GERL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S POLICY JPEC LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acddent) S ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per acddent) PROPERTY DAMAGE S (Per aoddent) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG i EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE S E DEDUCTIBLE S RETENTION $ $ WORKERS COMPENSATION AND x TYOU S [AT OTFI: ORY LIMITS A Fit EMPLOYERS LIABILITY qP- 12 8 5 8 8 4 3 8 01 / 01 / 04 ANY PROPRIETOR/PARTNER/EXECUTNE 01 / 01/ 05 E.L. EACH ACCIDENT S $ 1 ,0 0 0 0 r O 0 0 OFFICER/MEMBER EXCLUDED? If yes, E L DISEASE - EA EMPLOYEE $ $ 1 0 0 0 O 0 O SPECIAL PROVISIONS below es El, DISEASE - POLICY LIMIT S $ 1 , 000 , 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Proof of coverage for above Named Insured . CERTIFICATE HOLDER CANCELLATION INDIANC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 3, 840 25th Street REPRE TATWES, Vero Beach FL 32960 Aur IZEDREPRE Ta VE ACORD 25 (2001 /08) I © ACORD CORPORATION 1988 Internal Revenue Service District Director Department of the Treasury Date* 'MA 2 6 1985 Employer Identification Number. 59- 2496294 Accounting Period Ending: September 30 Form 990 Required: ® Yes No Indian River Memorial Hospital , Inc . 1000 36th Street Person to contact: Vero Beach , FL 32960 Brenda Wilcox/cdt Contact Telephone Number. (404) 221 - 4516 File Folder Number : 580062333 Dear Applicant : Based on information supplied in Your application for recognition oafnd and Your operations will be as stated from Federal income tax under 'section 50l ( c )eption , we have determined u are ( 3 ) -of the Internal RevenueCode . exempt We have further determined that cau meaning of section 509 ( a ) of the Code are of a private foundation within the section 170 (b ) ( 1 ) (A) (iii) g 509 (a) ( 1,� . YOU are an organizati ° n described in If your sources Of support , or change , please let us know so we can gconsider our othe � effectcof the chter , or anged oP operation exempt status and foundation status . Also , you should inform us of all changes in Your Your name or address , i t As of January 1 , 1984 , You are liable for taxes under the Federal Insurance Contributions Act ( social security taxes ) on remuneration of $ 100 or more each of employees g Imposed YourunderFederal during a calendar You pay to the Year . You are not liable for the tax Unemployment Tax Act ( FUTA ) . Since you are not a private foundation ' Y°u are not subject to the excise taxes under Chapter 42 of the Code . However , You are not automatically exempt from other Federal excise taxes . If Federal taxes S*Os have any questions about excise , employment , or other please let us know . j Donors may deduct contributions to t Bequests , legacies , deviseYOU as t provided in section 170 of the Code . s , transfers , deductible for Federal estate and gift tax purposes You or for your use are- if provisions of sections 2055 , 21069 and 2522oftheCodethey meet the applicable The box checked in the heading of this letter shows whether you must file Form 990 , Return of Organization Exempt from Income Tax , If Yes is checked , you are required to file Form 990 only if your '• are than 325 , 000 . If a return is required , It mustebeipts filedach by theYear l5th daymally of themore + month after the end of your annual $ 10 a day , nalty accountingperiod * The imposes a i up to a maximum of $ 5 , 000 , when a returnisfiled wlate , unlessethere of ill Is reasonable cause for the delay . C .1 c y luu 4h1'4U !! uL 1 'Cyull 'eu Lo ille reaerat income tax returns unless you are subject to the tax on unrelated business income under section 511 of the Code . If you are subject to this tax , you must file an income tax return on Form 990-T , Exempt Organization Business Income Tax Return . In this letter , we are not determining whether any of your present or proposed activities are unrelated trade or business as defined in section 513 of the Code . You need an employer identification number even if you have no employees . If an employer identification number was not entered on your application , a number will be assigned to you and you will * be advised of it . Please use that number on all returns you file and in all correspondence with the Internal Revenue Service . Because this letter could help resolve any . questions about your exempt status . and foundation status , you should keep it in your permanent records . If you have any questions , please contact the person whose name and telephone number are shown in the heading of this letter . Sincerely yours , i District /eclor cc : Edward J . Hopkins William J . Stewart Letter 947 ( DO) ( Rev. 10-83)