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HomeMy WebLinkAbout2005-328p INDIAN RIVER COUNTY GRANT CONTRACT r + This Grant Contract ("Contract" ) entered into effective this day of October 2005 , by and between Indian River County, a political subdivision of the State of Florida ; 1840 25th Street, Vero Beach , Florida , 32960-3365 ; and The Center for Emotional and Behavioral Health ( Recipient) , of: The Center for Emotional and Behavioral Health (CEBH ) 119037 th Street Vero Beach , Florida 32960 Camp Manatee - Therapeutic Summer Camp Background Recitals A. The County has determined that 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 proposal 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 (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 the 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 2005/2006 ("Grant Period") . The Grant Period commences on October 1 , 2005 and ends on September 30 , 2006 . - 1 - INDIAN RIVER COUNTY GRANT CONTRACT r + This Grant Contract ("Contract" ) entered into effective this day of October 2005 , by and between Indian River County, a political subdivision of the State of Florida ; 1840 25th Street, Vero Beach , Florida , 32960-3365 ; and The Center for Emotional and Behavioral Health ( Recipient) , of: The Center for Emotional and Behavioral Health (CEBH ) 119037 th Street Vero Beach , Florida 32960 Camp Manatee - Therapeutic Summer Camp Background Recitals A. The County has determined that 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 proposal 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 (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 the 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 2005/2006 ("Grant Period") . The Grant Period commences on October 1 , 2005 and ends on September 30 , 2006 . - 1 - 4 . Grant Funds and Payment. The approved Grant for the Grant Period is : EIGHTEEN THOUSAND , FIFTY THREE DOLLARS ($ 18 , 053 . 00 ) . The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for the 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 Obligation 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 to written notice . 5 . 2 . Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws and regulations . 5 . 3 . Quarterly Performance Reports . The Recipient shall submit quarterly, cumulative , 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 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 the 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 its 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 the 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 , 2005 provide to 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 : ( i ) Commercial General Liability Insurance in an amount not less than $ 1 , 000 , 000 combined single limit for bodily injury and property - 2 - 4 . Grant Funds and Payment. The approved Grant for the Grant Period is : EIGHTEEN THOUSAND , FIFTY THREE DOLLARS ($ 18 , 053 . 00 ) . The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for the 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 Obligation 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 to written notice . 5 . 2 . Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws and regulations . 5 . 3 . Quarterly Performance Reports . The Recipient shall submit quarterly, cumulative , 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 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 the 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 its 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 the 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 , 2005 provide to 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 : ( i ) Commercial General Liability Insurance in an amount not less than $ 1 , 000 , 000 combined single limit for bodily injury and property - 2 - damage , including coverage for premises/operations , product/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 ) Worker's 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 the County. In addition , the County may request such other proofs and assurances as it may reasonable 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 Worker's 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 - 4 IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . INDIAN RIVER COUNTY BOARD OF dd,N�•� h 8f4IO' NERS Thomas S . Lowther, Chgietn4o t ; BCC Approved : b Q i Attest : J . K. Barton , Clerk By: Deputy Clerk Approved . Jos ph A . Bair County Administrator Approved as to form and legal sufficiency: WMariZanE . Fell , n County Attorney RECIPIENT: 00/_ By: The Pen e or E otional and Behavioral Health (CEBH ) - 4 - damage , including coverage for premises/operations , product/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 ) Worker's 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 the County. In addition , the County may request such other proofs and assurances as it may reasonable 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 Worker's 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 - EXHIBIT A (Copy of complete Request for Proposal ) EXHIBIT - A - The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional and Behavioral Health @IRMH Director: Mariamma Pyngolil , RN E-mail : mariamma.Pyngolil (a irmh. org Address : 1190 37' Street Telephone: 772-563 -4666 ext 1838 Vero Beach FL 32960 Fax : 772-770-2025 Program Director: Michelle Bollinger, CTRA E-mail : michelle.bollinger(a irmh. org Address : 1190 37`h Street Telephone: 772- 563 -4666 ext 1880 Vero Beach FL 32960 Fax : 772-770-2025 Program Title : Camp Manatee Therapeutic Summer Camp ` - -1 P 1jl 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: PL-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 programming 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 2005 / 06 : $ a 0 , Total Proposed Program Budget for 2005 / 06 : $ 53 , 090 . 21 Percent of Total Program Budget : 37 . 7 % Current Program Funding ( 2004 / 05 ) : $ 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 : 4 Total Program Cost per Client : 1361 . 29 * *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 : kill The Organization 's Board ofDirectors *ag approve this applicatio n e T S kep hc, a Name of President/Chair of the Board Signa e Name of Executi e Director/CEO 3 4 IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . INDIAN RIVER COUNTY BOARD OF dd,N�•� h 8f4IO' NERS Thomas S . Lowther, Chgietn4o t ; BCC Approved : b Q i Attest : J . K. Barton , Clerk By: Deputy Clerk Approved . Jos ph A . Bair County Administrator Approved as to form and legal sufficiency: WMariZanE . Fell , n County Attorney RECIPIENT: 00/_ By: The Pen e or E otional and Behavioral Health (CEBH ) - 4 - The Center for Emotional and Behavioral Health @IRMH- 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. Indian River 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 R 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 drop-out 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, 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 . 27% of all American Adults have a diagnosis of Mental Illness ; Preventive and Health Promotion Programs such as Camp Manatee can help break this cycle. 4 The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC 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. Provides respite to parents and teaches them to be successful . . . . . . . . . Challenges the parents as parents left with no respite coupled with a lack of structure during the summer months throw them off and creates family discord. According to http ://www.mentalhealth. org/features/surgeongeneralreport/chapter3 /sect 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 existing 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 EXHIBIT A (Copy of complete Request for Proposal ) EXHIBIT - A - 4 The Center for Emotional and Behavioral Health @IRMH- 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. - Senior 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. 6 The Center for Emotional and Behavioral Health @IRM H- Camp Manatee Therapeutic Summer Camp — IRC- CSAC 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 : ( 1 )Director of Patient Care Services — Advanced Registered Nurse Practitioner in child & adolescent 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 — Bachelor ' s level Social Worker, 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 IRMH 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 . 4. 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 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 : OOam-3 : OOPM, with the option of before care from 8 : OOAM- 9 : OOAM 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 The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional and Behavioral Health @IRMH Director: Mariamma Pyngolil , RN E-mail : mariamma.Pyngolil (a irmh. org Address : 1190 37' Street Telephone: 772-563 -4666 ext 1838 Vero Beach FL 32960 Fax : 772-770-2025 Program Director: Michelle Bollinger, CTRA E-mail : michelle.bollinger(a irmh. org Address : 1190 37`h Street Telephone: 772- 563 -4666 ext 1880 Vero Beach FL 32960 Fax : 772-770-2025 Program Title : Camp Manatee Therapeutic Summer Camp ` - -1 P 1jl 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: PL-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 programming 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 2005 / 06 : $ a 0 , Total Proposed Program Budget for 2005 / 06 : $ 53 , 090 . 21 Percent of Total Program Budget : 37 . 7 % Current Program Funding ( 2004 / 05 ) : $ 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 : 4 Total Program Cost per Client : 1361 . 29 * *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 : kill The Organization 's Board ofDirectors *ag approve this applicatio n e T S kep hc, a Name of President/Chair of the Board Signa e Name of Executi e Director/CEO 3 The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC D . MEASURABLE OUTCOMES (Description of Intent) Use the Measurable Outcomes form. This descri tion a e does not need to be included in the ro osal. 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. ACTIVITIES : 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 . Thp 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 1 (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 The Center for Emotional and Behavioral Health @IRM H- Camp Manatee Therapeutic Summer Camp — IRC- CSAC D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all of the elements for the Measurable Outcome(s) 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 2006 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 @IRMH- 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. Indian River 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 R 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 drop-out 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, 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 . 27% of all American Adults have a diagnosis of Mental Illness ; Preventive and Health Promotion Programs such as Camp Manatee can help break this cycle. 4 The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC 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. Provides respite to parents and teaches them to be successful . . . . . . . . . Challenges the parents as parents left with no respite coupled with a lack of structure during the summer months throw them off and creates family discord. According to http ://www.mentalhealth. org/features/surgeongeneralreport/chapter3 /sect 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 existing 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 @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program 's collaborative partners and the resources that 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 Horne 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 Allowing psychology resident students to assist with (F . I.T) 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. The Manatee Center Discounted educational session �— V. B . Karate Center Free educational session — 2 hours 10 The Center for Emotional and Behavioral Health @IRMH- 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 1319 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 . 11 4 The Center for Emotional and Behavioral Health @IRMH- 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. - Senior 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. 6 The Center for Emotional and Behavioral Health @IRM H- Camp Manatee Therapeutic Summer Camp — IRC- CSAC 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 : ( 1 )Director of Patient Care Services — Advanced Registered Nurse Practitioner in child & adolescent 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 — Bachelor ' s level Social Worker, 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 IRMH 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 . 4. 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 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 : OOam-3 : OOPM, with the option of before care from 8 : OOAM- 9 : OOAM 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 The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC 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 2006 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 2006 Review, update and print all camp forms (registration, releases, medications), update file systems, review budget March 2006 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 2006 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 2006 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 2006 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 August 2006 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 Number of { �Unduplicated by Locaflon ~ s �tl'�✓• fes` �'d�a ✓R E- Current .,.. .q�.„ . , R Y V Budget 2I I 4 I 1N. Indian River-Co row. onSt. Lucie Co. • • 1 Ed Port Saint Lucie Total MOD V 91 1 Numberof Unduplicated Clients by Age �� � x7,77z 72 , �VVW g 44 Budget ", . ,. � P -r -^ DI MIA wiW Total1 The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC D . MEASURABLE OUTCOMES (Description of Intent) Use the Measurable Outcomes form. This descri tion a e does not need to be included in the ro osal. 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. ACTIVITIES : 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 . Thp 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 1 (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 The Center for Emotional and Behavioral Health @IRM H- Camp Manatee Therapeutic Summer Camp — IRC- CSAC D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all of the elements for the Measurable Outcome(s) 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 2006 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 Edit this Header. Type the organization and program name and the funder for whom it is being completed. The page # is already set at the bottom right of every page. I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below. " Core Budget Forms " 14 1 , center for Emotional & Behavioral Health/ Camp Manatee 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 : Center for Emotional & Behavorial Health/ Camp Manatee FUNDER : IRC -CSAC CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should be used for calculations and to write information only. R£VENU S «r Propo3ed Total Pr+cscjrar}1 a ` z ►ci"' 4(`x A j S :j GLLCIRA�AyIL�a, B('/' e ` tl,YF REV 1 Children's Services Council-St. Lucie 2 Children's Services Council-Martin 3 Advisory Committee-Indian River 20,000.00 20,000.00 167,818. 13 . 4 United WayrSt Lucie County 5 United Way4Urtin County, 6 United Way-Indian River County , : 7 Department of Children & Families 8 County Funds 9 Contributions-Cash 200.00 200.00 10 Program Fees 109000.00 300tDO0.00 11 Fund Raising Events-Net 12 Sales to Public - Net 13 Membership Dues 14 Investment Income 15 Miscellaneous 16 Legacies S Bequests 29000.00 2,000.00 17 Funds from Other Sources 18 Reserve Funds Used for Operating 19 le-Kind Donations- IRMH 199644.81 20 TOTAL REVENUES dwsn't induft Him 19 $32 00.00 $20,000. $74701018:13 ©CPEiVD/TI�RES *WAYAREM FOR Proposed Tota/ Program F tnder r c at+Etrer tue ower W u ? tu . Budget , Budgpt' � r wd, : � 21 Salaries - (must complete chart on next page 35,261 .89 18v578.73 49202409.27 22 FICA - Total salaries x 0.0765 7.65% 2,697.53 11421 .2 3219484.31 Retirement nua pension Tor qua 23 staff L 3.92% 722.81 0.00 164,734.44 Liffieffleatth - e Ica n - erm 24 Disab 1 13.2 . 2o446.86 0.00 537,659.71 Workers Compensatioa - # employees x 25 rate 1 .66 306.09 0. 69,759.99 Florida unemployment - W pr. 26 employees x $7,000 x UCT-6 rate 0. 17% 31 .35 0. 71144. 10 B-1 5/172005 The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program 's collaborative partners and the resources that 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 Horne 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 Allowing psychology resident students to assist with (F . I.T) 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. The Manatee Center Discounted educational session �— V. B . Karate Center Free educational session — 2 hours 10 The Center for Emotional and Behavioral Health @IRMH- 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 1319 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 . 11 Center for Emotional 8 Behavioral HeaRld Camp Manatee SALARIES A e n Gross Annual Portion of Salary on ed C % of G► bss,Annua/ POSITION LISTING Salary P m Proposed Funder specific Bi dyet: Salami PosrtOn Title Total Hrshvk (Agency) Ezarriple: Executive Director 140 his 70,000.00 10;000.00 5 :;. ,000.0Q a Director of Patient Care Services/40 hrs 95,808. 1 14,790.41 0.00 0.00° Psychologist Ucensed/24. hrs 341706. 19735.34 0.00 0.00° Manager of Activity Therapy/40 hrs . 58,980.21 51898.03 0.00 0.00° Camp Manatee Supervisod4O hrs 49200. 4200.00 4,200.00 100.00 Counselor - A group/40 hrs 20800. 21800.00 21800. 100.00° Counselor - A group/40 hrs 20800. 29800.00 2,800.00 100.00 Counselor - B group/40 hrs 2,800. 2,800.00 2,800.00 100.00 Counselor - B group/40 hrs 2,800. 29800.00 21800.00 100.00° Jr. Counselor - Camp Assistant/40 hrs 1 ,960. 1 ,960.00 it960.00100.00° Registered Nurse/40 hrs 54,781 . 1 51478.12 1 *218.73 2.22° #DIV/0! #DIVroI #DIVro! #DIV/0I #DIVro! #DIV/0! #DIV/01 #DIV/0 . #DIVi01 #DIV/01 Remaining positions throughout the agency 3,9401772.82 Total Salaries $49202,409.27 $359261 .89 518,578.7 0.44 Flaw B NE lTS DE7'AlL A (li�nit � SpOctc Budget Funder CtildinC on fmm tine 22 to 27 FICA 7 6s7s Mealtf� InsS th rw Ez � 1y ) Budget (A x �:) cam �cvrl Po3itt''dh Ti� 7D#al HitI-var Carple, vCas4 !Yl i sgxtao ws 5,000.00 982 SO 20000 * 510 00 , '_ 30ty;DO , . 200ad0 ' � < . '. . . � Director of Patient Care Services/40 hrs 0-001 0.00 0. Psychologist Licensed/24 hrs 0.001 0.00 0. Manager of Activity Therapy/40 hrs 0. 0.00 0. Camp Manatee Supervisor/40 hrs . 4.200. . 321 .30 321 .3 Counselor - A group/40 hrs 21800. 214.20 214.2 Counselor - A roup/40 hrs 21800. 214.20 214.201 Counselor - B group/40 hrs . 2s800.001 214.20 214.2 Counselor - B roup/40 hrs 2t8OO.M 214.20 214.2 Jr. Counselor - Camp Assistant/40 hrs I t960-001 149.94 149.91 Registered Nurse/40 hrs 1 ,218.7 93.23 93.2 0 0.001 0.00 0.0 0 0.001 0.00 0. 0 O.cq 0.00 0. 0 0. . 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 0.001 0 0.001 0.00 _. - 0.04 0 O.Oq 0.00 0.001 0 O.Oq 0.00 0. 0 0. 0.00 0.0 Total FunderRequestFringe Bert� $18,578.7 $10421 . $0. $0. $0. $0. $1 ,421 .2 B-1 5M 7r20o5 c ) »:i a OF ' i cs Ci 1n O i ,5uYI NN 5 fn: $ t .� 31. ,. ,, ., P m n q 5 M � ?. N N h � '�` n £ . N ;' m '. q ,p :� '•' h 3 v N 1OV N Q :'. l � t . : .; m xu �, � 7vd�� ��N' a, M ^ a WF T •, y�,' w .rt. *: N r l �Y . I ". o o > o o -� o d d ' . , 1. cN m _ .0 o _ 6 o N o n W � s f .'. ' o o 'h ) g '` o • ' o Q m Q O r `y tV m CIA r vx Im 19 x 10 111 49 C4 g � � a h 11 N 0 >< Frey uj ftx .11 $ V of • 4k e 'Sn Cz � � � � . .IikNagm' m � o � � a ; •C 5 � � E .� - 1- aeos 1- � � E � � w a 3 � qp K JLL � � � rn o � <- � c> � � � •� LL � EEaa •v : � v . The Center for Emotional and Behavioral Health @IRMH- Camp Manatee Therapeutic Summer Camp — IRC- CSAC 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 2006 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 2006 Review, update and print all camp forms (registration, releases, medications), update file systems, review budget March 2006 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 2006 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 2006 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 2006 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 August 2006 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 Number of { �Unduplicated by Locaflon ~ s �tl'�✓• fes` �'d�a ✓R E- Current .,.. .q�.„ . , R Y V Budget 2I I 4 I 1N. Indian River-Co row. onSt. Lucie Co. • • 1 Ed Port Saint Lucie Total MOD V 91 1 Numberof Unduplicated Clients by Age �� � x7,77z 72 , �VVW g 44 Budget ", . ,. � P -r -^ DI MIA wiW Total1 ` CrIN b FIINC1r L BhvroM IIeaMJGnp Lb�IN UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health/ Camp Manatee FY 03104 FY 04/05 FY 66/06 % INCREASE FYE_9/30/2004 FYE_9/30/2005 FYE_9/30/2006 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (ed GeoL B) eol. B REVENUES BUDGETED BUDGETED 1 Children's Services CouncilSt Lucie - 0.00 #DIV/01 z Children's Services Council-Martin 0.007#D1WV/01 3 AdvisoryCommittee-Indian River 20 000.00 249"5, 167 818.13 % 4 United W St Lucie County0.005 United Wa -Martin Coun 0.006 United Wa -Indian River Cou 0.00 7 Department of Children S Families 0.00 #DIV/OI e Courdy Funds 0.00 #DIV/01 9 Contributions-Cash 200.00 #DIV/01 io Program Fees_ 7t224*445,00 7o3482000.00 T 300 000. -0.65% 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 1s Miscellaneous 0.00 #DIV/01 16 Legacies S . „este 2000,00 #Dlvrol 17 Funds from Other Sources .-,-- 0.00 #DIV/01 1B Reserve Funds Used for Operating 0.00 #DIVIOI . is In-Kind Donations P"t mcwa.a In iobn 0.00 #DIV/01 20 TOTAL . . 792"1445,00 7,37Z445,00 747001813 . 1 .32% . x ate:•.. . 7M . � _ �'`< EXPENDITURES 21 Salaries 3 676 766. 410809009,00 4 202 409. 3.00% 22 FICA 259 96ZOC 293 753.00 321j484,31 9,44% . 23 Retirement 11 "9129,22 159 936 35 1649734,44 3.00% 24 Lifehiealth 487,906.&x 5419417,19 557 659.71 3.00% 25 Workers Compensation 61 034.3 67 728.15 69l759,99 3.00% 26 Florida Unemployment 61250.50 6936.02 79144,10 3.00% 27 Travel-Dally 2JI0.00 3 080.00 317240 3.00% 28 Travel/Conferences/Training 43 995.00 43 995.00 1 45140.40 2.60% 29 Office Su les 50 19.00 "1529.00 ` . 44 529.00 0.00% 3o Telephone 28 589.25 29 473.45 30 385.00 3.09% 31 Postagge/Shipping 41499,00 Z922,00 61060,00 107.39% 32 Utilities 68 612.00 65 000.00 7012W.00 8.00% 33 Occupancy (Building & Grounds 8729405,00 M1981 ,00 891l320,81 0.26% 34 PrIntina 3 Publications I 857.00 3 000.00 39120 4.00% 35 Subscri mbershi 17.00 5 55&O0 : 5jW&OO 0.00- - 36 Insurance 409 660. 375,57&00 375 000. =0.15% 37 EquipmentRentall S Maintenance 14;029ADI 17j568,OO 1795W,00 -0.39% 36 Advertising - 51000,001 59000.00 5000,00 0.00% 39 Equipment Purchases:Ca ' 1 Expense 11 274. 8v647.00 99000.00 4.08% 40 Professional Fees (Legai, Consulting) 306 287. 228 612 228,612.00 0.00% 41 Books/Educational Materials 2096WOO 29 080.00 2%080,00 0.00% 42 Food & Nutrition 1372328,00 141600.00 118SO38OO 46.64% 43 Administrative Costs 424936&00 430t730.48 472s795,75 9.77% 44 Audit Ex 0.00 0.00 0.00 #DIV/01 4s Specific Assistance to Individuals 0.00 0.00 0.00 #DIV/01 46 Other/Miscellaneous 800.001 800.00 19575,00 96.88% 47 OthedContract 871 ,908.001 872sODO,OO 872,000.000.00% 48 TOTAL 7 911 509.1 81345g928.6.4 8,551 ,276,18 2.46% 49 REVENUES OVER/ UNDER EXPENDITURES -667,064.141 9739483. 4 ,0819258. 11 .07% 5mrmas ss UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health! Cam Manatee FY 03/04 FY 04/05 FY 05/06 % INCREASE FYE 9/30!2004 FYE_WM2005 FYE CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED ("L C{DL Bycol. e REVENUES BUDGETED BUDGETED 1 Children's Services Council-St Lucie 0.00 #DIVIOI 2 Children's Services Council-Martin 0.00 #DIV/01 3 Advisory Committee4ndian River 20 000.00 20 000.00 20 000.00 0.00% 4 United Way-St Lucie County0.00 #DIV/01 6 United Way-Martin County 0.00 #DIV/OI 6 United. Way-Indian River County 0.00 #DIV/O! 7 Department of Children & Families 0.00 #DIV/01 e County Funds 0.00 #DIV/01 Contributions-Cash 200.00 _ 200.00 0.00% to Program Fees . 10 000.00 10 000.00 10 0110.00 0.00% 11 Fund Raising Events-Net 0.00 . #DIVI01 12 Sales to Public-Net 0.00 #DIV/01 13 Membership Dues 0.00 #DIV/01 14 Investment Income 0.00 #DIVIOI 1s Miscellaneous 0.00 #DIV/01 1s Legacies & Bequests : 000.00 29000.00 0.00% 17 Funds from Other Sources 0.00 #DIV/01 1a Reserve Funds Used for Operating 0.00 #DIVIOI 19 In-KlndDonations IRMH - 24222.35 18,820, 19644.81 4.38% m TOTAL . 30 000.00 34200.00 132,200.00 . 0,00% EXPENDITURES 21 Salaries 33177.9 34 .04 35j261 .89 3.09% 22 FICA 2538,1124616.61 , 4697.53 23 Retirement 684.78 701 .17 722.81 3.09% 24 LifeAieatth 4311L14 437&60 29446.86 3.09% Workers Compensation 289,99 296.92 306.09 3.09% 26 Florida Unemplory, meet 29.70 30.4131 .35 3.09% 27 Travel-Daily 300.00 300.00 364.50 21 .50% 2a TravellConferences/Trainin 0.00 #DIV/01 29 Office Supplies 0.00 #DIVIOI 3o Telephone 250.00 250.00 221 .25 W11 .50% 31 Postage/Shipping 95.00 95.00 100.00 5.26% 32 Utilities 775.00 775.00 722.00 -6.84% 33 OCCUIDanCy Wilding & Grounds 3900.00 1900.00 3t942.00 1 .08% 34 Printing & Publications 180.00 180.00 200.00 11.11 % 3s Subscri bershi . 100.00 100.00 100.00 d.00% 3s Insurance 0.00 #DIV/01 37 EquipmentRental & Maintenance 0.00 #DIVAM 39 Advertising 200.00 200.00 200.00 0.00% 39 Equipment Purchases:Ca . Exjxinse , 0.00 #D11//01 40 Professional Fees 1 Consulting) 0.00 #W/Of 41 Books/Educational Materials 1 200.00 1250.00 1351!. . 8.00% 42 Food & Nutrition 19000.00 1000.00 1099.54 9.95% 43 Administrative Costs 195W,00 1500.00 1689.00 12.60% 44 Audit Expense0.00 #DN/Of 45 Specific Assistance to Individuals 0.00 #DIV/Ol 46 Other/Misceilaneous 360.00 360.00 390.00 8.33% 47 OthedContract 0.00 #DIVIOI 48 TOTAL 48 898.63 50132.75 51844.81 3:42% 49 REVENUES OVER/ UNDER EXPENDITURES 489896.6AI -1T 932.75 -19 644.81 9.55% smra�oe w Edit this Header. Type the organization and program name and the funder for whom it is being completed. The page # is already set at the bottom right of every page. I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below. " Core Budget Forms " 14 1 , center for Emotional & Behavioral Health/ Camp Manatee 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 : Center for Emotional & Behavorial Health/ Camp Manatee FUNDER : IRC -CSAC CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should be used for calculations and to write information only. R£VENU S «r Propo3ed Total Pr+cscjrar}1 a ` z ►ci"' 4(`x A j S :j GLLCIRA�AyIL�a, B('/' e ` tl,YF REV 1 Children's Services Council-St. Lucie 2 Children's Services Council-Martin 3 Advisory Committee-Indian River 20,000.00 20,000.00 167,818. 13 . 4 United WayrSt Lucie County 5 United Way4Urtin County, 6 United Way-Indian River County , : 7 Department of Children & Families 8 County Funds 9 Contributions-Cash 200.00 200.00 10 Program Fees 109000.00 300tDO0.00 11 Fund Raising Events-Net 12 Sales to Public - Net 13 Membership Dues 14 Investment Income 15 Miscellaneous 16 Legacies S Bequests 29000.00 2,000.00 17 Funds from Other Sources 18 Reserve Funds Used for Operating 19 le-Kind Donations- IRMH 199644.81 20 TOTAL REVENUES dwsn't induft Him 19 $32 00.00 $20,000. $74701018:13 ©CPEiVD/TI�RES *WAYAREM FOR Proposed Tota/ Program F tnder r c at+Etrer tue ower W u ? tu . Budget , Budgpt' � r wd, : � 21 Salaries - (must complete chart on next page 35,261 .89 18v578.73 49202409.27 22 FICA - Total salaries x 0.0765 7.65% 2,697.53 11421 .2 3219484.31 Retirement nua pension Tor qua 23 staff L 3.92% 722.81 0.00 164,734.44 Liffieffleatth - e Ica n - erm 24 Disab 1 13.2 . 2o446.86 0.00 537,659.71 Workers Compensatioa - # employees x 25 rate 1 .66 306.09 0. 69,759.99 Florida unemployment - W pr. 26 employees x $7,000 x UCT-6 rate 0. 17% 31 .35 0. 71144. 10 B-1 5/172005 r Center for Emdional 8 Behavioral Heafth! Camp Manatee UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : Center for Emotional & Behavional Health/ Camp Manatee FUNDER: IRC - CSAC A B C FY 05/06 FY 05/06 % OF TOTAL FUNDER TOTAL VS. PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET col. B/col. A) . EXPENDITURES 21 Salaries . 35,261 .89 189578.73 52.69% 22 FICA . 2 697.53 19421 .27 52.69% 23 Retirement 722.81 0.00 0.00% 24 Life/Health 2,446.86 0.00 0.00% 25 Workers Compensation 306.09 0.00 0.00% 26 Florida Unemployment 31 .35 0.00 0.00% 27 TraVelm.Daify 364.50 0.00 0.00% 28 TravAiConferences/Trainin 0.00 0.00 #DIV/01 29 Ofl"ice Supplies 0.00 0.00 #DIV/01 30 Tele hone 221 .25 0.00 0000% 31 Postage/Shipping 100,00 0.00 0.00% 32 Utilities 722.00 0.00 0.00% 33 Occupancy. (Building & Grounds 3,9.4240 0.00 0.00% 34 Printin g & Publication200.00 0.00 0.00% 35 Subscription/Dues/Memberships 100900 0.00 0.00% 36 Insurance 0000 0.00 #DIV/01 37 E ui ment: Rental & Maintenance 0.00 040 #DN/01 38 Advertising 200.00 0.00 0.00% 39 Equipment Purchases:Ca ital Expense 0.00 10000 #DN/01 40 Professional Fees (Legal, Consulting) 0.00 0.00 #DIV/01 41 Books/Educational Materials 1 ,35040 0.00 0.00% 42 Food 8 Nutrition 1 ,099.54 0.00 0.000/0 43 Administrative Costs 13689.00 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 390.00 0.00 0.00%. 47Other/Contract 0.00 0.00 #DIV/01 48 TOTAL $51 ,844.81 $209000.00 38.580%/* 511 7120M e.a EXHIBIT B ( From policy adopted by Indian River County Board of county Commissioners on February 19 , 2002 ) " D . Nonprofit Agency Responsibilities After Award 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 and (September 30th) must be submitted on a timely basis . Each year, the Office of Management and 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 expense by type . These summaries should be broken down into salaries , benefit , 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. " EXHIBIT - B - Center for Emotional 8 Behavioral HeaRld Camp Manatee SALARIES A e n Gross Annual Portion of Salary on ed C % of G► bss,Annua/ POSITION LISTING Salary P m Proposed Funder specific Bi dyet: Salami PosrtOn Title Total Hrshvk (Agency) Ezarriple: Executive Director 140 his 70,000.00 10;000.00 5 :;. ,000.0Q a Director of Patient Care Services/40 hrs 95,808. 1 14,790.41 0.00 0.00° Psychologist Ucensed/24. hrs 341706. 19735.34 0.00 0.00° Manager of Activity Therapy/40 hrs . 58,980.21 51898.03 0.00 0.00° Camp Manatee Supervisod4O hrs 49200. 4200.00 4,200.00 100.00 Counselor - A group/40 hrs 20800. 21800.00 21800. 100.00° Counselor - A group/40 hrs 20800. 29800.00 2,800.00 100.00 Counselor - B group/40 hrs 2,800. 2,800.00 2,800.00 100.00 Counselor - B group/40 hrs 2,800. 29800.00 21800.00 100.00° Jr. Counselor - Camp Assistant/40 hrs 1 ,960. 1 ,960.00 it960.00100.00° Registered Nurse/40 hrs 54,781 . 1 51478.12 1 *218.73 2.22° #DIV/0! #DIVroI #DIVro! #DIV/0I #DIVro! #DIV/0! #DIV/01 #DIV/0 . #DIVi01 #DIV/01 Remaining positions throughout the agency 3,9401772.82 Total Salaries $49202,409.27 $359261 .89 518,578.7 0.44 Flaw B NE lTS DE7'AlL A (li�nit � SpOctc Budget Funder CtildinC on fmm tine 22 to 27 FICA 7 6s7s Mealtf� InsS th rw Ez � 1y ) Budget (A x �:) cam �cvrl Po3itt''dh Ti� 7D#al HitI-var Carple, vCas4 !Yl i sgxtao ws 5,000.00 982 SO 20000 * 510 00 , '_ 30ty;DO , . 200ad0 ' � < . '. . . � Director of Patient Care Services/40 hrs 0-001 0.00 0. Psychologist Licensed/24 hrs 0.001 0.00 0. Manager of Activity Therapy/40 hrs 0. 0.00 0. Camp Manatee Supervisor/40 hrs . 4.200. . 321 .30 321 .3 Counselor - A group/40 hrs 21800. 214.20 214.2 Counselor - A roup/40 hrs 21800. 214.20 214.201 Counselor - B group/40 hrs . 2s800.001 214.20 214.2 Counselor - B roup/40 hrs 2t8OO.M 214.20 214.2 Jr. Counselor - Camp Assistant/40 hrs I t960-001 149.94 149.91 Registered Nurse/40 hrs 1 ,218.7 93.23 93.2 0 0.001 0.00 0.0 0 0.001 0.00 0. 0 O.cq 0.00 0. 0 0. . 0.00 0. 0 0.001 0.00 0. 0 0.001 0.00 0.001 0 0.001 0.00 _. - 0.04 0 O.Oq 0.00 0.001 0 O.Oq 0.00 0. 0 0. 0.00 0.0 Total FunderRequestFringe Bert� $18,578.7 $10421 . $0. $0. $0. $0. $1 ,421 .2 B-1 5M 7r20o5 c ) »:i a OF ' i cs Ci 1n O i ,5uYI NN 5 fn: $ t .� 31. ,. ,, ., P m n q 5 M � ?. N N h � '�` n £ . N ;' m '. q ,p :� '•' h 3 v N 1OV N Q :'. l � t . : .; m xu �, � 7vd�� ��N' a, M ^ a WF T •, y�,' w .rt. *: N r l �Y . I ". o o > o o -� o d d ' . , 1. cN m _ .0 o _ 6 o N o n W � s f .'. ' o o 'h ) g '` o • ' o Q m Q O r `y tV m CIA r vx Im 19 x 10 111 49 C4 g � � a h 11 N 0 >< Frey uj ftx .11 $ V of • 4k e 'Sn Cz � � � � . .IikNagm' m � o � � a ; •C 5 � � E .� - 1- aeos 1- � � E � � w a 3 � qp K JLL � � � rn o � <- � c> � � � •� LL � EEaa •v : � v . 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 : CEBH - Center for Emotional & Behavioral Health 119037 th Street Vero Beach , Florida 32960 Attention : Mariamma Pyngolil , RN , Program Director 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 provision and term 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 context indicates otherwise , words importing the singular number include the plural number, and vise 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. EXHIBIT - C - t 1. /1. 4/2Q105 7. 1144 HC I P -V, ; 7725634564 , 304 gm AC981D. CERTIFICATE OF LIABILITY INSURANCE NP ap PRCIouCER j THIS CER71RCAT6 IS ISSUED A4 A MATTER OF [WORMATION DC NOT US$ I ONLY AND CQNFER9 NO RIGHTS UPON THE CERTIFICATE 6539 Du6rrfaoa 11v15 , , Suite 200ND OR AAOLDER, THIS CIEKTIFICATE DORS LLTERNkCOVERAGE AP ORDEDBYYTHEPO ICEASBELOW. Charlotte 9C 28211 1Ao�s: : H00 - 721 - 4F 149 Paxr704 - 365 - 7114 i INSURIR3AFFORDING COVIRAGE MAIC0 1 FNSURERA . Adnniral 7:nwarance C'O . _ a... n_. .. . .- . u�.-. vi aw-n��.glwRY�f wY�wY1MwYN .M .. .e. . .. Ip ian River Memorial HoRpital INSUREfae; AaMFlQb Au�OM" 1 ,1 , sn .. � . lira Nor aA ; INSURER C ' DOV38th Street Iw ___-.�. .. ....:.�� .w .�- #; ro leach PL 32960 IHs€rraEgO: COVERAGES INsurerR e THE Potc%8 OR iNSURANC6 LWMD Aii•OW HAV= BEEN iSEUFO TO TK INSUpgD NAMED Asovi FQR THr POW( Y "BRIOD IkOIOA"ED• wOTWITM=TANOPJC ANY RiOUIR "W,, RMM OM OONCIMON or ANY CONTRACT OR OTrtER0000MENT 'N°ITM MPCOTTQ WM!CH T -119 COAT,FICATA MAY ►E WSUEO OR MAY hIrAlNv TWE IN31URAN06 AFFQR06011Y Tt,E 1`06105* AESCRIBEC HEREIN IS SVWECT TO ALL T+;E TQRM6. VCLU9r0N8 ANG CONOMONS OF SUCH P01.0 M, A04Pte0ATE LIM'TS SWOWN MAY Pwo' ; eEEN FR6CUCEO 8Y PAO CtAIN& URANC 0061CY NIJM88R tlA Do r 8 v1Y LRS IS f RAL LiAB V+V 1 FAC H 00O3JRFtENCA 1 r a O O . O Q Q x t x CAMMERCIAL OENERAI Liaeltrc� CAPTIVE 6ZR 11 / 01 / 05 11 / Q ..JQs ?t MIBS�� �r^ 1 r -• X CLAIMS +Lsvb -,.,J O:Clta LIQ SRP IMY trirAt/s4�) a "OON4aADV INJVAY B a �,ooa oaa 1 eNCRALAGOMOAVC 3 $ 154001000 GENt AGOR£GATEgpL�IRM�IT APPUE9 iW PER, DUCTS • COMPIOPG S $ 5AG0000 00 Q vOLICY •� I AEG`t ' . . .- I LOC l r ALfioM081E 1 LAarltrfv Ii .'OM81M15p SWULE LIMM ANY "UTO I ` Me BR "m) aLL Owwo ALP03 gopikv Iii ua+ _^ 8 its 40HEOMEOAUTOS IM"GA80833367 li / 01 / D5 I1JQ1 / 06 IPmPL"QT4 B 8 XIN, I WREDALIT03 167.rA60033367 11 / 01 ! 05 21 / 0 ;, / 08 800n.Y ,NURY 8 NONAwNEDaUY09 MzA88933387 11JQLj05 11 / 01 / 06 1FraecWenq s t PROPERTY DAMA08 GAME L AKITY AuYO DULY . SA ACCIDENT S L. '.�.+wn'w r�wYufwf ANY AUTO II _ I , I ALiTOpNhII.YN � AG{i t m10ECSRA,18RaLLA WA61ILMY LACW DOCtAiPiGNDC i sZ0 r C00 r 0 () 0 A ; OCCUR a CLAIUSMADE CRL - Ft. - 10D33 1002 - 04 11 / 01105 11 ! 01 06 aaoR59AT@ S 1 / S30r000r0QQ Excess _ S DECUCTRUE ]LbCvd� SIR - ,••w • • RETENTION a � I AW;15M i A WON66R8C01lpRNBAYIOMANO A TOPY LNNY3 ER SIYIPLOY6R3" LU1 Uly gqmyy PWRXTOPR"AA'f ER/CXECVfI'A ( E.L . EACH ACCICENT $ OFFICBRINfM9EA EAC6uDEO7 r.l DI • EA I:Npt OTEE i Wftd"CdBB urm? S�EcIAI PRW,sro��s eaaw j E.L . DiSEAM • POLICY LBMT i A i + I I RESCRIFr1tlN OF 0►E11ATOtut t L.00arrOrys r V6r1,C(,ES i EKCLUSIONS ADOEa BY EMOCASEMfsN lSPEDIAL PROMSfONO Certificate Holder is added as Addttional Xneured with respect to their i.ntereot in contract wire th® Varled Iriaured . CERTIFICATE HOLDER CANCELLATION 1 Y yO SHOW-0 ANY OF TIIR AQOMP 1.&CRI6E0 POMOMS Of CANORLLBO 118rCRE TNM 99F"AT10 tlATR THP-RADE, TFC& tBSUI�iG INSURRP 1Nt L ENdRAV011 Tp q W). 3 Q DAY81MRI M NOYOWt0 YK4 RARMI:ATE HOLGBR 14AMSD TO YMB. yF:FTr 8YT FAIWRC To OC SO Spo" Istdiazs River County IMPOSE NOD8LIGATIONORUAMLrfOFANY MINOUPON T1t MURER, ftArRMYSOR .1540 45th Street REPRfc TATIYU4 Vero NBimph FL 32960 AUT �9Rerac- rA v�E r ACC1)t0 25123010s) 0 ACORD CORPORA OM 9gie ` CrIN b FIINC1r L BhvroM IIeaMJGnp Lb�IN UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health/ Camp Manatee FY 03104 FY 04/05 FY 66/06 % INCREASE FYE_9/30/2004 FYE_9/30/2005 FYE_9/30/2006 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (ed GeoL B) eol. B REVENUES BUDGETED BUDGETED 1 Children's Services CouncilSt Lucie - 0.00 #DIV/01 z Children's Services Council-Martin 0.007#D1WV/01 3 AdvisoryCommittee-Indian River 20 000.00 249"5, 167 818.13 % 4 United W St Lucie County0.005 United Wa -Martin Coun 0.006 United Wa -Indian River Cou 0.00 7 Department of Children S Families 0.00 #DIV/OI e Courdy Funds 0.00 #DIV/01 9 Contributions-Cash 200.00 #DIV/01 io Program Fees_ 7t224*445,00 7o3482000.00 T 300 000. -0.65% 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 1s Miscellaneous 0.00 #DIV/01 16 Legacies S . „este 2000,00 #Dlvrol 17 Funds from Other Sources .-,-- 0.00 #DIV/01 1B Reserve Funds Used for Operating 0.00 #DIVIOI . is In-Kind Donations P"t mcwa.a In iobn 0.00 #DIV/01 20 TOTAL . . 792"1445,00 7,37Z445,00 747001813 . 1 .32% . x ate:•.. . 7M . � _ �'`< EXPENDITURES 21 Salaries 3 676 766. 410809009,00 4 202 409. 3.00% 22 FICA 259 96ZOC 293 753.00 321j484,31 9,44% . 23 Retirement 11 "9129,22 159 936 35 1649734,44 3.00% 24 Lifehiealth 487,906.&x 5419417,19 557 659.71 3.00% 25 Workers Compensation 61 034.3 67 728.15 69l759,99 3.00% 26 Florida Unemployment 61250.50 6936.02 79144,10 3.00% 27 Travel-Dally 2JI0.00 3 080.00 317240 3.00% 28 Travel/Conferences/Training 43 995.00 43 995.00 1 45140.40 2.60% 29 Office Su les 50 19.00 "1529.00 ` . 44 529.00 0.00% 3o Telephone 28 589.25 29 473.45 30 385.00 3.09% 31 Postagge/Shipping 41499,00 Z922,00 61060,00 107.39% 32 Utilities 68 612.00 65 000.00 7012W.00 8.00% 33 Occupancy (Building & Grounds 8729405,00 M1981 ,00 891l320,81 0.26% 34 PrIntina 3 Publications I 857.00 3 000.00 39120 4.00% 35 Subscri mbershi 17.00 5 55&O0 : 5jW&OO 0.00- - 36 Insurance 409 660. 375,57&00 375 000. =0.15% 37 EquipmentRentall S Maintenance 14;029ADI 17j568,OO 1795W,00 -0.39% 36 Advertising - 51000,001 59000.00 5000,00 0.00% 39 Equipment Purchases:Ca ' 1 Expense 11 274. 8v647.00 99000.00 4.08% 40 Professional Fees (Legai, Consulting) 306 287. 228 612 228,612.00 0.00% 41 Books/Educational Materials 2096WOO 29 080.00 2%080,00 0.00% 42 Food & Nutrition 1372328,00 141600.00 118SO38OO 46.64% 43 Administrative Costs 424936&00 430t730.48 472s795,75 9.77% 44 Audit Ex 0.00 0.00 0.00 #DIV/01 4s Specific Assistance to Individuals 0.00 0.00 0.00 #DIV/01 46 Other/Miscellaneous 800.001 800.00 19575,00 96.88% 47 OthedContract 871 ,908.001 872sODO,OO 872,000.000.00% 48 TOTAL 7 911 509.1 81345g928.6.4 8,551 ,276,18 2.46% 49 REVENUES OVER/ UNDER EXPENDITURES -667,064.141 9739483. 4 ,0819258. 11 .07% 5mrmas ss UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME:Center for Emotional & Behaviorial Health! Cam Manatee FY 03/04 FY 04/05 FY 05/06 % INCREASE FYE 9/30!2004 FYE_WM2005 FYE CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED ("L C{DL Bycol. e REVENUES BUDGETED BUDGETED 1 Children's Services Council-St Lucie 0.00 #DIVIOI 2 Children's Services Council-Martin 0.00 #DIV/01 3 Advisory Committee4ndian River 20 000.00 20 000.00 20 000.00 0.00% 4 United Way-St Lucie County0.00 #DIV/01 6 United Way-Martin County 0.00 #DIV/OI 6 United. Way-Indian River County 0.00 #DIV/O! 7 Department of Children & Families 0.00 #DIV/01 e County Funds 0.00 #DIV/01 Contributions-Cash 200.00 _ 200.00 0.00% to Program Fees . 10 000.00 10 000.00 10 0110.00 0.00% 11 Fund Raising Events-Net 0.00 . #DIVI01 12 Sales to Public-Net 0.00 #DIV/01 13 Membership Dues 0.00 #DIV/01 14 Investment Income 0.00 #DIVIOI 1s Miscellaneous 0.00 #DIV/01 1s Legacies & Bequests : 000.00 29000.00 0.00% 17 Funds from Other Sources 0.00 #DIV/01 1a Reserve Funds Used for Operating 0.00 #DIVIOI 19 In-KlndDonations IRMH - 24222.35 18,820, 19644.81 4.38% m TOTAL . 30 000.00 34200.00 132,200.00 . 0,00% EXPENDITURES 21 Salaries 33177.9 34 .04 35j261 .89 3.09% 22 FICA 2538,1124616.61 , 4697.53 23 Retirement 684.78 701 .17 722.81 3.09% 24 LifeAieatth 4311L14 437&60 29446.86 3.09% Workers Compensation 289,99 296.92 306.09 3.09% 26 Florida Unemplory, meet 29.70 30.4131 .35 3.09% 27 Travel-Daily 300.00 300.00 364.50 21 .50% 2a TravellConferences/Trainin 0.00 #DIV/01 29 Office Supplies 0.00 #DIVIOI 3o Telephone 250.00 250.00 221 .25 W11 .50% 31 Postage/Shipping 95.00 95.00 100.00 5.26% 32 Utilities 775.00 775.00 722.00 -6.84% 33 OCCUIDanCy Wilding & Grounds 3900.00 1900.00 3t942.00 1 .08% 34 Printing & Publications 180.00 180.00 200.00 11.11 % 3s Subscri bershi . 100.00 100.00 100.00 d.00% 3s Insurance 0.00 #DIV/01 37 EquipmentRental & Maintenance 0.00 #DIVAM 39 Advertising 200.00 200.00 200.00 0.00% 39 Equipment Purchases:Ca . Exjxinse , 0.00 #D11//01 40 Professional Fees 1 Consulting) 0.00 #W/Of 41 Books/Educational Materials 1 200.00 1250.00 1351!. . 8.00% 42 Food & Nutrition 19000.00 1000.00 1099.54 9.95% 43 Administrative Costs 195W,00 1500.00 1689.00 12.60% 44 Audit Expense0.00 #DN/Of 45 Specific Assistance to Individuals 0.00 #DIV/Ol 46 Other/Misceilaneous 360.00 360.00 390.00 8.33% 47 OthedContract 0.00 #DIVIOI 48 TOTAL 48 898.63 50132.75 51844.81 3:42% 49 REVENUES OVER/ UNDER EXPENDITURES 489896.6AI -1T 932.75 -19 644.81 9.55% smra�oe w 11 � 14r�005 11 : 44 MC ) R ' 177256134564 NQ , 304 D®3 „ A OAP.. CERTIFICATE OF LIABILITY INSURANCE z OP PRODUCER THIS CERTIFICATE I$ ISSUED W3 A MATTER OF W01" IATION Florida uosv: tsl AseccInm Svc I ONLY AND CONFERS No RIGHTS UPON THE CER71PICATE ►MOLDER. THIS CERTIFICATE DOZES NOT AMINO , EMNb OR MaaciobtRa G71 30067 x675 Terrell Rd . ALTER THE COVERAOB AFFORDED By THE POLICIES BELOW, tl6T BhoRaw : E00 - { 76 _ 7601 Pax : 770 � 85C - 098L INSURERS AFFORDING COVIRAGE I NAIC0 1NSURERf tN&iJReRA: CeaR liiRnGa1 CraauU, w caq►,wy �,wll Ind,i4a River Mtmbrial Hospital Ip'�"�iR °' Greg P(O ;,},� INSURER C: I IOU 36tH straet i vera Beach AL 32960 1 INSURER a COVERAGES TWE POLICIES OF ;NBUAANCE LISTED BELOW IL.vE BEEN ISSUEDTO THE tNSILR60NAMED ABOVE F61R THE POLICY PSRIQD INDICATIEO, NOYWITHSTANOINC ANY 811420 MENT,. TERN OR CONDITION OF ANY CONTkAew r' OR OTMF,R DOCUNF.NT VITM RESPrCTTO WHiCM Tr!IS Omf ATE MAY BE t',j&%00R MAYa+CRTAIN, TH!, 04564tANCC AFFOROLD PY TrIC POS C 'r• S OCSCPISW MrRCIN IS SUBJECT TC ALL TI-!E73", MXCLU91ONS ANO CANOITICA OK AUCla h4uCICS AGGACO % LrMlts Sr'I"N %tAT NAVE 9GGn W,FDWCIEO DY PAi00LpIM6, RSTR'.�oRr� uaANce PaWtcY NW� 0 {► I lrR>tITB 1 GENERA! WIANLI!Y I AtN OCCURRENCS i COFAMERGAI OGNCAAL LW9'LI7Y i ! RrFaSEe oCw+Metl ► -•_ ,.Y CLAtM3 L}AQE L7 OCCUR -LIED FAO (Any &W Pwwpna g _- - _ 3ER30%AL & AOV INJUTW S 241411IAL A03REQATE S 1XN1 WNW! WN1MRAPPLIES PER, i � POcICY I� JEC I ' !'ROCUCyS - COMPfOn AM ! g w i WtGO OPILE VABILITY COIw81N1?b B!NG! E LIMIT AWYAL:TO &Rotes idea) f L uv14fiOALrf00 i SCwE011LE0AUT05 ! RY IP�w� f yl MIRK AUTOS I A=$ 6016Y NGN-0WNED I {i rry eeN�enq S PR fPCCIQ�MtOAWAGEeke S tiAIU1C,6 Wlt1B16(fY AW"0 QNLY „ E4 ACCMNT I S - ..! ANY AUTO _ QTWERTKAN SACC }„3 AUTO ONLY; ✓ CIL9 i R%GL'S+DAtNEtRELtA17A31: T! r:ACHOCCURREWE i $ i— @CCWR a CLAIMS MnOr A6GREGATR: IS I I a DEDUCteL! j I iS j i RETENTION $ WOWF W COMPENSATION AND EMPLOVERRPWIAML” I X _,F,` M�T„s ER A ANYPRaPR �RlPAA�wAFSuTIVE w " 12l1588436Te f 01101 / 05 O1 / 02/ OG ' rW, FACHi1CCsGGNT s $ 1 � 0a3 1100 OFFIGERrMENBERE%CLUOiO + Cle, OIESAK , FAEmPLOYE S $ 1 , 000 040 Uy!a, JattI1R! under &PEC!AL PFROV6ION6 WpwML OIBEASE • POLC4' LRAtr e l c QQ r o c o ! j I OWCRWIIQN QF oPRRAY10W5 / LCKiATiOtuS t venrt.>,gS ' S1fCWU910N9 ADORN ew firypORSEMENT r SnECIRL p'ROVI91ON9 Proof of Cover;S+ £ ur iodian Saver meumoria], 1105pital „ i CURTIFlCATE MOIL OR CANCELLATION I)MIANC 6140"0 ANY OF THE APOV'A 0"CitA tf P0464CINS OF CANCFLLRO 40FORS TWE WMMATWN DATE TwIEREOF, THE ISSUING IN"RBR W16W 64MAVOM TCt kw6 30 DAY$ r AjrrCN NDYCN YO THE COWI!rIOAT4 4ftOUR NAMDTO TPIP LN". 04T PAILURR TO 00310 SNAL : tndi d>e Kiefer County IMPOSE Na ORLICATION OR WASIL " 0III ANY KIND UPON TMF IHBUREq, ITE AOEINTA OR 1040 29th Street REPRB ATU6S0 Vero aaach FL 32960 AUT w " PTa ve P ACGRD 25 t2o0T/vo -- m ACORa CORPORATION 1986 r Center for Emdional 8 Behavioral Heafth! Camp Manatee UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : Center for Emotional & Behavional Health/ Camp Manatee FUNDER: IRC - CSAC A B C FY 05/06 FY 05/06 % OF TOTAL FUNDER TOTAL VS. PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET col. B/col. A) . EXPENDITURES 21 Salaries . 35,261 .89 189578.73 52.69% 22 FICA . 2 697.53 19421 .27 52.69% 23 Retirement 722.81 0.00 0.00% 24 Life/Health 2,446.86 0.00 0.00% 25 Workers Compensation 306.09 0.00 0.00% 26 Florida Unemployment 31 .35 0.00 0.00% 27 TraVelm.Daify 364.50 0.00 0.00% 28 TravAiConferences/Trainin 0.00 0.00 #DIV/01 29 Ofl"ice Supplies 0.00 0.00 #DIV/01 30 Tele hone 221 .25 0.00 0000% 31 Postage/Shipping 100,00 0.00 0.00% 32 Utilities 722.00 0.00 0.00% 33 Occupancy. (Building & Grounds 3,9.4240 0.00 0.00% 34 Printin g & Publication200.00 0.00 0.00% 35 Subscription/Dues/Memberships 100900 0.00 0.00% 36 Insurance 0000 0.00 #DIV/01 37 E ui ment: Rental & Maintenance 0.00 040 #DN/01 38 Advertising 200.00 0.00 0.00% 39 Equipment Purchases:Ca ital Expense 0.00 10000 #DN/01 40 Professional Fees (Legal, Consulting) 0.00 0.00 #DIV/01 41 Books/Educational Materials 1 ,35040 0.00 0.00% 42 Food 8 Nutrition 1 ,099.54 0.00 0.000/0 43 Administrative Costs 13689.00 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 390.00 0.00 0.00%. 47Other/Contract 0.00 0.00 #DIV/01 48 TOTAL $51 ,844.81 $209000.00 38.580%/* 511 7120M e.a EXHIBIT B ( From policy adopted by Indian River County Board of county Commissioners on February 19 , 2002 ) " D . Nonprofit Agency Responsibilities After Award 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 and (September 30th) must be submitted on a timely basis . Each year, the Office of Management and 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 expense by type . These summaries should be broken down into salaries , benefit , 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. " EXHIBIT - B - 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 : CEBH - Center for Emotional & Behavioral Health 119037 th Street Vero Beach , Florida 32960 Attention : Mariamma Pyngolil , RN , Program Director 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 provision and term 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 context indicates otherwise , words importing the singular number include the plural number, and vise 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. EXHIBIT - C - t 1. /1. 4/2Q105 7. 1144 HC I P -V, ; 7725634564 , 304 gm AC981D. CERTIFICATE OF LIABILITY INSURANCE NP ap PRCIouCER j THIS CER71RCAT6 IS ISSUED A4 A MATTER OF [WORMATION DC NOT US$ I ONLY AND CQNFER9 NO RIGHTS UPON THE CERTIFICATE 6539 Du6rrfaoa 11v15 , , Suite 200ND OR AAOLDER, THIS CIEKTIFICATE DORS LLTERNkCOVERAGE AP ORDEDBYYTHEPO ICEASBELOW. Charlotte 9C 28211 1Ao�s: : H00 - 721 - 4F 149 Paxr704 - 365 - 7114 i INSURIR3AFFORDING COVIRAGE MAIC0 1 FNSURERA . Adnniral 7:nwarance C'O . _ a... n_. .. . .- . u�.-. vi aw-n��.glwRY�f wY�wY1MwYN .M .. .e. . .. Ip ian River Memorial HoRpital INSUREfae; AaMFlQb Au�OM" 1 ,1 , sn .. � . lira Nor aA ; INSURER C ' DOV38th Street Iw ___-.�. .. ....:.�� .w .�- #; ro leach PL 32960 IHs€rraEgO: COVERAGES INsurerR e THE Potc%8 OR iNSURANC6 LWMD Aii•OW HAV= BEEN iSEUFO TO TK INSUpgD NAMED Asovi FQR THr POW( Y "BRIOD IkOIOA"ED• wOTWITM=TANOPJC ANY RiOUIR "W,, RMM OM OONCIMON or ANY CONTRACT OR OTrtER0000MENT 'N°ITM MPCOTTQ WM!CH T -119 COAT,FICATA MAY ►E WSUEO OR MAY hIrAlNv TWE IN31URAN06 AFFQR06011Y Tt,E 1`06105* AESCRIBEC HEREIN IS SVWECT TO ALL T+;E TQRM6. VCLU9r0N8 ANG CONOMONS OF SUCH P01.0 M, A04Pte0ATE LIM'TS SWOWN MAY Pwo' ; eEEN FR6CUCEO 8Y PAO CtAIN& URANC 0061CY NIJM88R tlA Do r 8 v1Y LRS IS f RAL LiAB V+V 1 FAC H 00O3JRFtENCA 1 r a O O . O Q Q x t x CAMMERCIAL OENERAI Liaeltrc� CAPTIVE 6ZR 11 / 01 / 05 11 / Q ..JQs ?t MIBS�� �r^ 1 r -• X CLAIMS +Lsvb -,.,J O:Clta LIQ SRP IMY trirAt/s4�) a "OON4aADV INJVAY B a �,ooa oaa 1 eNCRALAGOMOAVC 3 $ 154001000 GENt AGOR£GATEgpL�IRM�IT APPUE9 iW PER, DUCTS • COMPIOPG S $ 5AG0000 00 Q vOLICY •� I AEG`t ' . . .- I LOC l r ALfioM081E 1 LAarltrfv Ii .'OM81M15p SWULE LIMM ANY "UTO I ` Me BR "m) aLL Owwo ALP03 gopikv Iii ua+ _^ 8 its 40HEOMEOAUTOS IM"GA80833367 li / 01 / D5 I1JQ1 / 06 IPmPL"QT4 B 8 XIN, I WREDALIT03 167.rA60033367 11 / 01 ! 05 21 / 0 ;, / 08 800n.Y ,NURY 8 NONAwNEDaUY09 MzA88933387 11JQLj05 11 / 01 / 06 1FraecWenq s t PROPERTY DAMA08 GAME L AKITY AuYO DULY . SA ACCIDENT S L. '.�.+wn'w r�wYufwf ANY AUTO II _ I , I ALiTOpNhII.YN � AG{i t m10ECSRA,18RaLLA WA61ILMY LACW DOCtAiPiGNDC i sZ0 r C00 r 0 () 0 A ; OCCUR a CLAIUSMADE CRL - Ft. - 10D33 1002 - 04 11 / 01105 11 ! 01 06 aaoR59AT@ S 1 / S30r000r0QQ Excess _ S DECUCTRUE ]LbCvd� SIR - ,••w • • RETENTION a � I AW;15M i A WON66R8C01lpRNBAYIOMANO A TOPY LNNY3 ER SIYIPLOY6R3" LU1 Uly gqmyy PWRXTOPR"AA'f ER/CXECVfI'A ( E.L . EACH ACCICENT $ OFFICBRINfM9EA EAC6uDEO7 r.l DI • EA I:Npt OTEE i Wftd"CdBB urm? S�EcIAI PRW,sro��s eaaw j E.L . DiSEAM • POLICY LBMT i A i + I I RESCRIFr1tlN OF 0►E11ATOtut t L.00arrOrys r V6r1,C(,ES i EKCLUSIONS ADOEa BY EMOCASEMfsN lSPEDIAL PROMSfONO Certificate Holder is added as Addttional Xneured with respect to their i.ntereot in contract wire th® Varled Iriaured . CERTIFICATE HOLDER CANCELLATION 1 Y yO SHOW-0 ANY OF TIIR AQOMP 1.&CRI6E0 POMOMS Of CANORLLBO 118rCRE TNM 99F"AT10 tlATR THP-RADE, TFC& tBSUI�iG INSURRP 1Nt L ENdRAV011 Tp q W). 3 Q DAY81MRI M NOYOWt0 YK4 RARMI:ATE HOLGBR 14AMSD TO YMB. yF:FTr 8YT FAIWRC To OC SO Spo" Istdiazs River County IMPOSE NOD8LIGATIONORUAMLrfOFANY MINOUPON T1t MURER, ftArRMYSOR .1540 45th Street REPRfc TATIYU4 Vero NBimph FL 32960 AUT �9Rerac- rA v�E r ACC1)t0 25123010s) 0 ACORD CORPORA OM 9gie 11 � 14r�005 11 : 44 MC ) R ' 177256134564 NQ , 304 D®3 „ A OAP.. CERTIFICATE OF LIABILITY INSURANCE z OP PRODUCER THIS CERTIFICATE I$ ISSUED W3 A MATTER OF W01" IATION Florida uosv: tsl AseccInm Svc I ONLY AND CONFERS No RIGHTS UPON THE CER71PICATE ►MOLDER. THIS CERTIFICATE DOZES NOT AMINO , EMNb OR MaaciobtRa G71 30067 x675 Terrell Rd . ALTER THE COVERAOB AFFORDED By THE POLICIES BELOW, tl6T BhoRaw : E00 - { 76 _ 7601 Pax : 770 � 85C - 098L INSURERS AFFORDING COVIRAGE I NAIC0 1NSURERf tN&iJReRA: CeaR liiRnGa1 CraauU, w caq►,wy �,wll Ind,i4a River Mtmbrial Hospital Ip'�"�iR °' Greg P(O ;,},� INSURER C: I IOU 36tH straet i vera Beach AL 32960 1 INSURER a COVERAGES TWE POLICIES OF ;NBUAANCE LISTED BELOW IL.vE BEEN ISSUEDTO THE tNSILR60NAMED ABOVE F61R THE POLICY PSRIQD INDICATIEO, NOYWITHSTANOINC ANY 811420 MENT,. TERN OR CONDITION OF ANY CONTkAew r' OR OTMF,R DOCUNF.NT VITM RESPrCTTO WHiCM Tr!IS Omf ATE MAY BE t',j&%00R MAYa+CRTAIN, TH!, 04564tANCC AFFOROLD PY TrIC POS C 'r• S OCSCPISW MrRCIN IS SUBJECT TC ALL TI-!E73", MXCLU91ONS ANO CANOITICA OK AUCla h4uCICS AGGACO % LrMlts Sr'I"N %tAT NAVE 9GGn W,FDWCIEO DY PAi00LpIM6, RSTR'.�oRr� uaANce PaWtcY NW� 0 {► I lrR>tITB 1 GENERA! WIANLI!Y I AtN OCCURRENCS i COFAMERGAI OGNCAAL LW9'LI7Y i ! 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ANY AUTO _ QTWERTKAN SACC }„3 AUTO ONLY; ✓ CIL9 i R%GL'S+DAtNEtRELtA17A31: T! r:ACHOCCURREWE i $ i— @CCWR a CLAIMS MnOr A6GREGATR: IS I I a DEDUCteL! j I iS j i RETENTION $ WOWF W COMPENSATION AND EMPLOVERRPWIAML” I X _,F,` M�T„s ER A ANYPRaPR �RlPAA�wAFSuTIVE w " 12l1588436Te f 01101 / 05 O1 / 02/ OG ' rW, FACHi1CCsGGNT s $ 1 � 0a3 1100 OFFIGERrMENBERE%CLUOiO + Cle, OIESAK , FAEmPLOYE S $ 1 , 000 040 Uy!a, JattI1R! under &PEC!AL PFROV6ION6 WpwML OIBEASE • POLC4' LRAtr e l c QQ r o c o ! j I OWCRWIIQN QF oPRRAY10W5 / LCKiATiOtuS t venrt.>,gS ' S1fCWU910N9 ADORN ew firypORSEMENT r SnECIRL p'ROVI91ON9 Proof of Cover;S+ £ ur iodian Saver meumoria], 1105pital „ i CURTIFlCATE MOIL OR CANCELLATION I)MIANC 6140"0 ANY OF THE APOV'A 0"CitA tf P0464CINS OF CANCFLLRO 40FORS TWE WMMATWN DATE TwIEREOF, THE ISSUING IN"RBR W16W 64MAVOM TCt kw6 30 DAY$ r AjrrCN NDYCN YO THE COWI!rIOAT4 4ftOUR NAMDTO TPIP LN". 04T PAILURR TO 00310 SNAL : tndi d>e Kiefer County IMPOSE Na ORLICATION OR WASIL " 0III ANY KIND UPON TMF IHBUREq, ITE AOEINTA OR 1040 29th Street REPRB ATU6S0 Vero aaach FL 32960 AUT w " PTa ve P ACGRD 25 t2o0T/vo -- m ACORa CORPORATION 1986