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FY15 SRC CFMF Presciption Asst grant applicationUaue Fear MEMOiRIAL FOUNDATION '11-11S APPI--, I CATION FOR FUINDING W11,1, BE ACCEPTED ONLY IF A LE'1"YER OF INQUIRY HAS BEEN SUBMIT rrED ANDAPPROVED BYTHEFOUNDA110N. Thank you for subin I tting your grant application to Cape Fear Memorial Foundation. Please note that one (1) copy of the application, with original signatures, must be RECEIVED in the Foundation office by 5:00 p.m. on January 15"', 2015. Applications should be mailed via REGULAR mail or hand delivered to: Anna Erwin, CPA, President Cape Fear Memorial Foundation 2508 Independence Boulevard Suite 200 Wilmington, NC 28412 (91 0) 452-0611 phone (910) 452-5879 fax APPLICATION CHECKLIST on 11'1(�IL!dc B0111 ( F) FXCCUtT\ C D1D-'Ct0!- VND Board t- g:" signaturc 111cludc a cc)p% ("t, doff, organj,-/�,',wlorl,� 116 (betLi-Y1 in�'ItIon Or I .ter -I'll 990 f'()r the hich,ide rcpc�rts' knat"Ic"d st"I""nu 2 (4) hiclude, organj, ,.atlonal charl Ottav'ul"flblc') (5) co-[-y of�'t)Uj- CUrrej,[ noic ()flhicers. (6) ;�q)�ilication w1th Auacl-irnentts 1(1: a iv, it,cln'ifdn.org j ****Please call (910) 452-0611 if you have any questions or concerns***** CAPE FEAR MEMORIAL FOUNDATION - GRANT APPLICATION FORM Pau I of I- Last Revised: 11/2512014 (JCD) Organization Information Name-. New Hanover County Senior Resource Center Physical Address: 22122 S, College Road Wiln-iingron, NC 28403 Mailing Address: _2222 S. College Road Wilmington, NC" 28403 Telephone #:: 910-799-6400 Contact Information Primary Contact Telephone #: E-mail Address: Ms. Brenda "Ben" Brow 910-798-6410 bbr0w(i(,nhcgov'.corn CEO/Executive Director information Name: Avril finder Telephone #: 910- 798 -7184 E-mail Address: apinder(r(,nlicgovxorn Fax #: 910-798-6411 Title: Senior Resource Center Manager Fax -+"f- : 910-798-6411 Title: Assistant County Manager Fax # - 910- 798 -7277 1. Summarize the organization's history and CUrrent operations. (Please limit response to 1000 words) Mission Statement. To act as the focal point for aging services in New Hanover County by providing services which promote wellness, encourage independence, and enhance quality of life for all older persons. SERVICES: BLOOD PRESSURE CHECK: Blood pressure health screenings are offered on the 4" Monday of each month from 10:00 AM to 12:00 Noon CONGREGATE MEALS: Individuals 60 years of age and older may participate in the Congregate Meal Service, Monday-Friday from 9­30 AM to 1:00 PM. Meal is served 11:30 to 12:00. A voluntary donation of $1.50 is recommended. Visit the Senior Center @ 2222 South College Road and register with the Nutrition Site Manager r g Y aret Bryant. a� [Y INCONTINENCE SUPPLIES PROGRAM: Offers absorbent underwear (Depends /Poise /etc.) at a senior discount, through a collaboration with a local medical supplier, Contact Valorie Hatten @ 798-6485 or vhattenQnhcgov.com EMERGENCY ASSISTANCE: Assists persons 60+ up to $50.00 per year for basic needs (i.e. electric or water bills, meds) Contact Gayle Ginsberg @ 798-6402 or gginsberci@nihcqov.com or Jean Wall @ 798-6443 or iwall@ncgov.com ENSURE/BOOST: Ensure/Boost available for purchase at a senior discount, through a collaboration with a local medical supplier. Contact Richard @ 798-6444. Pickup days/times: Tuesdays 8-1 lam, Thursdays 2-4:30prn. CAPE FEAR MEMORIAL FOUNDATION - GRANT APPLICATION FORM pag'c 2 of 12 Last Revised: 11/2512014 (JGD) FITNESS/HEALTH PROMOTIONS & FAIRS/HEALTH SCREENINGS: A listing of exercise classes and other health promotion opportunities is available at the Ambassador's Desk and is published in our newsletter. The Senior Center also has treadmill and exercise bike equipment available on a first-come-first-serve basis. Prior to using Senior Center exercise equipment, the individual must sign a release of responsibility waiver. Waivers are in the switchboard office. The Hugh MacRae nature Trail is located adjacent to the Senior Center with a 0.3 and 0.6 mile trail for nature walks. FANS PROGRAM: Fans are provided for seniors with no means of cooling their home. FAMILY CAREGIVER RESPITE SUPPORT: Provides short term respite services to caregivers who are caring for a family member or friend over the age of 60. Contact any of the Social Workers listed below. FOSTER GRANDPARENT PROGRAM: Individuals 55+ (who meet an income requirement) volunteer to nurture and mentor at-risk children in pre-schools, elementary schools and after- school programs, and nurture babies at the Kelly House. Contact Beth Wooten @ 798-6408 or bwooten@nhcg,ov.com HOME DELIVERED MEALS: Participants must be 60 years of age and older, homebound, and unable to prepare his/her own meal adequately. For information, Contact Jean Wall Cab 798- 6443 and arrange an appointment for an in-home assessment. To volunteer to deliver meals, contact Ashley Huffman @ 798-6423 or ahuffman_@nhcgov.com. INSURANCE (MEDICARE AR,&,D) COUNSELING: The Senior Health Insurance Information Program (SHIIP) has RSVP volunteer insurance counselors trained by the SHIIP program and the NC Department of Insurance. Volunteer counselors are available for walk-in service on Tuesdays and Thursdays from 11:00 AM to 1:00 PM. For more information, contact Valerie Smith @ 798-6406 or vsmith(a)-nhcqov.,com NEWSLETTER: Individuals can subscribe for only $10.00 per year copies are available bi- monthly. PHONE PALS FOR FRIENDSHIP: Designed to provide companionship for isolated and home- bound elderly by matching them with an RSVP volunteer caller. Contact Valorie Hatten @ 798 - 6485 or vhattenp_nhcgov,com PRESCRIPTION DRUG ASSISTANCE: We will do our best to evaluate your medication needs and help you get your medicine at the lowest possible cost by locating any prescription assistance programs available. Your cooperation is essential and will require a signed partnership agreement. Contact Pamela Wall (cD- 798-6422. RETIRED AND SENIOR VOLUNTEER PROGRAM (RSVP)-. Matches the varied interests and skills of volunteers age 55 and older with community needs by offering a diversity of volunteer service opportunities through a wide range of placements. Contact Tracy, Ash @ 798-6407 or tash(a)_n,hcgov.com or Valerie Smith @ 798-6406 or vsmith(o),nhcqov.com SENIOR CENTER ACTIVITIES DEPARTMENT: Schedules classes, programs, dances, games, contests, workshops and special events. Contact Shantell Davis @ 798-6409 or srdavis(d_)798 nhcgov,com or Greg Kennedy -6403 G SENIOR GAMES: A year-round health promotion program for persons 55 and older to participate in competitive sport and art events on a local, State, and National level. Contact Mark Sinclair (c� 251-9622 x229 SPECIAL NEEDS REGISTRY: A database of individuals with special needs who may require additional assistance prior to, during, and after an emergency event such as a hurricane, The Registry is maintained by trained RSVP volunteers in support of the NHC Special Needs Task Force which evaluates and allocates available resources to meet determined needs, Contact Jeanette Bell@ 'bell&nhpgov.com SUPPORT GROUPS: Call the Switchboard at 798-6400 for information on individual contact and time listings or refer to the newsletter for Support Groups for Blind & Visually Impaired, Family Caregiver, Parkinson's & Lewy Body Dementia, Wilmington Essential Tremor Awareness Group (WETAG) and others. TAX ASSISTANCE: The Volunteer Income Tax Assistance (VITA) Program is available each year from February 1 through April 15. VITA volunteers prepare basic State and Federal Tax Returns for individuals at no charge, however donations to the Senior Resource Center helps the Center continue to sponsor this program. Contact Valerie Smith @ 798-6406 or vsmith@nhcgov.com or Tracy Ash @ 798-6407 or tash(cD-nhcqov.com TRANSPORTATION- GENERAL AND MEDICAL: Provided for qualified individuals 60+ for CAPE FEAR Mi'MORIAL FOUNDATION - GRAN] APPLICATION FORM PnLc 3ot'1 Last Revised: 11/25/2014 (JCD) medical appointments, to SRC nutrition site, and small group shopping. Contact Sam 798- 6401 for an application. INFORMATION REFERRAL and CASE ASSISTANCES: a Social Worker and Case Worker collaborate with community agencies to assist clients and locate resources that meet their needs. Contacts: Valorie Hatten @ 798 -6485, vhatten(aD_nhcgov.com Gayle Ginsberg @ 798 -6402 gginsberga)nhcgov.com Jean Wall @ 798 -6443 jwall(a)nhcgov.com • ADULT DAY CARE ADULT DAY HEALTH & GROUP RESPITE: • FAMILY CAREGIVER SUPPORT PROGRAM: • DISASTER PREPAREDNESS PLANNING /RESPONSE: • ENERGY ASSISTANCE: • FOOD DISTRIBUTION: • HOME HEALTH SERVICES: • HOME REPAIR AND MODIFICATION: • HOSPICE CARE REFERRAL: • HOUSING REFERRAL: • IN -HOME AIDE SERVICES: Provided via contract. • LONG TERM CARE FACILITIES: • MEDICAID: • MENTAL HEALTH: • NOTARY SERVICES: • REHABILITATION SERVICES: • REPORT SUSPECTED ABUSE NEGLECT OR EXPLOITATION: • RESPITE CARE: 2. Please attach an organizational chart or summarize the organization's management /personnel structure. (Please limit response to 500 words). SENIOR RESOURCE CENTER ORGANIZATIONAL CHART (2014 -15) BRENDA "BEN" BROW, SRC Manaqer DIANE BERRY: Administrative Specialist RICHARD LOESER: Administrative Specialist CHRIS DODSON: SRC Transportation Program Coordinator HAROLD NORRIS: Transportation Program Assistant GREG KENNEDY: Activities Program Manager SHANTEL DAVIS: Activities Program Assistant MARLENE CARNEY: Part-Time Switchboard Operator MARION Johnson - McIntyre: Part-time Switchboard Operator SENIOR COMMUNITY SERVICE EMPLOYMENT TITLE V WORKER: Part -Time Switchboard Operator (not County employee) AMBER SMITH: Social Work Supervisor Life Enrichment Program (LEP) GAYLE GINSBERG: Social Worker JEAN WALL: Social Worker VALORIE HATTEN: Econ. Case Worker REBECCA "BECKY" HAYES: LEP Program Assistant PAM WALL: Prescription Assistance Counselor ELLEN CONNOR: Nutrition Program Manager ASHLEY HUFFMAN: Nutrition Program Coordinator - Volunteer Drivers DARLENE WILLIAMS- GANTZ: Nutrition Program Assistant- Packer MARGARET BRYANT: Nutrition Program Assistant - Congregate Site Manager KARLA BRIDGERS: Nutrition Program Assistant - Meal Delivery Truck Driver TRACY ASH: Retired & Senior Volunteer Program (RSVP) and Foster Grandparent Program (FGP) Manager VALERIE SMITH: RSVP Program Coordinator JEANETTE BELL: RSVP Program Assistant (Part-Time) BETH WOOTEN: FGP Program Coordinator CAPE FEAR MEMORIAL FOUNDATION - GRANT APPLICATION FORM Page 4 of 12 Last Revised: 11/25/2014 (JGD) SU111111ariZC the background of organization's key personnel. (Please limit response to 500 words) Z- - The NHC Senior Resource Center (SRC) is responsible to the New Hanover County Board of Commissioners. The manager of the Department reports directly to Avril Pinder, one of the Assistant County Managers. The Senior Resource Center works with two advisory boards: VOCAL, Inc (Volunteer Older Citizen Action League, Inc) and the Home and Community Care Block Grant Committee (HCCBG). Both of these advisory committees provide advice and direction as well as recommendations to the NH County Board of Commissioners for distribution of Home and Community Block Grant federal and state funds. Key personnel include: Brenda "Ben" Brow- , a retired Registered Nurse with years of management and supervisory experience and NHC employee for the past 10 years, is the Program Manager for the Senior Resource Center. She reports directly to Avril Pinder, Assistant County Manager. Amber Smith: Social Work Supervisor: Amber has worked for the County for more than ten years. She has a Bachelor of Social Work degree and was previously an Adult Protective Service worker at DSS. Amber is Ms. Wall's supervisor. Pam Wall- Pam has an Associate Degree in Business Administration from Cape Fear Community College, was a Licensed Insurance Agent for NC Property & Casualty, Life & Health, worked as a physicians' office Claims and Billing clerk and came to the SRC from Onslow County DSS Medicaid case worker. Pam has been instrumental in establishing the SRC prescription assistance program as the primary referral source to assist seniors with prescription assistance in New Hanover County. Referrals come from DSS, doctor offices, Social Security Administration, Health Department, social workers, churches, and pharmacists. 4. Is the organization accredited by any agency or are any accreditations planned? If yes, please provide details. The New Hanover County Senior Resource Center is certified a "Center of Excellence" by the North Carolina Division of Aging and Adult Services. 5. Briefly discuss the organization's board and staff developincut policies. Additionally, discuss the organization's participation in the offerings for development offered ti-y QEN0. (Please include future plans) The Senior Resource Center works with two advisory boards: VOCAL, Inc (Volunteer Older Citizen Action League, Inc) composed of active senior community leaders attuned to senior issues, and the Home and Community Care Block Grant Committee (HCCBG) whose appointment is approved by County Commissioners. Both of these advisory committees provide advice and direction as well as recommendations to the NH County Board of Commissioners for distribution of Home and Community Block Grant federal and state funds. VOCAL board requires initial orientation from SRC Management and monthly updates. The HCCBG Advisory Committee receives additional training from the Cape Fear Council of Governments Area Agency on Aging New Hanover County has a variety of training and development programs to support a culture of continuous learning by providing a comprehensive offering of training and professional development opportunities for our employees. NHC is committed to developing the most knowledgeable, experienced and dedicated staff of professionals in local government. NHC does this by providing organizational and employee development opportunities that support the County's mission and strategic goals, effectively and efficiently serving the public as the Model of Good Governance. The Core Curriculum identifies courses of general application to all employees; examples include Customer Service, technology proficiency (MS Outlook, MS Word, MS Excel ... ), Diversity Awareness, and Interpersonal Relations. Customer Service Certification Curriculum — Elevated customer focus is an organization- CAPE FEAR MEMORIAL. L FOUNDAJ ION - GRANT APPLICAI ION I-'OR-%4 Page S of 12 Last Revise& 1 112 512 0 1 4 (JGD) wide standard by which all customers come away from contact with us feeling they have been served professionally and respectfully, and that they were our priority. Another new program, NHC internal coach, is available to all management level employees to assist them in their professional growth. While NHC values QENO, NHC does not currently participate in QENO trainings. NHC does access all other aspects of UNCW training in particular the Swain Center's Professional and Continuing Education. We are committed to staff development and see UNCW as a valuable resource for our department and for New Hanover County. Does the organization have any affiliations with national organizations to which dues or fees are paid? If yes, please provide details. Not applicable Does your organization now, or does it plan, to engage in the promotion of political causes or in affecting any state or federal legislation? If yes, please explain. The SRC collaborates with the NC Senior Tarheel Legislature (STHL) program established by the NC General Assembly on July 24, 1993. Each County has one representative and an alternate who reports and makes recommendation to the NC General Assembly. They provide information and education to senior adults on the legislative process and matters being considered by the NC General Assembly. They promote citizen involvement and advocacy concerning aging issues, and assess the legislative needs of older adults by convening a forum modeled after the NC General Assembly PART 11: PROJECT/PROGRAM - (Quantify whenever possible.) What is the purpose of this request? (Please firnit response to one sentence) The NHC SRC is requesting funding for the Prescription Assistance Counseling Program which provides education and guidance on the complex Medicare prescription drug plans and assists seniors in identifying, completing applications, and obtaining low and/or no cost prescription medications from pharmaceutical companies, subsidy companies, physician samples, and other resources. What is the geographic area and target population to be affected? The area serviced will be New Hanover County and the target population is residents who are 60+ years of age in New Hanover County. Is this a new or an existing program /project" This is an existing program. Summarize the program/project. (Please lirnit response to 1000 words) The Prescription Assistance Counseling Program's primary focus is to assist seniors one-on-one in obtaining low and/or no cost prescription medications from pharmaceutical companies, subsidy programs, physician samples, and other resources that may be identified. Another focus will be to continue to assist seniors with applications for the Low Income Subsidy program. In addition, grant funds will be used to meet the demand for one-on-one counseling, assistance and enrollment services as well as continuing our community outreach and education initiatives for this coming year Outreach and Collaboration Strategy An important aspect of the Prescription Drug Assistance Program has been to provide a CAPE FEAR MEMORIAL FOUNDATION - GRANT APPLICATION FORM Pa,�c 6 of 12 Last Revised: 11/25/2014 (JGD) central location where people can get answers to their questions. The Program Coordinator provides education to seniors and community groups in New Hanover County about prescription assistance. The goal is to educate seniors about assistance programs so they can become their own advocate in seeking prescription assistance on an ongoing basis to avoid seniors omitting costly medications which could put them at risk of long term health complications. The prescription assistance program educates individuals in asking for samples or how to access programs that can reduce their cost of medications. Scope of the Program The seniors in our community are frustrated and confused by the Medicare Prescription Drug Plan and the rising cost of prescriptions while living on a fixed income. The most important aspect of the project has been to provide a local resource where people can get face to face answers to their questions and get some relief from the stress now being experienced by many of our seniors. This also helps reduce the burdens that have been passed along to family. Pam educates clients about the gaps in Medicare D coverage and discusses options that will have the lowest financial impact on them while they are in the Medicare D "donut hole". The donut hole exists because the majority of plans offer no gap coverage for prescription costs between $2,850 and $6,455. After a Medicare beneficiary spends a total of $4,550 out-of-pocket for prescription drugs, Medicare will pay 95% of those costs. This means that a married coupled may have to pay $9,100 out-of-pocket in a year before their prescription drugs are covered at 95%. From April 1, 2014 through December 30, 2014, more than 700 residents benefited from this health care counseling. The prescription assistance program saved clients $100,898.41 (April 1, 2014 through December 30, 2014) in prescription cost by assisting them in getting medications directly from pharmaceutical companies, samples, RX programs, etc. Without assistance most of these individuals would have gone without their medications or would have cut them in half. The number of individuals needing prescription assistance continues to grow and the demand is now greater than ever because of the aging baby boomer population. Beneficiaries are required to navigate a system that is changing rapidly, in part because of requirements imposed by the new health care law. 5. Is this an evidence based intervention (Cite previous Use/SUccess and sources)'' "Not applicable" is an acceptable answer to this questiOrl. Not applicable G. Define the roles of the prograrn/proJect's key personnel (please specify the personnel as new or existing in the organization) and other partner agencies (include letters of agreement from any collaborative partner). Pam Wall, has been the Prescription Assistant Coordinator at NHC Senior Resource Center since 8/2013. The Prescription Assistant Coordinator's essential job responsibilities include: • Interviews and registers eligible clients or the responsible party of a client which includes fielding telephone inquiries, assessing eligibility, completing state/federal forms, and conducting periodic reassessments. • Conduct in-depth face to face assessments (home and office) with seniors (60+) to review current prescription medications and available resources to evaluate what assistance may be available to reduce prescription cost. • Conduct research of free/low cost prescription drug programs (approximately 100 programs) and match medication plans to client needs. CAPE FEAR MEMORIAL- FOUNDATION- GRANT APPLICATION FORNI Palge i ol'i 2 Last Revised: 11/25/2014 (JGD) • Communicate to clients the procedure for receipt of free/low cost prescription drugs and assist clients with application process to secure medication. • Network with physician offices for receipt of medication for clients. • Network with and make client referrals to pharmacists for medication review and education. • Make referrals to other sources of long term assistance programs (i.e. Medicaid). • Maintain a computer database of all clients served. • Attend training, as required by the state, to operate and maintain the medication Access and Review Program software. • Prepare monthly reports as required by grants. • Performs various public relation duties including preparing and delivering presentations to community groups. The Prescription Assistance Coordinator reports directly to the Senior Resource Center Social Work Supervisor, Amber Smith. Amber Smith has worked for the County for more than ten years. She has a Bachelor of Social Work degree and was previously an Adult Protective Service worker at DSS. Amber's background and Pam's knowledge of the ins and outs of the prescription plans, local resources, and drug companies provide a high level of service to our senior citizens. Amber will provide all reports to the Foundation regarding this grant. 7. What are the program/project quantitative measures (number served, success rate)? Quantitative and qualitative performance measures will be identified at the outset of the funding period and adjusted as necessary throughout the period of funding. The Coordinator will collect baseline data for this purpose as well as projecting needs for future years. The information will be provided to the Senior Resource Center Program Manager and the Social Work Supervisor on a monthly basis and to the Cape Fear Memorial Foundation quarterly. This will include data such as numbers of individuals counseled by categories, outcomes and dollar savings, outreach eventsiactivities, and certain demographic information. PART III: EVALUATION OF RESULTS Identi fv/De fine results of the program pr 'ect. (Please limit response to 500 words) 0J The goal of the Prescription Drug Assistance program is to provide one location where seniors in New Hanover County can go for information, one-on-one counseling, special assistance with navigating the complicated Medicare and prescription drug plan system, education about Medicare D, and receive assistance in locating prescription medications at a free or reduced cost as well as providing prescription assistance education. The program will serve approximately 1000 people in the next year through the following services: • Assistance with prescription drug/contacting pharmaceutical companies • Enrollment in Medicare Part D assistance • Billing/Statement help • Donut Hole counseling • NCRx enrollment • Medicare Advantage issues • Education on how to navigate Medicare and prescription assistance programs. 2. List the prograrn/project critical steps and timeline for completion. The most critical step for this program is securing additional funding. Since the program is already in existence, the relationships with referring agencies, pharmacies, and CARE FEAR MEMORIAL. FOUNDATION - GRANT APPLICATION FORM Last Revised: 1 1125120 1 4 (JGD) physicians are very strong. Many pharmacists, doctors, and referral sources call Pam for her help in guiding their customers to the right plan or assisting clients in locating prescription funding because the individual is unable to afford their medication. Timeline- ongoing. We are researching grants and private funding sources to support this vital program. We are at a crucial time for seniors. Health Care Reform has attempted to make it easier for seniors, but the "Donut Hole" continues to exist. Seniors Medicare premiums continue to remain high and there are several medications that are not covered because they are not on the Medicare formulary. There are many seniors who simply cannot afford their medications and do not know how to access prescription assistance programs. As more and more baby boomers reach Medicare age, the need for assistance has steadily increased. It is imperative that the Coordinator be well versed in Health Care Reform and its impact on seniors. Timeline- ongoing. What milestones will the organization recognize as steps toward success in the timeline? The most critical milestone is obtaining funding for this vital program. This program relies on grant funds. The demand for assistance has increased, therefore the funding needed to continue this program will also need to increase. The current position has only had enough funding for 18 hours a week. In order to keep up with the demand of providing assistance, the position hours will need to increase to 25 hours a week. The prescription assistance program is one is the most vital programs offered to citizens. Almost all of the other services provided by the Senior Resource Center are grant funded or generate revenue. This program is vital, yet falls into the category of non - mandated, does not generate revenue because we do not charge for the services, making it vulnerable when County budgets tighten. 4. Cite expected benefits to the community as a whole upon success of this program/project. This program assists more than 1000 seniors in New Hanover County over a 12 month period. This program was able to help seniors save more than $150,000 in prescription costs last year- for many seniors that meant not having to choose between their medicines and groceries. It provides a single place where seniors can get information, assistance in accessing programs, and education on how to receive long term prescription assistance. PART IV: FINANCIAL INFORMATION I . Attach financial statements (audits, compilations, or forms 990) for the most recent 2 fiscal years. If deficits were incurred, how were they covered? See attached 2. List the organization's fimding sources and arnounts over the previous 2 years by category (private, grants, fee for service, etc.)? CAPE FEAR MEMORIAL FOUNDATION - GRANT APPLICA'T'ION FORM Page 9 of I2 Last Revised: 11/25/2014 (JGD) PREVIOUS SOURCES OF FUNDING (PAST 2 FISCAL YEARS) FY 2013 FY 2014 Home Community Care Block Gran 971,040 Home Community Care Block Grant 957,253 NC DOT Transportation Grant 112,500 NC iwil- Transportation Grant 112,500 Family Caregiver Respite Grant 23,000 Family Caregiver Respite 23,000 Cape Fear Memorial Foundation 7,500 Cape Fear Memorial Foundation 7,500 Catherine Kennedy Home Foundati( 5,000 Catherine Kennedy Home Foundatic 5,000 Foster Grandparent Grant 159,055 Foster Grandparent 152,693 RSVP Grant 111,097 RSVP 111,097 WAVE -ROAP Transportation 47,912 WAVE -ROAP Transportation 42,841 Health Promotion 0 Health Promotion 4,000 Sr. Center General Purpose 11,680 Sr. Center General Purpose 11,680 Senior Health Insurance Info 3,532 Senior Health Insurance Info 4,329 SHIIP-Low Income Subsidy 1,7001SHIIP-Low income Subsidy 1,0001 1,454,016 Total S 1,432,893 Total S 3. Does the organization have any endowment funds? What are the restrictions on these funds' New Hanover County does not have an endowment. The County does maintain a fund balance. 4. Please develop a complete PROGRAM/PROJECT 13UDGE11' including expenses and income for the period the funds are requested. PROJECT BUDGET: From: 04/15/2015 To: 04/14/2016 Expenses (By Category) Income (By Sources) Salar.y (19 hours week X S15 /ho u 14,820 Cape Fear M ernoirial Foundation 9,500 FICA 1,134 Catherine Kennedy Foundation 5,000 Supplies 546 VOCAL 2,000 Total Expenses; $1 16,500 Total Income: $1 16,500 5. Please itemize the sources of funding for this REQ(JEST. Include public, private, fee for service, fundraising and other sources in addition to the status (budgeted, pending, approved, or- declined) of the projection. FUNDS REQUESTED FOR THIS PROJECT Frorn:04/15/2015 To:04/14/2016 Organization Status Amount Cape Fear Memorial Foundation requested 9,500 Catherine Kennedy Home Foundation VOCAL requested 5,000 VOCA1_ approved 2,000 16,5001 CAPE FEAR MEMORIAL FOUNDATIO'Ni- GRANT APPLICAI ION, FORM of 12 Last Revised: 11/25/2014 (JGD) 6. Please develop a complete OPERATING BUDGET for the organization as a whole including expenses and income for the period the funds are requested. Expenses (By Category) Income (By Category) Wellness & Health Promotion Cape Fear Memorial Foundation Wellness & Health Promotion 9500 Senior Health Insurance $4,329 NC Department of Insurance $4,329 Information Program 2,000 (Grant) approved (Medicare)Training & Supplies DOT 5310 Transportation Grant approved (RSVP Volunteer 112,500 Family Caregiver Respite Grant approved Program) Foster Grandparent Grant Evidence -based Health $2,000 Cape Fear Council of $2,000 Promotion (Matter of Balance) WAVE -ROAP Transportation Grant Governments Area Agency on 42,841 Instructor Certification and approved Aging (Grant) Senior Health Insurance Information Program Grant Supplies 4,329 SHIIP -Low income Subsidy Grant approved Prescription Assistance — Health Promotion -E /B grant Catherine Kennedy Fnd. $5,000 salary $16,500 (Grant) $9,500 $15 x 38hr /pp/ x 26pp = $14,820 Cape Fear Memorial Fnd $2,000 X.0765 FICA = $1,134 (Grant) Supplies + $546 VOCAL (Grant) Emergency Utilities $6,000 Emergency Escrow Fund $6,000 Assistance Fund (Heat, Water (Private Donations specified for bills,etc )A$50- $100 /client/ ear Emergency Fund TOTAL $28,829 TOTAL $28,829 7. Please itemize the sources of funding for the ORGANIZATION as a whole. Include public, private, fee for service, fundraising and other sources in addition to the status (budgeted, pending, approved, or declined) of the projection. FUNDS REQUESTED FOR ORGANIZATION Organization Status Amount Cape Fear Memorial Foundation pending 9500 Catherine Kennedy Foundation pending 5,000 VOCAL approved 2,000 Home and Community Care Block Grant approved 957,253 DOT 5310 Transportation Grant approved 112,500 Family Caregiver Respite Grant approved 23,000 Foster Grandparent Grant approved 152,693 Retired and Senior Volunteer Program Grant (RSVP) approved 111,097 WAVE -ROAP Transportation Grant approved 42,841 Sr. Center General Purpose grant approved 11,680 Senior Health Insurance Information Program Grant approved 4,329 SHIIP -Low income Subsidy Grant approved 1,000 Health Promotion -E /B grant approved 4,000 total 1,454,016 8. If the funds are to be used for capital acquisition, please attach quotes or estimates. N/A CAPE FEAR MEMORIAL FOUNDATION - GRANT APPLICATION FORM Page I I of 12 Last Revised: 11/25/2014 (JGD) 9. If program /project increases operating costs, how will these increases be funded after the grant period? We will seek grant funding from other sources and will ask New Hanover County for support. 10. How will this program /project increase the sustainability of the organization as a whole? This program allows the New Hanover County Senior Resource to continue to focus on its mission "To act as the Focal Point for Aging Service in NHC by providing services which promote wellness, encourage independence and enhance quality of life fo all older persons" . We are the primary organization in New Hanover County providing this valuable service to seniors. PART V: REPORTING REQUIREMENTS PLEASE NOTE - Cape Fear Memorial Foundation requires periodic progress reports to be completed informing the Foundation of the progress made by the organization's program /project. Grant payments are contingent upon receipt and review of these reports. If Progress Report for nis are enclosed for projects pr°ev ioust -, funded for which an annual r Dort has not yet been made. please complete the fora-is and return with this ApDhCatlon. SUBMITTED BY: Typed or Printed Name of CEO. %Executive Director Typed or Printed Name of Board Chair fF � ,f 4 Signature of CEO /Executive Director ignature of Beard Chair Title Date Date CAPE FEAR MEMORIAL FOUNDATION - GRANT APPLICATION FORM Last Revised: 11/25/2014 (JGD) Page 12 of 12 w a� G W �i r+7 rn ttT O1 � D � o; �O 1r N O art N N V' O O O O O O is W zU CG r-( 1U Q7 p F .-+ w rn U r ,-: co N N 1 A a7 M r{ �i O H tai �i Q Ei co ri 01 pqM N r-Ic) U] C7 ri r m r OY lA H a� u rl-ry e N v st a'� N rQ1 Q � � N a N a go m m� 1— 0Wa w uo Q_ O OH4' a ri r m U O i.n �o ,-s O a i N `2i `j vi x -C c o-4 a �to to .-i H pw `a a, i W v ,- M a a 4 tr r H H a 0 u a 0 a a H ZZZZZZ ?+ o� M kn ri a 0.14 n ,ad MW rl rt rl to 0 Ct a a+ m r iC eN 6 tIt N tO CD co H ON m N ri 6Hi h u) rn In u) b I ri N W W Ln iD r-I m m 01 HU I ri oh y.11� C�ji M tD M C W I Ln N O a h h In ri N \ a �+ �W hh h � E� In 01n Ha a m� Ha U) wH 99 o9c h h In A% Li tl2 v 0 a rn a 0 0 a�Z °Ka o cn n G� O W U U %0 �w H1'�7 2 v w v 0 v, a 0 H m m r1 N v� va W aa ixW KC H w o i h H a b� P9 4 N M a cn in o aNO N �N i h Ol H N M In 5 Lq h N +a M ri t 1 0 O O a \ U C7 H H a 0 u a 0 a a H ZZZZZZ ?+ o� M kn ri a 0.14 n ,ad MW rl rt rl to 0 Ct a a+ m r iC eN 6 tIt N tO CD co H ON m N ri 6Hi h u) rn In u) b I ri N W W Ln iD r-I m m 01 HU I ri oh y.11� C�ji M tD M C W I Ln N O a h h In ri N \ a �+ �W hh h � E� In 01n Ha a m� Ha U) wH 99 o9c h h In A% Li tl2 v 0 a rn a 0 0 a�Z °Ka o cn n G� O W U U %0 �w H1'�7 2 v w v 0 v, a 0 H m m r1 N v� va W aa ixW KC H w F. m Revised Moy 2014 Clerk to the Board and County Commissioners 1 New Hanover County I North Carolina Page 1 of 2 NEW HANOVER COUNTY (HTTP: / /WWW.NHCGOV.COM) Commissioners and Clerk to the Board ( http : / /commissioners.nhcgov.com) 0 10 inttps: /Y#Mp NHCGov.com (http: / /www.nhcgov.com) > County Commissioners and Clerk to the Board hanover county) Welcome to NHC Clerk to the Board and County Commissioners The New Hanover County Board of Commissioners and the Office of the Clerk to the Board welcome you to our web site. We are here to provide you with information on the activities and actions of your governing body. You will find notices of future meetings, agenda packages for board meetings, and minutes of meetings dating back to 1868. Additionally, we invite you to participate in County government by serving on one of our boards and committees. Just click on the Boards & Committees tab to find the committee application and information on each of the committees. Thank you for the opportunity to serve you. 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