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Home My WebLink AboutAdvantage Smile for KidsApplicant: Deschutes County Community Grant Program 2014-15 Application Review Rating Worksheet Advantage Smiles for Kids Category/Grant Amount: Title: Health, Mental Health, Addictions / $11,000 Providing Orthodontic Treatment to At -Risk Kids throughout Oregon Review Criteria: 1. Organization: • Stable and positive history of providing services in Deschutes County. • Experience delivering similar programs, projects, or activities as those proposed. • Mission and goals are consistent with proposed program, project, or activity. • Stable and experienced Board of Directors or other leadership group. • Adequate staff and/or volunteers to implement proposed program, project, or activity. Points awarded for this section (maximum of 25). 2. Financial Status: • Adequate financial resources available to conduct and sustain operations. • Broad and diverse base of funding sources. • Financial need for a Community Grant to implement proposed program, project, or activity. • Proposed budget is consistent with and appropriate for the fixed grant amount available in the selected Community Grant category. Points awarded for this section (maximum of 25). 3. Program, Project, or Activity: • Program, project, or activity does not address emergency food, clothing, or shelter. (These activities are supported by Deschutes County through a separate grant program in conjunction with United Way's Emergency Food and Shelter program.) • Request is consistent with the fixed dollar amounts indicated in the category/grant amount description at the top of this form. • Number of individuals to be served is appropriate to the budget and scale of proposed program, project or activity. • Serves vulnerable and/or underserved populations and/or communities. • Positively impacts welfare of the community. • Complements, but does not duplicate, existing Deschutes County services. • Implementation strategy is suitable to achieving the stated goals and objectives of proposed program, project, or activity. • Partnerships or collaboration with other agencies are included in implementation strategy. • Other sources of funds or in-kind support are available to supplement Community Grant funds. Points awarded for this section (maximum of 35). 4. Performance Management: • Stated outputs are relevant and reasonable to the scale of the proposed program, project, or activity. • Stated outcomes are relevant and reasonable to the scale of the proposed program, project, or activity. Points awarded for this section (maximum of 15). TOTAL NUMBER OF POINTS AWARDED: COMMENTS: NAME OF RATER: Deschutes County Fiscal Year 2014-15 Community Grant Application Advantage Smiles for Kids (ASK) Submittal Instructions and Cover Sheet A complete application will consist of the following: 1. This cover sheet, signed and dated. 2. Narrative responses to the attached questions on no more than four single -sided, single-spaced pages. 3. Attachments: a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the Internal Revenue Service (IRS). b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ form or, if the organization is not required to file either form with the IRS, a financial statement that provides equivalent information concerning activities and governance, revenue, expenses, and net assets or fund balances. c. An operating budget specific to the proposed operations, program, project, or activity. d. A roster of the organization's Board of Directors. Submit the complete application electronically to iudithu@deschutes.org no later than 5:00 p.m. on October 24, 2014. Incomplete and/or late applications will not be reviewed or considered. Please complete the following: Contact Name: Michael Vendrame Organization Name: Address: City: Advantage Smiles for Kids (ASK) 442 SW IJmatilla Avenue Suite 200 Redmond Telephone Number: Email Address: State: OR Zip Code: 97756 541-504-3912 m i ch ael vnadvantagedental .com Application is being submitted to which Community Grant Program funding category*? N Health, Mental Health, and Addictions Services ❑ Arts and Culture ❑ Other Essential Services: Includes services to youth; underserved, indigent, and/or vulnerable populations; animal welfare; or the environment. Certification: On behalf of the organization specified above, 1 certify the following: 1. All information included in this application is accurate. 2. 1 am authorized by the governing board to submit this grant application. 3. This organization is located in Deschutes County. 4. If awarded, Community Grant funds will be used in support of Deschutes County residents only. 5. This organization is in good standing with the U.S. Internal Revenue Service and is currently designated as a 501(c)(3) tax-exempt entity. Signature: \� �`:� s& Print Name: Michael Vendrame Title: Administrative Director Date: October 15, 2014 Deschutes County Fiscal Year 2014-15 Community Grant Application Advantage Smiles for Kids (ASK) Questions Please respond to the questions below in the order shown. Reponses must be thorough, but provided on no more than four single -sided, single-spaced pages. Required attachments such as proof of non- profit status and copies of tax forms are excluded from the four page limit. Any additional documents submitted beyond those stated in the instructions, such as brochures, leaflets, newsletters, or reports, will not be considered a part of the application and will be discarded without review. Organization 1. Describe the history of the organization, including the year the organization was established. Advantage Smiles for Kids (ASK) is a 501(3) (c), non-profit organization that provides orthodontics "braces" for at -risk children throughout Oregon. ASK was created in March 2004 by a group of dentists and orthodontists that continually saw children in rural areas of Oregon that desperately needed orthodontics but could not afford the high cost of treatment. The Oregon Health Plan/Medicaid does not provide medically necessary orthodontics for children in Oregon, therefore, there is a huge demand for ASK services. Since 2014, more than 341 children have been approved for orthodontic treatment through the ASK program. In the last year, 10 of these children were living in Deschutes County. 2. State the organization's mission, goals, and programs or services provided. The ASK mission is to improve the quality of life for low-income, at -risk children by providing the orthodontic and associated dental care necessary to produce a happy, healthy smile. ASK has a special focus on identifying children with low self-esteem that are suffering from ridicule and bullying due to the look of their teeth. 3. Describe the leadership and structure of the organization. ASK is governed by a Board of Directors comprised of 9 business and medical professionals. The Executive Director is R. Mike Shirtcliff, DMD. ASK has two full time staff members. Kyle House, DDS Brenda Turner, Process Facilitator Cindy Shirtcliff, LCSW Juliana Panchura, DMD Don Laird, Health Care Attorney Boni Smith, Dental Service Professional Linda Dwight, Retired School Teacher Benita Wong, DDS Rob Orr, DDS Board Chair President Vice -President Treasurer Secretary Board Member Board Member Board Member Board Member Dentist Professional Board Facilitator Social Worker Orthodontist Attorney Dental Service Professional School Teacher Orthodontist Dentist Program, Project, or Activity 1. Provide a title of the proposed initiative for which funds are being requested. Advantage Smiles for Kids (ASK) is focused on a single year-to-year project, which is "Providing orthodontic treatment to at -risk kids throughout Oregon". Funds awarded through the Deschutes Co. Community Grant Foundation would be specifically designated for children residing in Deschutes County only. 2. Describe the goals and objectives of the proposed initiative. The goal of the ASK program is to provide needed orthodontic care for children that would otherwise never have the opportunity to have "braces" either due to a lack of finances and/or access to necessary orthodontic care. Socially, statistics show that children with bad teeth are 7 times more likely to be teased and bullied by their peers. This behavior often results in distraction from normal work and play which often times leads to the development of anti -social behaviors, lower school performance and a higher risk of dropping out. ASK not only provides braces but helps each child build skills for future educational and job opportunities by requiring monthly volunteer work during their entire treatment time. ASK also requires that each child's grades are in good standing before their orthodontic treatment begins. 3. Identify the target population which will be served. A Deschutes Co. Community Grant award will serve children living in Deschutes County, typically between the ages of 12 and 16 years of age, considered "at -risk" and deserving of braces based on the aesthetic look of their teeth. Each child must be referred by a teacher, counselor, caseworker or medical professionals. These referrals help ASK identify those children with the highest need. 4. Identify the geographic area(s) of Deschutes County which will benefit. All children living in Deschutes County and meeting the ASK criteria are eligible to apply to the ASK program. 5. Describe how the proposed initiative will positively impact the community and complement existing services currently provided by Deschutes County. Many Deschutes County services working with children make referrals to the ASK program. These services understand that without ASK help, these same children will continue to experience mouth pain, ridicule and low self-esteem that will affect their psychological and physical health negatively. Also, these children have more missed days of school and visits to the emergency room due to mouth pain. Without ASK, other services are Tess effective in helping the overall health of a child. Children that receive necessary orthodontic care demonstrate an immediate increase in self-esteem and less missed school days therefore creating less of a demand on schools and communities. 6. Describe in detail how the proposed initiative will be implemented. ASK receives referrals every day from medical, school and county professionals as well as other non-profit organizations. After a rigorous application process, applicants are screened by a committee of dental professionals. Approved applicants are required to have their dentistry completed, have good dental hygiene, and grades of a "C" or above. Once a child starts their monthly volunteer work they begin treatment by an orthodontist in their community. In Deschutes County, Dr. Burgess, Dr. Rosenzweig, The Brace Place, and Dr. Panchura partner with the ASK program to provide orthodontic treatment. ASK negotiates the dentistry and orthodontic fees, funds the treatment, tracks the child's progress and monitors their volunteer work. 7. Describe specifically how the requested funds will be used. Awarded funds will be used to pay dental and orthodontic treatment fees for ASK approved children living in Deschutes County at a dramatically reduced rate. 8. Identify any partner agencies which will collaborate to implement the proposed initiative. ASK relies on the Redmond and Bend -La Pine school districts, DHS and other non-profit organizations such as The Tooth Taxi, The Kids Center, Saving Grace, Family Access Network, and The Kemple Clinic for referrals and assistance in determining whether a child is "at -risk. Agencies such as; libraries, the Humane Society, thrift shops, and nursing homes agree to let ASK kids volunteer at their organizations. 9. Describe other sources of funding that will support the proposed initiative. *Advantage Dental Professional Group has agreed to once again match dollar for dollar a Deschutes Co. Community Grant Award. Advantage Dental Professional Group is the largest financial contributor to the ASK program. They make a large annual donation to the ASK general fund, and donate staff salaries and office space. For 2014-2015, the Spirit Mountain Community Foundation awarded ASK $50,000 for treating children specifically residing in the 11 counties they represent. In addition, ASK has an annual auction and raffle that raises close to $60,000 per year. The remaining funding comes from grants, private foundations and corporate donors such as Crest -Oral B, Assured Dental Labs, Henry Schein, and Wells Fargo. ASK is continually looking for new funding for it's program. Performance Measurement 1. Identify quantifiable outputs anticipated to be achieved through the proposed initiative (examples: number of persons served, programs or events held, animals rescued, acres restored or protected). With a Deschutes County Community Grant award and a corporate match of $11,000 from Advantage Dental Professional, a minimum of 8 at -risk children living in Deschutes County will receive braces in 2015. 2. Describe the anticipated outcomes of the proposed initiative (examples: fewer persons institutionalized, greater knowledge and understanding of local history, fewer animals in shelter care, more natural areas available for wildlife and recreation). The immediate outcome for children receiving orthodontic treatment is a reduction in tooth pain, more confidence, improved social peer relationships, grade improvement, Less missed days of school, and less trips to the emergency room for tooth pain, therefore creating less of a burden on schools and the healthcare system. Long term outcomes are improvement in education and job opportunities, more success at work and in relationships, and better long term health with less risk of disease. The monthly volunteer work requirement gives these children opportunities to learn new skills, build a resume for summer jobs, and in many cases provide a new mentor in their life. In the long term, the volunteer work helps instill the importance of giving back to their communities and hopefully passing it on to the next generation. Overall, these outcomes create less of a burden on their communities and a decrease in health care costs to society. Advantage Smiles for Kids 2015 Organizational & Project Budget REVENUE Advantage Consolidated Advantage Dental Professional Grants/Foundations Wildhorse Foundation Anna May Foundation C. Giles Hunt Family Trust Foundation Gordon Elwood Foundation Cow Creek Foundation Oregon Community Foundation Spirit Mountain Deschutes Community Grant Reser Family Foundation St. Charles Community Foundation Facebook Foundaion West Family Foundation Special Events Grand Prize Summer Event Raffle Summer Auction-silent/live Wine Fundraiser Fundraising $'s AmazonSmile Raffle Sponsor donations -Corporations Corporate Donations Pacific Continental Bank Crest Oral B Individual Donations Misc. donations at ASK auction Sponsor A Smile Sponsors ASK Board Members Donation Adv. Dental Employee payroll deduction PacificSource Health Plans Dr. Lanahan Robberson Ford Dr. Randy Morgan -8-2014, lst pymnt. $10K match for Deschutes Grant Dental Providers Eastern Oregon kids only Souther Oregon kids only Southern Oregon kids only 4 Southern Oregon counties only Douglas County only 11 NW Oregon counties only Deschutes Co. children only Jefferson Co. only Crook County Only $25 per bottle donation quarterly deposits made sponsor a child 2015 to sponsor a child. Total Actual Revenue In -Kind Donations Advantage Professional Management 2 Full time staff members Total Income Expenses Organizational Budget Expenses for ASK Rent & Utilities Admin. staff 2 Full time Bank fees Business Expenses License/Fees Marketing & Fundraising Expenses Special Event Expenses/Fundraising-auction & raffle Taxes 2015 10,000.00 pledged 100,000.00 Requesting 9,000.00 Requesting 3,000.00 Requesting 6,000,00 submitted 6,000,00 submitted 6,000.00 submitted 12,000.00 submitted 25,000.00 received 11,000.00 submitted 6,000.00 requesting 9,000.00 requesting 3,000.00 requesting 9,000.00 requesting 25,000.00 estimate 25,000.00 estimate 250.00 estimate 30.00 estimate 10,000.00 requesting 1,000.00 pledged 5,000.00 requesting 5,000.00 estimate 3,000.00 pledged 3,000.00 pledged 3,000.00 requesting 1,500.00 pledged 3,000.00 requesting 1,500.00 pledged 301, 260.00 130,000.00 pledged 431,280.00 18,000 130,000 2,200 Office Supplies & legal 2,495 800 2500 21,172.50 200 177,368 Total Organizational Expenses Project Expenses for ASK Orthodontist fees for 80 new kids approved in 2014 Extraction fees/records fees preparation for braces. Emergency removal of braces 3 kids @ $200 each Total Project Budget Expenses 240, 000.00 2,500.00 600.00 420,467.50 � c 0 � � � � 0 � � 0 � 0 � w (9 z et E-MAIL drhouse@akid.zdentalzone.com E 2 ° ° \ t cindvs@advantagedenta1.com jpanchura@gmail.com dlairdCwlrlaw.com Roborr50@.Rmail.com boni@epuerto.org 5416804728@vzwpix.com S 1 E E % E.71 2 Cu C > 2 / FAX # co 0) 3 Lc) / a CO c Q 541-567-4270 0 541-504-3907 L 9 CO % e 541-672-0977 7 9 03 9 7 CO c q 7 0 7 Q PHONE # i0 541-504-3913 (ofc) e 541-680- 9028 (cell) 0 541-387-8688 (ofc) 0 541-490- t 541-567-9550 (hm)la 541-571- 6250 (cell) 03 40 G CU 0 e 541-382-0410 (ofc) a 541-788- 03 1 = ITU CO ri G05 , 7 = Tv 5 41-756-7414 (hm) 541-404- 4805 (cell) e 541-680-4728 03 CO ? al ADDRESS 442 SW Umatilla Ave t# Redmond, OR 97756 419 State Street 144 Hood River, OR97031 29564 Knight Road Hermiston, OR97838 1524 NW Primrose Lane Roseburg, OR 97471 ƒ § C k co PO Box 10567 Eugene, OR 97440 401 Ponderosa Drive Roseburg, OR 97471-8918 94753 Haynes Lane North Bend, OR 97459 242 Aster Winchester, OR 97495 1160 Liberty Street SE Salem, OR97302 NAME R. Mike Shirtcliff, DMD (Dentist) Executive Director Kyle House, DDS (Dentist) Board Chair (New 2012) Brenda L. Turner (Process Facilitator) President (New 2013) Cynthia Shirtcliff, LCSW (Social Worker) Vice - President (New 2012) Juliana Panchura, DMD (Orthodontist) Treasurer Don Laird (Health Care Attorney) Secretary Robert Orr, DDS (Dentist) Board Member Boni Smith (Dental Services/Business Owner) Board Member Linda Dwight (Substitute Teacher) Board Member Benita Wong, DDS (Orthodontist) Board Member (New 2014) Furor 990"EZ Department of the Treasury Internal Revenue Service Short Form Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) e• Do not enter Social Security numbers on this form as it may be made public. ► Information about Form 990 -EZ and its Instructions is at www,Us.gov/form990. OMB No.1545.1150 2013 Open to Public Inspection A For the 2013 calendar year, or tax year beginning .January 1 , 2013, and ending December 31 , 20 13 B Check it applicable: ❑-I Address change 00Name change Intliat Mum Terminated Amended rettun 0 Adeasauon pending G Accounting Method: Q Cash 0 Accrual Other (specify) ► 1 Website: ► advantagesmIlesforkids.org J Tax-exempt status (check only one) —131501(c)(3) ❑ 501(ei ( ) 1 (insert no.) ❑ 4947ia)(1) or 0527 K Form of organization; 0 Corporation 0 Trust 0 Association 0 Other L Add Tines 5b, 6c, and lb, to line 9 to determine gross receipts. if gross receipts are 9200,000 or more, or if total assets (Part 11, column (B) below) are $500,000 or more, file Form 990 Instead of Form 990 -EZ ► $ C Name of organization .Advantage Smiles for Kids D Employer Identification number 67.0690147 Number and street (or P.O. box, if mail is not delivered to street address) 442 SW Umatilla Ave Roomisulte 200 City or town, state or province. country. and ZIP or foreign postal code Redmond, OR 97756 E Telephone number 541-504.3980 F Group Exemption Number ► H Check ► 0 if the organization Is not required to attach Schedule B (Form 990, 990 -EZ, or 990 -PF). 171 264 Part 1 Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I) Check if the organizatlon used Schedule 0 to respond to any question in this Part I Revenue 1 Contributions, gifts, grants, and similar amounts received 2 Program service revenue Including government fees and contracts . 3 Membership dues and assessments 4 investment income 5a Gross amount from sale of assets other than inventory . . . . b Less: cost or other basis and sales expenses . . 5a . . . 1 113,897 4 (9) • 5b c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) . . . . 5c 6 Gaming and fundraising events a Gross income from gaming (attach Schedule G if greater than ' n'',' $15,000) ( 8a 1 28 720 ': b Gross income from fundraising events (not including S of contributionsF<F: from fundraising events reported on line 1) (attach Schedule G if the sum of suchross income and contributions exceeds $15,000) 9 . 6b x8,656 ..A� c Less: direct expenses from gaming and fundraising events . . . 6c 4,438N` d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract` line 6c) 6d s2 sea 7a Gross sales of inventory, less returns and allowances 7a •er 7b b Less; cost of goods sold _". c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) 7c 8 Other revenue (describe in Schedule 0) 8 9 Total revenue. Add Lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 ► 9 166,775 Expenses 10 Grants and similar amounts paid {list in Schedule 0) 10 11 Benefits paid to or for members 11 12 Salaries, other compensation, and employee benefits 12 13 Professional fees and other payments to independent contractors . . , . . . . . . 13 136,049 14 Occupancy, rent, utilities, and maintenance 14 15 Printing, publications, postage, and shipping 15 16 Other expenses (describe in Schedule 0) 16 1,640 17 Total expenses. Add lines 10 through 16 ► 17 187,589 INet Assets 18 excess or (deficit) for the year (Subtract line 17 from line 9) 18 (20,913) 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end -of -year figure reported on prior year's return) • k 19 150,201 20 Other changes in net assets or fund balances (explain in Schedule 0) . . . . . , . . . 20 21 Net assets or fund balances at end of year. Combine lines 10 through 20 ► 21 129,294 For Paperwork Reduction Act Notice, see the separate Instructions. Cat. No. 106421 Form 9$O -EZ (2013) Form 990 -EZ (2013) Page 2 Balance Sheets (see the instructions for Part It) Check if the organization used Schedule 0 to respond to any question in this Part II . 0 (A) Beginning of year 22 Cash, savings, and investments 23 Land and buildings 24 Other assets (describe in Schedule 0) 26 Total assets 26 Total liabilities (describe In Schedule 0) 27 Net assets or fund balances (line 27 of column (B) must agree with line 21) . IZED Statement of Program Service Accomplishments (see the instructions for Part Ill) Check if the organization used Schedule 0 to respond to any question in this Part 111 150,207 22 (3) End of year 129,293 23 24 150,207 25 129,203 26 150,207 27 129.253 What is the organization's primary exempt purpose? See Schedule 0 Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of parsons benefited, and other relevant information for each program title. Expenses (Required for section 501(c){3} and 501(c)(4) organizations and section 4047(a)(1) trusts: optional for others.) 28 Amounts paid to orthodontists to provide dental care to at risk children (Grants $ 29 If this amount includes foreign grants check here - . 1 28a leg 398 (Grants $ 30 J! If this amount includes foreign grants, check here . . 29a (Grants $ ) If this amount includes foreign grants, check here 31 Other program services (describe in Schedule 0) (Grants $ ) If this amount includes foreign grants, check here 32 Total) Part IV 30a 31a 32 program service expenses (add lines 28a through 31a 159,393 List of Officers, Directors, Trustees, and Key Employees (list each one even if not compensated—see the instructions for Part N) Gheck if the organization used Schedule 0 to respond to an question in this Part IV ❑ (a) Name and title (b) Average hobs per week devoted to poef (o) Reportable compensation (Forms W-2/1099-MISC) (it not paid, enter -0-) (d) Health benefits, contributions to employee benefit plans, and deferred compensation (e} Eotimaled amount of other compensation R. Mike Shlrtongxecutive Director 0 0 0 0 K,xle HouseiDirector 0 0 0 0 Brenda Tumer, President_ 0 0 0 0 Cynthia Shirtctifff, Director — _--, 0 0 0 0 Juniana Panchura, Director 0 0 0 0 Don Laird, Director o 0 0 Robert Orr, Director 0 0 0 0 Boni Smith, Director.. . 0 0 0 0 Linda Dwight, Director 0 0 0 0 Christopher Matthews Director _ 0 0 0 0 Form 990 -EZ (2013) Applicant: Deschutes County Community Grant Program 2014-15 Application Review Rating Worksheet Volunteers in Medicine (VIM) Category/Grant Amount: Title: Health, Mental Health, and Addictions / $11,000 Healthcare Sponsorship for 33 VIM Patients Review Criteria: 1. Organization: • Stable and positive history of providing services in Deschutes County. • Experience delivering similar programs, projects, or activities as those proposed. • Mission and goals are consistent with proposed program, project, or activity. • Stable and experienced Board of Directors or other leadership group. • Adequate staff and/or volunteers to implement proposed program, project, or activity. Points awarded for this section (maximum of 25). 2. Financial Status: • Adequate financial resources available to conduct and sustain operations. • Broad and diverse base of funding sources. • Financial need for a Community Grant to implement proposed program, project, or activity. • Proposed budget is consistent with and appropriate for the fixed grant amount available in the selected Community Grant category. Points awarded for this section (maximum of 25). 3. Program, Project, or Activity: • Program, project, or activity does not address emergency food, clothing, or shelter. (These activities are supported by Deschutes County through a separate grant program in conjunction with United Way's Emergency Food and Shelter program.) • Request is consistent with the fixed dollar amounts indicated in the category/grant amount description at the top of this form. • Number of individuals to be served is appropriate to the budget and scale of proposed program, project or activity. • Serves vulnerable and/or underserved populations and/or communities. • Positively impacts welfare of the community. • Complements, but does not duplicate, existing Deschutes County services. • Implementation strategy is suitable to achieving the stated goals and objectives of proposed program, project, or activity. • Partnerships or collaboration with other agencies are included in implementation strategy. • Other sources of funds or in-kind support are available to supplement Community Grant funds. Points awarded for this section (maximum of 35). 4. Performance Management: • Stated outputs are relevant and reasonable to the scale of the proposed program, project, or activity. • Stated outcomes are relevant and reasonable to the scale of the proposed program, project, or activity. Points awarded for this section (maximum of 15). TOTAL NUMBER OF POINTS AWARDED: COMMENTS: NAME OF RATER: , Deschutes County Fiscal Year 2014-15 Community Grant Application Submittal Instructions and Cover Sheet A complete application will consist of the following: 1. This cover sheet, signed and dated. 2. Narrative responses to the attached questions on no more than four single -sided, single-spaced pages. 3, Attachments: a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the Internal Revenue Service (IRS). b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ form or, if the organization is not required to file either form with the IRS, a financial statement that provides equivalent information concerning activities and governance, revenue, expenses, and net assets or fund balances. c. An operating budget specific to the proposed operations, program, project, or activity. d. A roster of the organization's Board of Directors. Submit the complete application electronically to judithu@deschutes.org no later than 5:00 p.m. on October 24, 2014. Incomplete and/or late applications will not be reviewed or considered. Please complete the following: Contact Name: Kat Mastrangelo Organization Name: Address: City: Volunteers in Medicine Clinic of the Cascades (VIM) 2300 NF. Neff Rd. Bend Telephone Number: Email Address: State: OR Zip Code: 97701 (541) 585-9005 kat_mastrangelonvim-cascades.org Application is being submitted to which Community Grant Program funding category*? ▪ Health, Mental Health, and Addictions Services ❑ Arts and Culture ❑ Other Essential Services: Includes services to youth; underserved, indigent, and/or vulnerable populations; animal welfare; or the environment. * Please refer to the funding guidelines for more information. Certification: On behalf of the organization specified above, I certify the following: 1. All information included in this application is accurate. 2. I am authorized by the governing board to submit this grant application. 3. This organization is located in Deschutes County. 4. If awarded, Community Grant funds will be used in support of Deschutes County residents only. 5. This organization is in good standing with the U.S. Internal Revenue Service and is currently designated as a 501(c)(3) tax-exempt entity. Signature: 4. Print Name: Kat Mastrange o Title: Date;_ (0 - Z Z- ZL(L-J Executive Director Volunteers in Medicine Clinic of the Cascades (VIM) Deschutes County Community Grant Application For Fiscal Year: July 1, 2014—June 30, 2015 A. ORGANIZATION 1. History of VIM Volunteers in Medicine Clinic of the Cascades (VIM) opened its doors in 2004, to provide care to the uninsured using the collaborative power of medical and non-medical volunteers. Since then, VIM has served over 10,700 patients, leveraging volunteer hours into an estimated $61 million in healthcare services and benefits to the community. In January, 2014, the Affordable Care Act (ACA) was implemented. Prior to the ACA, low-income people had very limited access to the Oregon Health Pian (OHP)/Medicaid. Now that barrier no longer exists. Thousands of Oregonians have received OHP, with many having insurance for the first time. Those with incomes over the OHP threshold, were able to purchase low-cost insurance plans due to government subsidies and tax -credits. The ACA had an enormous impact on VIM. In the last nine months, 78% of our patients from 2013 have either moved to OHP, or they have been able to purchase insurance plans of their own. Yet, even with this change, we're still here, seeing patients. The ACA wasn't designed as a universal healthcare system that would give everyone access to medical care. An estimated 5,300-7,300 people continue to remain uninsured — just in Central Oregon. Over the last few months, we have shifted our focus to meet this new need. VIM is now functioning as a medical safety net clinic for those who have been left behind by the ACA. 2. Mission and Goals Mission: To improve the health and wellness of the uninsured and medically underserved through the engagement of professionals, community partners and dedicated volunteers. VIM has three main goals: 1. Keep uninsured, low-income adults who live or work in Central Oregon as healthy as possible so that they can work, take care of their families and contribute to the community. 2. Decrease community medical costs by providing on-going, accessible medical care to those who are unable to afford it on their own. 3. Utilize the vast level of volunteer expertise and desire to give -back that our community is known for. This is what started VIM ten years ago, and it continues as powerfully today. VIM has 544 in - clinic volunteers and over 400 local medical partners who serve the uninsured, without charge. 3. Leadership Structure Kat Mastrangelo is VIM's Executive Director, under a policy board governance structure. B. PROGRAM, PROJECT OR ACTIVITY 1. Title: Healthcare Sponsorship for 33 VIM Patients 2. Goals and Objectives Goal: Provide 33 low-income, uninsured Deschutes County adults with one year of comprehensive healthcare. This will include primary and specialty medical care, prescription medication, mental health care, and limited dental care, as needed. Objectives: 1. Volunteers will provide primary, and some specialty, medical care to patients in the VIM clinic. 2. For specialty care that is outside the capacity of the clinic volunteers, patients will be referred to one of VIM's Community Medical Partners for services such as radiology, surgery, etc. 3. VIM's charitable pharmacy will provide patients with required medications at no cost through partnership programs with AstraZeneca, Merck, and other companies. 4. Patients will receive necessary mental health counseling through VIM's partnership with OSU-Cascades Masters in Counseling students in addition to volunteer therapists and counselors. 5. Basic dental services and dental hygiene will be available on a limited basis through VIM's partnership with volunteer Central Oregon dentists and hygenists for a materials fee. 6. Services received by each patient will be tracked by VIM's electronic medical records system. 3. Target Population Our target population continues to be low-income adults who are medically uninsured. However, since January, 2014, we have altered our eligibility process to reflect the changes brought on by the Affordable Care Act (ACA). All potential VIM patients must first complete the ACA enrollment process to see if they are eligible for any insurance programs. This process is facilitated by VIM volunteers who have been certified to do this work. Once the ACA enrollment process is complete, any potential patient must meet VIM's Five Basic Guidelines: 1. Is not eligible for ACA programs and/or does not have health insurance. 2. Is at least 18 years old. 3. Lives or works in Deschutes, Crook or Jefferson County. 4. Has some income, but it must be less than 200% of the Federal Poverty Line (about $23,340 for a single person, or $47,700 for a family of four). Income may come from a part-time, full-time, or seasonal job – or—from a student loan, unemployment, or other assistance. 5. Completes a VIM eligibility screening every nine months, and an ACA screening each year, to ensure he/she continues to meet the requirements for care at VIM. We are also following the same financial guidelines as the Affordable Care Act programs. Here are examples of the patients we now serve: CATEGORY 1 Patients: Income less than 138% of the Federal Poverty Level (FPL) (less than $16,104 annually for a single person, or $32,913 for a family of four) a) Permanently Residing Immigrants (with Green Cards) who have been paying taxes, but living in the U.S. for less than 5 years. (These individuals are not eligible for the Oregon Health Plan/Medicaid.) b) Temporarily Residing Immigrants who have been issued a visa to be in the U.S. for a period of time for work, school, etc. c) Undocumented Immigrants, most of whom came into Central Oregon on a temporary work visa and continued to stay after it expired to be able to support their families. d) Newly insured Oregon Health Plan (OHP) patients who are facing long wait times to see their new primary care provider. (VIM providers who volunteer in the clinic will see these patients temporarily, until they have their first appointment at their designated clinic.) 2 CATEGORY 2 Patients: Income 139 — 200% of the Federal Poverty Level ($16,105 - $23,340 annually for a single person, or $32,914 - $47,700 for a family of four) e) People who are in-between open enrollment periods. These include U.S. citizens, Permanently Residing Immigrants (with Green Cards), and Temporarily Residing Immigrants. (VIM's community volunteers will help them enroll in a paid insurance plan during the next open enrollment period, which is Nov. 15, 2014 — Feb. 15, 2015.) f) Undocumented Immigrants, per above. g) Low income individuals with exceptional financial circumstances that have qualified them for a VIM hardship exemption. (Reviewed on a yearly basis.) 4. Geographic Area of Deschutes County VIM patients come from all parts of Deschutes County. S. Impact on the Community and Existing Services Mosaic Medical and St. Charles Family Care are considered safety net clinics, along with VIM. Outside of VIM the uninsured are charged on a sliding scale because the clinics use paid staff, and are either partially reimbursed with federal funds, or they write off the care provided for nonprofit tax purposes. At VIM, all of our care is provided by volunteers. We don't charge for care, although we do encourage patient donations. Also, due to our strong community medical partnerships our care often includes the more expensive services, such as specialty referrals and prescription medications. In 2013-14, VIM volunteers facilitated 10,412 patient visits. Many of our patients have multiple chronic conditions, but are able to work, and thrive, with this consistent access to care and medications. VIM also gives volunteers a deeply meaningful way to be in service. Our volunteers include retired, and currently employed, medical professionals and lay -persons, along with third -year OHSU medical students and COCC pharmacy technician interns. This year, we are also sharing two OSU Masters in Counseling interns with Deschutes County Behavioral Health, who is providing the student oversight. 6. Implementation We will identify 33 patients who live in Deschutes County as recipients of this grant. Providing their care will be an extension of the work that we do each day. If a sponsored patient leaves VIM's care during the year, we will replace that person with another to complete the grant cycle. 7. How Funds will be Used We estimate patient care at VIM to be valued at $1,681 per patient for one year. Deschutes County grant funds will pay only for direct program costs for 33 patients at $338 each. This is 28% of the value of care. The remaining 72% will be from operating cost donations of $145 per person, and from in-kind services that include: 1. Volunteer Services: VIM's volunteer medical professionals provide all the medical care in the clinic. Trained lay -person support staff assist with patient scheduling, medical records, eligibility screening, and enrolling eligible patients into Affordable Care Act programs. Conservatively, we estimate these volunteer services to be valued at $900,000 per year, or about $450 per patient. 2. Prescriptions: Our charitable pharmacy provides prescription medications to patients at no charge, thanks to Prescription Assistance Programs with pharmaceutical companies and donated medications. The value of these medications is $1.5 million per year, or $749 per patient. 3 Together these services leverage the County funds of $338 per patient by 355%. Additional in-kind services that are not reflected in our budget include specialty medical services from our 400+ community partners, other products and services to further support patient care, and a myriad of other ways this care benefits the person, their family, and the community. (Note: 33 patients at $338 equals $11,154. VIM will use other funds to supplement the $154 above the grant request.) 8. Partner Agencies VI M's primary partners are our volunteers, interns and community medical partners. Since the ACA, we have also been working quite closely with the Latino Community Association, assisting their clients with medical services. In turn, they are helping our staff and volunteers become more culturally aware, so that we can best understand and meet the needs of our Latino patients. We've also been working closely with Mosaic Medical and St. Charles Family Care to provide temporary care for patients who are on long wait -lists to be seen by their new OHP providers. And, due to the chaotic roll-out of the ACA, we continue to meet monthly with Cover Oregon Community Partners that include Deschutes County Health Department, Crook County Health Department, Mosaic Medical, St. Charles Health System, Latino Community Association, Healthy Beginnings and others to coordinate efforts and share resources. 9. Other Sources of Funding The County will provide funds to cover 28% of the care provided. VIM will provide the remaining 72%. D. PERFORMANCE MEASUREMENT 1. Grant Outputs At the end of the grant year we will provide a report that captures data for each of the 33 sponsored patients. This will include: 1) number of visits to the clinic; 2) number of medical problems; 3) number of prescription medications; and 4) number of lab visits and procedures per patient. 2. Anticipated Outcomes VIM keeps people healthy, while helping to keep community medical costs down. Without VIM, most low- income, uninsured people will wait until they are very ill and then seek care in the emergency room, which is required by law to treat everyone who walks in. But an ER isn't set up like a doctor's office. It won't provide ongoing care or prescriptions for chronic conditions, mental health counseling, dental care, or any other care that is necessary, but is considered non -urgent. VIM provides all of this. Another important distinction is the cost of care. One visit to the ER is an average of 10 times the cost of a visit to a primary care provider. When iow-income, uninsured people use the ER and can't pay their bill, the costs get passed on to the public in the form of higher insurance rates and hospital fees. Last year we saved St. Charles Health System an estimated $1 million in ER care through our work. In fact, when the Oregon Health Policy & Research's Return on Community Investment Analysis from February, 2010, is applied to this donation, the estimated value of this grant to the community is 10:1, or $110,000. Thank you for the support that Deschutes County has given VIM in the past. Our partnership has had a very positive impact on our patients, and on the community. We deeply appreciate your consideration of this new proposal. 4 I/. VOLUNTEERS I N MEDICINE FUNIC OE TIlE CASCADES Budget for Fiscal Year2014-15 Expenses per Patlent Dlrect Program Costs per Patient Direct Program Costs for 33 Patients Sponsored by $11,000 Community Grant INCOME Deschutes County Community Grant rS11,000.00 $474,000.00 511,000.00 Development (fundraising) 5154.00 Patient Donations / fees 517,000.00 50.00 OHSU Medical Student Fee and other 510,000.00 $0.00 Sub -total income $512,000.00 $11154.00 Endowment Draw 580,000.00 _ 50.00 Endowment Gains 590,000.00 $0.00 Additional Transfer from Endowment 5285,606.00 50.00 Sub -total endowment $455,606.00 $0.00 Sub -total Income and endowment _ $967.606.00 $11,154.00 In -Clinic Volunteer Services 11n -kind) 5900,000.00 514,827.76 Charitable Pharmacy Medications (In-kind) $1,500,000.00 524,712.93 Sub -total In-kind $2,400000.00 $39,540.69 TOTAL $3,367,606,00 90,694.69 EXPENSES Salaries and Wages 5600,250.00 5299.60 $209.62 56,917.46 Taxes 5105,000.00 552.421 _ 536.69 51,210.90 Empl Benefits 550,000,00 524.96 517.47 $576.58 Unemployment insurance & Workers Comp 59,400.00 54,69 $3,28 5108.34 Contract Labor 52,500.00 51.25 50.88 $28.88 Medical & Dental Supplies and Services 54,750.00 52.37 51.66 $54.75 Pharmaceuticals 51,500.00 50.75 50.53 517.33 Facility Maintenance $10,000.00 - __ $4.99 53.49 5115.27 Rent 51.00 50.00 _ 50.00 50.00 Telephone / Internet 58,000.00 53.99 52.79, 592.17 Utilities $7,500.00 $3.74 52.62 586.39 Accounting/ Legal 55,000.00 52.50 51.75 S57.75 Consulting/ Investment Counsel _ 56,000.00 53.00 52.10 569.30 Bank Charles 1 Creditcard Fees 52,000.00 51.00 50.70 523.10 Dues Subscriptions Licenses 52,700.00 51.35 $'0.95 531.19 Materials Supplies 57,500.00 $3.74 $2.62 $86.39 Equip Repair/ Maintenance 58.000.00 S3.99 $2.79 592.17 Postage Delivery 56,000.00 53.00 52.10 569.30 Printing / Copying 57,500.00 $3,74 52.62 586.39 IT Support 517,000.00 58.49 55.94 5196.12 Software / Licenses / Website 513,500.00 56.74 54.72 5155.69 Travel/Meals/Entertainment 54,500.00 $2.25 $1.58 $51.98 Outreach Adv Marketing $20,500.00 510.23 57.16 5236.31 Recognition 51.000.00 50.50 50.35 511.55 Spec Events Exp $2,500.00 51.25 50.88 528.88 Food and Bev 51,325.00 $0.66 50.46 S15.25 Training/ Education 52.500.00 51.25 50.88 528.88 Medical Liability Insurance and D&C) 514,180.00 $7.08 54.96 - 516355 Depreciation 547,000.00 523.47 516.43 $542.16 Sub -total expenses $967,606.00 $483.00 $338.00 $11,154.00 In -Clinic Volunteer Services (in-kind) 5900,000.00 5449.33 5449.33 514,827.76 Charitable Pharmacy Medications (in-kind) 51,500,000.00 5748.88 5748.88 524,712.93 Sub -total !n -kind $2,400,000.00 $1,198.20 $1,I98.20 539,540.69 TOTAL 53,367,606.00 51,681.20 51,536.20 $50,694.68 Sub total Personnel cost 5767,150.00 Sub total non -personnel cost $200,456.00 Program 70% _ $677,324.20 Development 21% 5203,197.26 Admin 9% 567.084.54 VOLUNTEERS IN MEDICINE CLINIC OF THE CASCADES 2014 - 2015 BOARD OF DIRECTORS As of October, 2014 John Teller, MD, Physician, Bend Memorial Clinic, VIM Board Chair Tanya Hayden, Vice -President, Bend Research, Inc., VIM Board Vice -Chair Kurt Barker, Attorney, Karnopp Petersen, LLP, VIM Board Secretary Kate Dunning, CPA, Director of Finance, Humm Kombucha, VIM Board Treasurer Michel Boileau, MD, Chief Clinical Officer, St. Charles Health System Cynthia Kane, PhD, Consultant - Physician Contracting, Kane Health Care Consulting, LLC Steven Koski, D Div, Senior Pastor, First Presbyterian Church John MacMillan, Vice -President, Private and Business Banking, Wells Fargo Dan Stevens, Sr. Vice -President & COO Community Health Plans, PacificSource Health Plans Bill Winnenberg, Principal, Type B Consulting LLC Emeritus Board Members Bob Hakala, MD, Physician and VIM Co -Medical Director Jim Lussier, President, The Lussier Center Jim Petersen, Attorney, Karnopp Petersen, LLP Rod Ray, PhD, CEO, Bend Research, Inc. 2300 NE Neff Road • Bend, OR 97701• phone (541) 330-9001 • fax (541) 585-9002 • www.vim-cascades.org 53675 09/30/2014 3:03 PM Form 990 Department of the Treasury Internal Revenue Service Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) ► Do not enter Social Security numbers on this form as it may be made public. ► Information about Form 990 and its Instructions Is at www.lrs.novlform99D. A For the 2013 alendar Years or taxyear bepinninii 4/ 01/ 13 , and ending 03/31 /14 B Check if applicable: I C Name of organlzallon VOLUNTEERS IN MEDICINE CLINIC OF THE CASCADES JAddress change Name change Initial return L] Terminated II Amended relum I ] Application pending 0^43 Nu. rr,n5 00.17 2013 Open to Public Inepectlon Doing Business As D Employer Identification number 93-1327847 Number and street (or P.O. box if mall Is not delivered to street address) 2300 NEFF ROAD Room/suite E Telephone number 541-330-9001 City or town, state or province, country, end ZIP or foreign postal code BEND OR 97701 O Gaessrnctripts5 1,805,539 F Norms and address of principal el sr 1 Tak-uxemp( slates: AXI 50t(03) 1 1601(0) ( ) 1 tirrsell re) 14s47(ajtll.or 152/ wenelto:► WWW. VIM—CASCADES . ORG K Form of oroatlzalleiv Xt Ccrperation j Trust Association I 0th#n ► H(a) Is this a group relum for subordinates' Yes X No H(b) Are all subordinates included? IJ Yes No If "No," attach a list. (see Instructions) Ilio) Group exompllori numlxn ► L Yew of formation: 2001 [M Slato or Irma domicile: OR ran 1 summary Activities & Governance 1 Briefly describe the organization's mission or most significant activities: TO IMPROVE THE HEATLH AND WELLNESS OF THE MEDICALLY ENGAGMENT OF PROFESSIONALS, COMMUNITY PARTNERS AND DEDICATED 2 Check this box ► if the organization discontinued its operations or disposed of more than 3 Number of voting members of the governing body (Part VI, line la) 4 Number of independent voting members of the governing body (Part VI, line 1 b) 5 Total number of individuals employed in calendar year 2013 (Part V, line 2a) 6 Total number of volunteers (estimate if necessary) 7a Total unrelated business revenue from Part VIII, column (C), line 12 UNINSURED THROUGH VOLUNTEERS. 25% of its net asse s. 3 THE 14 4 14 5 18 6 589 7a 0 7b 0 b Not unrelated business taxable Income from Form 90.T, line 34 . , .... .. Revenue 8 Contributions and grants (Part VIII, line 1h) ,• • . 9 Program service revenue (Part VIII, line 2g) 10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) 11Other revenue (Part VIII, column (A), lines 5,6d, Bc, 9c, 10c, and 11 0) 12 Total revenue — add lines 8 through 11 (must equal Part VIII. column (A), line 12) ..... Prior Year Current Vast 703,199 528, 718 51, 314 48.719 107, 428 240,719- 40,71911 11, 724 6, 000 873, 665 824, 151 0 Expenses I 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 14 Benefits paid to or for members (Part IX, column (A), line 4) 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 16aProfessional fundraising fees (Part IX, column (A), line 11e) b Total fundraising expenses (Part IX, column (D), line 25) ► 136, 697 17 Other expenses (Part IX, column (A), lines Ila -11d, 11f -24e) 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 19 Revenue Tess expenses. Subtract line 18 from line 1.2 , _ 0 726,240 699, 515 0 186, 765 183, 018 _ 913, 005 882, 533 —39,340 of Current Year —58, 382 End of Year t 20 Total assets (Part X, line 16) 21 Total liabilities (Part X, line 26) 22 Net assets or fund balances. Subtract line 21 from line 20 eplr Inning 2,888,047 2,926,064 16, 822 13, 357 2,871,225 2,912,707 Part 11 Signature Block Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. Sign Here Signature of officer 16, KAT MASTRANGELO Pr Type or print name and title Dale EXECUTIVE DIRECTOR Paid Preparer Use Only Print/Type preparer's name (BRENDA M. BARTLETT Preparer's signature Date Fern'snanro F SGA CPAS & CONSULTANTS, LLP Check JXf,11 PTIN self-employed P00273868 Flrrn'aE)Nl! 20-1592634 Firm's address ) 499 SW UPPER TERRACE DR BEND, OR 97702 Phone no. 541-388-7888 May the IRS discuss this return with the preparer shown above? (see Instructions) Yes J No For Paperwork Reduction Act Notice, see the separate Instructions. Form 990 (2013) DAA 53675 09/30/2014 3:03 PM Form 990 (20 3) VOLUNTEERS IN MEDICINE 93-1327847 page 2 Part 111 Statement of Program Service Accomplishments Check if Schedule 0 contains a response or note to any line in this Part 111 .., . . . !XI 1 Briefly describe the organization's mission: TO IMPROVE THE HEATLH AND WELLNESS OF THE MEDICALLY UNINSURED THROUGH THE ENGAGMENT OF PROFESSIONALS, COMMUNITY PARTNERS AND DEDICATED VOLUNTEERS. 2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990 -EZ? If "Yes," describe these new services on Schedule 0. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services? If "Yes," describe these changes on Schedule 0. 4 Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported. Yes L 1, No Yes LI No 4a (Code: ) (Expenses $ 675 r 508 including grants of $ ) (Revenue $ SEE SCHEDULE 0 4b (Code: (Expenses $ Including grants of$ ) (Revenue $ 4c (Code: ) (Expenses $ including grants of $ ) (Revenue $ 4d Other program services. (Describe in Schedule 0.) (Expenses $ including grants of $ ) (Revenue $ 4e Total program service expenses ► 675, 508 DAA Form 990 (2013) Applicant: Deschutes County Community Grant Program 2014-15 Application Review Rating Worksheet Deschutes Family Recovery Category/Grant Amount: Title: Health, Mental Health, and Addictions / $11,000 Off to a Good Start Review Criteria: 1. Organization: • Stable and positive history of providing services in Deschutes County. • Experience delivering similar programs, projects, or activities as those proposed. • Mission and goals are consistent with proposed program, project, or activity. • Stable and experienced Board of Directors or other leadership group. • Adequate staff and/or volunteers to implement proposed program, project, or activity. Points awarded for this section (maximum of 25). 2. Financial Status: • Adequate financial resources available to conduct and sustain operations. • Broad and diverse base of funding sources. • Financial need for a Community Grant to implement proposed program, project, or activity. • Proposed budget is consistent with and appropriate for the fixed grant amount available in the selected Community Grant category. Points awarded for this section (maximum of 25). 3. Program, Project, or Activity: • Program, project, or activity does not address emergency food, clothing, or shelter. (These activities are supported by Deschutes County through a separate grant program in conjunction with United Way's Emergency Food and Shelter program.) • Request is consistent with the fixed dollar amounts indicated in the category/grant amount description at the top of this form. • Number of individuals to be served is appropriate to the budget and scale of proposed program, project or activity. • Serves vulnerable and/or underserved populations and/or communities. • Positively impacts welfare of the community. • Complements, but does not duplicate, existing Deschutes County services. • Implementation strategy is suitable to achieving the stated goals and objectives of proposed program, project, or activity. • Partnerships or collaboration with other agencies are included in implementation strategy. • Other sources of funds or in-kind support are available to supplement Community Grant funds. Points awarded for this section (maximum of 35). 4. Performance Management: • Stated outputs are relevant and reasonable to the scale of the proposed program, project, or activity. • Stated outcomes are relevant and reasonable to the scale of the proposed program, project, or activity. Points awarded for this section (maximum of 15). TOTAL NUMBER OF POINTS AWARDED: COMMENTS: NAME OF RATER: Deschutes County Fiscal Year 2014-15 Community Grant Application Submittal Instructions and Cover Sheet A complete application will consist of the following: I. This cover sheet. signed and dated. 2. Narrative responses to the attached questions on no more than four single -sided, single-spaced pages. 3. Attachments: a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the Internal Revenue Service (IRS). b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ form or, if the organization is not required to file either form with the IRS, a financial statement that provides equivalent information concerning activities and governance, revenue, expenses, and net assets or fund balances. c. An operating budget specific to the proposed operations, program, project, or activity. d. A roster of the organization's Board of Directors. Submit the complete application electronically to judithu@deschutes.org no later than 5:00 p.m. on October 24, 2014. Incomplete and/or late applications will not be reviewed or considered. Please complete the following: Contact Name: L. Thomas Clark Organization Name: Address: City: Deschutes Family Recovery, Inc 531 NW Harriman Street Bend Telephone Number: Email Address: State: I Oregon Zip Code: 97701 541-38R-4053 lthomasclarkpc@aol.com Application is being submitted to which Community Grant Program funding category*? X Health, Mental Health, and Addictions Services ❑ Arts and Culture ❑ Other Essential Services: Includes services to youth; underserved, indigent, and/or vulnerable populations; animal welfare; or the environment. * Please refer to the funding guidelines for more information. Certification: On behalf of the organization specified above, I certify the following: I. All information included in this application is accurate. 2. I am authorized by the governing board to submit this grant application. 3. This organization is located in Deschutes County. 4. If awarded, Community Grant funds will be used in support of Deschutes County residents only. 5. This organization is in good standing with the U.S. Internal Revenue Service and is currently designated as a 501(c)(3) tax-exempt entity. Signature: Print Name: L. Thomas Clark Title: President/Chair Date: Organization 1. Deschutes Fancily Recovery, Inc (DFR) is a 501(c)(3) organization that was established in 2006 to provide support services to parents in Deschutes County who are in court supervised treatment program. Support services include, but are not limited to, medical/dental care, housing assistance, transportation, utilities, childcare, food, and clothing. Funds available through DFR remove barriers that participants face in engaging in treatment and finding recovery from their addiction. Drug court participants struggle with securing clean & sober housing, accessing transportation to drug court hearings and related treatment appointments, accessing appropriate clothing for job search and employment, and meeting their own physical and emotional needs so they care provide the safety and welfare of their children. The mission of the Deschutes County Family Drug Court program is to promote accountability and substance abuse recovery for parents and ensure the safety and welfare of their children. Using a team approach, the program provides close judicial supervision, intensive substance abuse treatment and comprehensive wraparound services. The goals of the DCFDC program to: (1) lessen the impact of illegal drug use on the community, law enforcement agencies, courts and corrections, (2) reduce community rates of addiction and substance abuse, (3) help drug addicted parents and pregnant women become sober and responsible caregivers, (4) create environments in which children arc healthy and safe from abuse and neglect, and (5) promote positive, pro -social behavior. The average length of time to successfully complete the program is 18 months. 2. DFR is governed by a volunteer board of directors. The following is the current roster of the board: L. Thomas Clark - President Daniel Derlacki - Vice President Jvon Danforth - Treasurer Kathy Eckman - Secretary Jacques DeKalb Patrick Carey Robert Snyder Program, Project, or Activity 1. OFF TO A GOOD START: Total Project Cost = $ 9806.19 2. The goal of this project is to ensure participants of the Deschutes County Family Drug Court program are provided with essentials for basic self care so that they get "off to a good start". The objectives will be to (1) provide each participant with a package of essential items to meet their basic needs for personal care & hygiene, and for engaging in the program and their recovery, and (2) sustain participant's access to products that will continue to support their recovery by providing incentives to Family Drug Court participants who maintain compliance with program rules and expectations. 3. DCFDC is a court-supervised intensive treatment program designed to serve a target population of Deschutes County residents, 18 years of age or older, who have had, or are at risk of having, their children removed from their custody as a result of substance abuse. Additional eligibility criteria include an active dependency and/or criminal case; a child or children who they are actively parenting or are working toward actively parenting; a willingness to participate in the program; and a significant and current substance abuse problem as demonstrated by a drug-related criminal charge, dependency case, and/or probation violation, or a history of positive drug tests. Upon admission 92% of individuals admitted are homeless and 94% are unemployed. More than half enter the program directly from jail and others have been transient with little or no possessions, including personal care products and adequate clothing. 4. Eighty-four percent (84%) of families served through the Family Drug Court program reside in Bend. Twelve percent (12%) reside in Redmond. Four percent (4%) reside in southern Deschutes County in or near LaPine. 5. Research has shown Drug Courts to significantly reduced re-arrest or reconviction rates by an average of approximately 8 to 26 percent, with the "average of the averages" reflecting approximately a 10 to 15 percent reduction in recidivism. Meta-analyses have shown Drug Courts to reduce crime by as much as 35 to 40 percent (National Association of Drug Court Professionals: www.nadcp.org). Local statistics demonstrate that Family Drug Court is having a positive impact on the community and complement existing services in Deschutes County. In partnership with Deschutes Family Recovery, Inc and other community agencies, the Deschutes County Family Drug Court program has accomplished the following: • The program has successfully graduated/completed 57 parents. • The criminal recidivism rate for program graduates is 7%, compared to 16% nationally for similar programs and even higher for individuals with court involvement but who do not participate in an intensive, court-supervised substance abuse treatment program. • The family reunification rate for program graduates is 95%, compared to 51% nationally. • One hundred percent (100%) of program graduates have long term, stable housing upon program completion compared to less than 37% at admission. • Upon program completion, 72% of participants have full or part time employment This project will prepare participants of the Deschutes County Family Drug Court to more fully engage in services available through the program and make changes in their lives that will improve personal outcomes, as well as outcomes for their family and their community. 6. The project will be implemented immediately upon receipt of funds. Board Members and volunteers will solicit products from local retailers at reduced costs and prepare welcome packets for all new participants. The welcome packets will consist of a backpack or duffel bag, essential personal care items, daily planner and notebook, basic recovery materials (Alcohol Anonymous or Narcotics Anonymous Big Book and Step Working Guide), and a gift certificate for any clothing items needed in order for them to present appropriately in court and/or the treatment setting. Upon admission to the program, all participants are assigned to work with a Certified Recovery Mentor. Mentors are employees of BestCare Treatment Services and provide support to newcomers to help them successfully reintegrate into the community and to engage in the recovery process. The assigned Mentor, or other program staff, will provide a tutorial to the participant in (1) using a daily planner to attend all Family Drug Court obligations, parent/child visits, and treatment appointments, (2) finding community-based 12 steps meetings and an introduction to the recovery materials provided, and (3) dressing appropriately for court and related appointments. All participants will have the opportunity to visit DFR's Clothing Closet (a storage unit with donated clothing items) with their Mentor or other staff to pick out 2-3 outfits, if needed, for court and to use the gift certificate to purchase items not available at the Clothing Closet. Research demonstrates the use of tangible incentives is impactful for high-risk, antisocial offenders who comprise the target population for drug court. Participants in FDC have often habituated to punishment and are not accustomed to receiving positive reinforcement. Tangible rewards like the small items purchased for the `Judge's basket' are effective in exerting greater control over their behavior than threats of punishment. For this reason, participants have the option to earn incentives from the judge for compliance with their treatment plan and FDC rules. Additional funds will be used to purchase incentive items for the participants who are in compliance with Family Drug Court rules and expectations. Incentives are awarded in court by the presiding judge as an incentive for continued positive behavior and progress towards meeting their personal and family goals. 7. The funds will be used as follows: Personal Organization: $494.00 ($26.00 per participant x 19 admissions/year) • Daily Planner(s) ($10.00) • Backpack ($15.00) • Journal/Spiral Notebook ($1.00) Recovery Publications $437.00 ($23.00 per participant x 19 admissions/year) • Big Book ($13.50) • Step Working Guide ($9.50) Personal Care 7 Hygiene 5475.19 ($25.01 per participant x 19 admissions/year) • Hairbrush ($2.64) • Shampoo ($2.50) • Body Soap ($1.50) • Toothbrush ($1.97) • Toothpaste ($2.97) • Deodorant($2.94) • Razor ($2.37) • Shaving Cream ($2.24) • Condoms ($5.88) Clothing Voucher/Gift Certificate $950.00 • Gift Certificates (i.e. WalMart,Target) ($50.00 per participant x 19 admissions/year) Incentives ($7450.00) • Basket Incentives ($5 per client x 25 clients/per week) $6500.00 • Advanced Incentives ($20 per week) $1040.00 8. Deschutes Family Recovery, Inc is proud to support Deschutes County Family Drug Court along with the following community partners: • Deschutes County Circuit Court • Deschutes County Behavioral Health • Deschutes County District Attorney's Office • Deschutes County Sheriff's Office • Deschutes County Department of Parole and Probation • Deschutes County Department of Human Services — Child Welfare • CASA of Central Oregon • BestCare Treatment Services • Healthy Families of the High Desert • Deschutes County Local Bar 9. Deschutes Family Recovery has received grants from the Oregon Community Foundation. Cow Creek Umpqua Indian Foundation, Deschutes County Sheriff's Office, and has received past year Deschutes County Community Grant's to support other wraparound services and supports provided to families affected by addiction. Other services include, but are not limited to, housing, transportation, childcare, medical/dental care, etc. No other funds have been solicited or received for the purpose of the project detailed herein. Performance Measurement 1. Deschutes Family Recovery will track and be able to report on the following quantifiable outputs: a. Total Number of Participants Served b. Total Number Welcome Packets Distributed c. Total Number of Incentive Items Awarded d. Retention rates of FDC participants 2. Deschutes Family Recovery anticipates the followed improved outcomes as a result of this project: a. Improved retention rates for drug court participants b. Improved personal hygiene and personal appearance of drug court participants roan 990 -EZ Department of the Treasury Internal Revenue Service Short Form Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(e)(1) of the Internal Revenue Code (except private foundations) ► Do not enter Social Security numbers on this form as it may be made public. ► Information about Form 990-E2 and its instructions is at www.irs.gov/form990. Open to Public Inspection A For the 2013 calendar year. or tax year beginning , 2013, and ending B Check II applicable ❑ Address change ❑ Name change ❑ Inm,al return ❑ Terminated ❑ Amended return 20 C Name oforgenamor. Deschutes Family Recovery Inc D Employer identification number 56.2601109 Number and Street (or P 0 box, II mall 19 not deavered to Street address) 521 NW Harriman Cly or town, state or province, country. and ZIP or foreign postai co40 Ranm+sane (a—'4 +L=r 7 �a w nds OR 97701 G Accounting Method 0 Cash 0 Accrual Other (spectly) ► 1 Website: ► J Tax-exempt status (check only one) — 0 501(6)13) Q 501(c)1 ) 4 (Insert no) ❑ 4947{a)0) or 0527 K Form of organization ❑ Corporation ❑ Trust 0 Association 0 Other 4 E idlepPICAteriumber 541.388-4053 F Group Exemption Number ► H Check ► 0 If the organization is not required to attach Schedule B (Form 990, 990 -EZ, or 990 -PF). L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts If gross receipts are $200,000 or more, or If total assets (Part II, column (B) below) are $500,000 or more, file Form 990 Instead of Form 990 -EZ ► Part I Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I) Check if the organization used Schedule 010 respond to any question in this Part 1 1 Contnbutions, gifts, grants, and similar amounts received . . . 1 3.2764.00 2 Program service revenue including government fees and contracts 3 Membership dues and assessments . . . . . . . . . . . . . . 4 Investment income 5a Gross amount from sale of assets other than inventory 5a Pa d 2 m 0. W b Less: cost or other basis and sales expenses 5b 2 c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from I ne 5a) 6 Gaming and fundraising events a Gross income from gaming (attach Schedule G if greater than $15,000) . . . . . . . . . . I6aI b Gross Income from fundraising events (not including $ of contributions from fundraising events reported on line 1) (attach Schedule G if the sum of such gross Income and contributions exceeds $15,000) . . 6b c Less: direct expenses from gaming and fundraising events . . . 6c d Net income or (loss) from gaming and fundraising events (add lines 6a and 8b and subtract line 6c) 7a b c 8 9 10 11 12 13 14 15 16 17 Net Assets Gross sales of inventory, less retums and allowances 7a Less. cost of goods sold I lb Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) 7c Other revenue (descnbe in Schedule 0) 8 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 ► 9 32764.00 Grants and similar amounts paid (list in Schedule 0) Benefits paid to or for members RECEIVE®.. ,i1nt Salaries, other compensation, and employee benefits , . . . . . . Professional fees and other payments to independent contracto APR 2 3 20I4 - Occupancy, rent, utilities, and maintenance . . . . . . . Pnnting, publications, postage, and shipping . . . . . , " 115 Other expenses (describe in Schedule O) OGD.EN. UT 116 ti , 4884.00 :h) )112 6 1114 22462 00 13 Total expenses. Add lines 10 through 16 17 18 Excess or (deficit) for the year (Subtract line 17 from line 9) 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end -of -year figure reported on prior year's retum) 20 Other changes in net assets or fund balances (explain in Schedule 0) 21 Net assets or fund balances at end of tear. Combine lines 18 through 20 For Paperwork Reduction Act Notice, see the separate Instructions. Cat No 106421 18 723 00 8088.00 04.00 19 18332.00 20 593.00 . ► 21 18332.0Q Form 990 -EZ (2013) Form 990-F1 (2013) Part 1I Balance Sheets (see the instructions tor Part II) Check if the organization used Schedule 0 to respond to any question in this Part II . 22 Cash,'savings, and investments 23 Land and buildings 24 Other assets (descnbe in Schedule 0) 25 Total assets . . . . . . . . . . . . . 26 Total liabilities (describe in Schedule 0) . - _ _ . . 27 Net assets or fund balances (line 27 of column (B) must agree with line 21) Statement of Program Service Accomplishments (see the instructions for Part ill) Check if the organization used Schedule 0 to respond to any question in this Part III - (] What is the organization's primary exempt purpose? To support Deschutes Co. Famil Dru Court Descnbe the organization's program service accomplishments for each of its three largest program services, as measured by expenses In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title. pS:2r- - pro vid.. 1 4r' 413 p7r- c,`-, ,q .c i ,n Pepe 2 0 (A) Beginning of year 18.332.00 22 (B) End or year 16412.00 23 24 18332.00 Part 111 28 29 eott-ct Chid ierl (Grants $ 30,122.00) If this amount includes fore)gn grants. check here . , ► (Grants $ 30 ) If this amount Includes foreign grants, check here . . 25 1641100 26 27 16412.00 Expenses (Required for section 501(c))3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional fon others.) 28a 22462.00 (Grants $ ) If this amount includes foreign grants, check here . . . . ► 0 31 Other program services (describe in Schedule 0) . . . . . . . , . . . rants $ ) If this amount includes foreign grants, check here . . . ► 0 32 Total program service expenses (add lines 28a through 31a) ► Part IV 30a 31a 32 List of Officers, Directors, Trustees, and Key Employees (list each one even if not compensated—see the instructions for Part IV) Check if the organization used Schedule 0 to respond to any question in this Part IV [ (a) Name and elle (b) Average hours per week devoted to p stheek (e) Reportable compensation (Forms W-2/1099-MISC) 01 not paid, enter -0-) (d) Health benefits, contnbutions to employee benefit plans, and deferred compensation to) Estimated amours of other compensation L. Thomas Clark Pres-Treas 5 hrs. 521 NW Harriman/ Bendy OR 97701 Randy Johnson 521 NW frarr)rnan, Bond, OR 67701 Director 2 hrs. Patrick Carey 521 NW Harriman, Send OR 97701 Director 2 hrs. Robert Snyder 621 NW Harriman, Bend. OR 07701 » . Director 2 hrs Jacques DeKalb 521 NW Harriman, Bend, OR 97701 Director 2 hrs. Form 990 -EZ (2013) Applicant: Deschutes County Community Grant Program 2014-15 Application Review Rating Worksheet Healing Reins Category/Grant Amount: Title: Health, Mental Health, Addictions / $11,000 Equine Assisted Psychotherapy for Drug & Alcohol Recovery Program Review Criteria: 1. Organization: • Stable and positive history of providing services in Deschutes County. • Experience delivering similar programs, projects, or activities as those proposed. • Mission and goals are consistent with proposed program, project, or activity. • Stable and experienced Board of Directors or other leadership group. • Adequate staff and/or volunteers to implement proposed program, project, or activity. Points awarded for this section (maximum of 25). 2. Financial Status: • Adequate financial resources available to conduct and sustain operations. • Broad and diverse base of funding sources. • Financial need for a Community Grant to implement proposed program, project, or activity. • Proposed budget is consistent with and appropriate for the fixed grant amount available in the selected Community Grant category. Points awarded for this section (maximum of 25). 3. Program, Project, or Activity: • Program, project, or activity does not address emergency food, clothing, or shelter. (These activities are supported by Deschutes County through a separate grant program in conjunction with United Way's Emergency Food and Shelter program.) • Request is consistent with the fixed dollar amounts indicated in the category/grant amount description at the top of this form. • Number of individuals to be served is appropriate to the budget and scale of proposed program, project or activity. • Serves vulnerable and/or underserved populations and/or communities. • Positively impacts welfare of the community. • Complements, but does not duplicate, existing Deschutes County services. • Implementation strategy is suitable to achieving the stated goals and objectives of proposed program, project, or activity. • Partnerships or collaboration with other agencies are included in implementation strategy. • Other sources of funds or in-kind support are available to supplement Community Grant funds. Points awarded for this section (maximum of 35). 4. Performance Management: • Stated outputs are relevant and reasonable to the scale of the proposed program, project, or activity. • Stated outcomes are relevant and reasonable to the scale of the proposed program, project, or activity. Points awarded for this section (maximum of 15). TOTAL NUMBER OF POINTS AWARDED: COMMENTS: NAME OF RATER: Deschutes County Fiscal Year 2014-15 Community Grant Application Submittal Instructions and Cover Sheet A complete application will consist of the following: . This cover sheet, signed and dated. 2. Narrative responses to the attached questions on no more than four single -sided, single-spaced pages. 3. Attachments: a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the Internal Revenue Service (IRS). b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ form or, if the organization is not required to file either form with the IRS, a financial statement that provides equivalent information concerning activities and governance, revenue, expenses, and net assets or fund balances. c. An operating budget specific to the proposed operations, program, project, or activity. d. A roster of the organization's Board of Directors. Submit the complete application electronically to j i thu y)descchutes.org no later than 5:00 p.m. on October 24, 2014. Incomplete and/or late applications will not be reviewed or considered. Please complete the following: Contact Name: Organization Name: / E /14/ E/ A 5 771C /G 9f [ )77 . Address:0 C2X 5 3 City: Telephone Number: Email Address: State: Zip Code: fix(Dg / ,_ 5' — / 9/ 0 h �c ti.v ail /Ai_s v CO2. Application is being submitted to which Community Grant Program funding category*? Health, Mental Health, and Addictions Services ❑ Arts and Culture ❑ Other Essential Services: Includes services to youth; underserved, indigent, and/or vulnerable populations; animal welfare; or the environment. * Please refer to the funding guidelines for more information. Certification: On behalf of the organization specified above, 1 certify the following: 1. All information included in this application is accurate. 2. I am authorized by the governing board to submit this grant application. 3. This organization is located in Deschutes County. 4. If awarded, Community Grant funds will be used in support of Deschutes County residents only. 5. This organization is in good standing with the U.S. Internal Revenue Service and is currently designated as a 501(c)(3) tax-exempt entity. Signature: Print Name: 1 Title: E / cL Date: / o a/1/. `2 C o /(._, Deschutes County Fiscal Year 2014-15 Community Grant Application Questions ORGANIZATION: HEALING REINS THERAPEUTIC RIDING CENTER 1. Describe the history of the organization, including the year the organization was established. Healing Reins Therapeutic Riding Center (HRTRC) is a 501 © 3 non-profit organization established in 1999. In 2001 Healing Reins earned its distinguished status as a PATH International (Professional Association of Therapeutic Horsemanship International) Premier Accredited Center. HRTRC is nationally recognized for its excellence in providing professional equine -assisted therapeutic services. It is the only nationally accredited organization in all of Central Oregon east of the Cascades offering professionally certified staff and best practices in horse -centered therapy. HRTRC has expanded over the years and today serves 145 children and adults with disabilities and special needs each week throughout the year. The organization provides instruction and intervention for 1,200+ individuals annually. HRTRC leases an ADA approved facility complete with indoor riding arena with fourteen stalls, an outdoor arena and a Sensory Integration/Challenge Trail Course with beautiful views of the Oregon Cascades. 2. State the organization's mission, goals, and programs or services provided. Our mission, "to heal with horses", means improving the wellness of Central Oregonians through nationally accredited, affordable, horse -centered therapies and programs. Our goal is to be the standard of excellence in our industry by providing the highest quality experience to children, adolescents, adults and families who experience physical and cognitive disabilities and emotional and behavioral special needs through best practices. HRTRC began offering Adaptive Riding in 2000 and Hippotherapy (physical therapy on horseback — a nationally recognized treatment strategy for clients of all ages) in 2004. In 2009, HRTRC began offering Equine Assisted Mental Health and Learning services through equine - assisted counseling for veterans of war. This program has expanded since then to include individual and group clients referred by mental health providers and agencies such as: KIDS Center, Greater Oregon Behavioral Health, Deschutes County Health Services, Rimrock Trails Adolescent Treatment Center, New Leaf Academy, St. Charles Cancer Center and the Bend VA. HRTRC is able to utilize its resources to serve diverse vulnerable populations successfully. 3. Describe the leadership and structure of the organization. Healing Reins is fully staffed to provide all the necessary components for this initiative to be successful. Executive Director, Dita Keith, has been employed by HRTRC since 2007 and has been an active and involved Bend community member since 1992. With the assistance of Program Director, Polly Cohen, programs are designed and implemented based on careful analysis of community demand for services. Resources are managed such that the majority of finds raised are used to support direct services. HRTRC has four (4) full-time and four (4) part time employees for a total of 5.5 FTE and the organization enjoys a solid reputation in the community. With involvement and oversight of an eleven (1 1) member Board of Directors comprised of a diverse cross-section of our business community, Healing Reins is strategically forward-looking and extremely fiscally conservative. (See attached BOD list.) PROGRAM, PROJECT OR ACTIVITY 1. Provide a title of the proposed initiative for which funds are being requested. Funds are being requested for an Equine Assisted Psychotherapy for Drug & Alcohol Recovery Program. This initiative is a collaborative project between Healing Reins (HRTRC) and Best Care Treatment Services (BCTS). 2. Describe the goals and objectives of the proposed initiative. The goal of this initiative is to address substance abuse, a complex public health issue with wide-ranging repercussions that affects our community and communities nationwide. The objective of this initiative is to immediately enhance the success of Deschutes County's drug and alcohol treatment services through equine -assisted therapy, a unique and remarkably effective strategy. Due to the increasing number of cutbacks in insurance plans, residential treatment programs for drug and alcohol rehabilitation are no longer able to provide the length of stay necessary for long-term behavioral modification and individual wellness. This impacts not only the individual, but their families and other individuals and businesses in our community. Equine -assisted therapy has achieved results nationwide and is recognized as often quicker and more effective than the traditional modality of "talk therapy". For vulnerable teens and adults struggling to overcome addiction, hands-on mental health and learning with the horse as therapeutic partner is a direct, imrnersive way to achieve resilience and recovery. 3. Identify the target population which will be served. 7'he target population to be served by this initiative is residential and/or out-patient clients of BCTS, ages 18+ that are receiving treatment in Deschutes County and have lirnited or no financial resources for this therapy. 4. Identify the geographic area(s) of Deschutes County which will benefit. All of Deschutes County will benefit from the implementation of this initiative. "Substance abuse has a major impact on individuals, families, and communities. The effects of'substance abuse are cumulative, significantly contributing to costly social, physical, mental, and public health problems. These problems include: teenage pregnancy, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), other sexually transmitted diseases (STDs), domestic violence, child abuse, motor vehicle crashes, physical_,li'ghts, crime, homicide" - www.healthypeopk.gov/2010 5. Describe how the proposed initiative will positively impact the community and complement existing services currently provided by Deschutes County. HRTRC staff will join with BCTS in their mission to advocate and provide compassionate care in the treatment and prevention of addiction and mental illness. This project will enhance the treatments currently being offered by BCTS, thereby more effectively and immediately addressing the community's need for resources to combat growing substance abuse -related issues in Deschutes County. Horse - centered therapy is experiential in nature and allows clients to learn about themselves through personal, hands-on interactions and the resulting relationships with the animals. Clients learn about trust, responsibility, verbal and non-verbal cues and communication, and healthy self-concept and boundaries through their work with the horses on site at Healing Reins. Because the therapy model is animal - assisted, the environment is natural, wholesome and very conducive to authentic participation and ultimately to recovery. The sights, sounds, smells and positive elements of the arena/barn setting are the antithesis ofa typical session between a therapist and client in office. This is why residential treatment centers for addiction recovery such as Hazelden, Cirque Lodge, Touchstone Ranch, Sierra Tucson and others utilize equine therapy as part of their treatment plans. Equine -assisted therapy has been around for a long time. Ii was originally started as a therapy for people with physical disabilities and developmental disorders and has been successfidly used as part of the treatment for various psychological issues such as depression, anxiety, and eating disorders as well. People recovering from addiction have also been found to benefits from interactions with horses. This type of outdoor therapy experience combines the power of nature with the benefit offorming a relationship with an animal to help build confidence, trust; patience, and self-esteem. - www.addictionrecoveryguide.org "Equine -assisted therapy is especially beneficial for clients who tend to intellectualize. It assists patients in getting out of their heads and into their hearts and bodies. Intellectualizing is a major block 10 recovery for many individuals we see here. Being able to break through this is huge for many patients. Equine therapy helps patients get in touch with their emotions and feelings. Many patients have avoided feeling emotions, for so long that they don't know how to anymore. Through working with horses, feelings offear, anger, resentment, sadness, loneliness, joy and peace are brought to surface." - Lynn Moore, Acres for Life, an equine -based Twelve Step program: affiliated with Hazelden The community will benefit because public health problems and financial burdens related to substance abuse rates will be reduced as more people are served. Equine therapy is a holistic approach to helping clients learn and personally grow in the following areas: assertiveness, teamwork, empathy, confidence, independence, social responsibility and accountability, anxiety reduction, stress tolerance, impulse control, emotional awareness and regulation and problem -solving skills. People who struggle with drug and alcohol addiction experience significant feelings of inadequacy and diminished self-confidence. Equine -assisted therapy allows individual clients to develop relationship and a sense of personal responsibility. Clients working through addiction feel supported and needed by the horses as they work with them during their treatment. A sense of personal value helps addicts gain control over their addiction. And because horses are non judgmental and exist "in the moment", they are highly effective teachers, mirroring the attitudes and behaviors of the humans with whom they work. Building positive rapport translates to the client's ability to develop healthy coping/life skills — to substitute the negative behaviors affiliated with drug and/or alcohol abuse with positive tools that encourage re -learning and rebuilding relationships to live a sober, healthy life. Group process offers shared experience and support so that lessons learned in the arena will translate to home, school and work. Equine -assisted therapy helps individuals develop appropriate communication and social skills. Behavioral cues practiced with a therapy animal can be applied to other settings such as getting along with family, peers, colleagues and counselors. While the symptoms of addiction are well documented, each person brings different strengths, needs, abilities and preferences into the treatment setting. HRTRC and BCTS teams will work together to individualize the treatments to address personal barriers by recognizing and drawing upon strengths that can become motivators for sustained recovery so that clients can maintain sobriety and sustain a life in recovery. 6. Describe in detail how the proposed initiative will be implemented. Through a collaboration with Best Care Treatment Services, Healing Reins will duplicate the program we currently provide to Rimrock Trails Adolescent Treatment Center residents. Since 2011, HRTRC has been successfully partnering with Rimrock Trails to deliver equine -assisted therapy to their population of 14-18 year old teens in residence for substance abuse. Six -eight residents are brought to Healing Reins from their Prineville facility twice weekly. Together, Healing Reins and Rimrock Trails have successfully served 150+ adolescents through this therapeutic model. HRTRC has all the professionally certified staff, the curriculum, trained horses and skilled volunteers to carry out this initiative without adding additional resources. HRTRC will work with BCTS to finalize the details of service when the project is funded with a goal of offering four-week sessions for BCTS's clients beginning January 5, 2015. 7. Describe specifically how the requested funds will be used. This initiative consists of 40 total weeks of group therapy. Groups will be comprised of eight (8) clients, each of whom will be participate in equine therapy at HRTRC for four (4) consecutive weeks. BCTS's clients are generally in residential treatment for 30-45 days. BCTS's Program Director, Dennis Crowell, and counselors will refer clients and they estimate that 75-80% of their total clients will be eligible for equine -assisted therapy services. Clients not referred would consist of those not physically able to participate and/or those who have had significant trauma that would preclude their participation. BCTS also estimates that 80-85% of clients who participate in a four week session will make appreciable therapeutic progress by receiving these services. Participants will be able to enroll in additional four (4) week therapeutic sessions if deemed necessary as long as they remain in BCTS's out-patient program. Each weekly session will be comprised of ninety (90) direct contact minutes, which is consistent with the program in place with Rimrock Trails. HRTRC will provide two (2) certified staff facilitators and one (1) volunteer for each participant each week. All HRTRC staff and volunteers have received training and have experience working with substance abuse clients through equine -assisted programs. One HRTRC staff member is a counseling intern with trauma, PTSD and substance abuse experience. BCTS will provide two (2) staff members which will include a licensed professional counselor for all sessions plus a counseling intern. BCTS will contribute their staff time to this project. At the end of each weekly session, counselors from both entities will co -facilitate a process group. Process groups serve to enhance the learning and connect the work with the horses to life skills and behavioral changes for success in recovery. Funds requested will be used as scholarships to support the enrollment of referred client participants at HRTRC for one full year. Enrollment fees offset staffing and horse usage expenses. The cost for each week of therapy is $50/person/90-minute session/week. This program will provide therapy for 80 total clients annually. IIRTRC is respectfully requesting $11,000.00 from Deschutes County to be applied to the total project cost of $24,000.00. 8. Identify any partner agencies which will collaborate to implement the proposed initiative. This project is a collaboration between Healing Reins Therapeutic Riding Center and Best Care Treatment Services. 9. Describe other sources of funding that will support the proposed initiative. HRTRC fundraises actively throughout the year and receives individual and business donations, along with grants from various sources, to help support its programs. $4,000.00 in recent grant awards are restricted to equine -assisted mental health services and will be utilized in the treatment of BCTS clients at HRTRC. Healing Reins will contribute an additional $1,000.00 received via fundraising activities. Ongoing funding contracts with Pacific Source Community Solutions and other OHP funding sources will contribute staff time and transportation services to the overall project. HRTRC receives $44,800 in annual in-kind support which includes professional services, hay, feed, dental and farrier services, and other veterinary costs. HRTRC has 125+ weekly volunteers trained to assist in the operation of our facility and in programs which allows us to offer various services to the community at a fraction of the actual cost. Annual volunteer hour contributions total in excess of 7,000 hours. PERFORMANCE MEASUREMENT 1. Identify quantifiable outputs anticipated to be achieved through the proposed initiative (examples: number of persons served, programs or events held, animals rescued, acres restored or protected). The proposed initiative will give BCTS the ability to offer equine -assisted therapy as a complementary rehabilitative care strategy to approximately 60-80 BCTS clients to be served at HRTRC. The initiative will give HRTRC the ability to enhance its mission of service to the population categorized as "in treatment" and help expand its mental health service provider profile in the community. The initiative will utilize 60 program hours at HRTRC over 40 service weeks. The initiative will engage 60-80 community volunteers over the course of the project. 2. Describe the anticipated outcomes of the proposed initiative (examples: fewer persons institutionalized, greater knowledge and understanding of local history, fewer animals in shelter care, more natural areas available for wildlife and recreation). Evidence based research has proven that there are many benefits to the use of equine -assisted therapy to treat individuals with substance abuse issues, including but not limited to: reduced stress (the biggest single predictor of relapse), relapse rates reduced by up to 50%, increased sense of self-worth, behavior modification, increased coping skills, improved communication skills and lower crime rates. Additional outcomes include more comprehensive treatment options for clients without financial resources or insurance, enhanced programming capability for an already recognized county service provider, and fewer client interactions with DHS which can ultimately relieve county staff case loads. Healing Reins Therapeutic Riding Center Project Budget 2015 PROJECT SUMMARY Equine -Assisted Psychotherapy for Drug & Alcohol Recovery INCOME REQUIRED FUNDING SUPPORT / ALL SOURCES + STATUS STATUS First Story secured HRTRC fundraising earmarked for initiative secured Joseph M. Schenck Foundation secured BCTS staff+ travel - Pacific Source + OHP budget secured allocation TOTAL REQUEST of ALL SOURCES Expenses - Use of Funds Client Support Funding to support 8 clients/wk x 4 service wks. @ $50/client/wk. = $1,600/mo. Total # of clients/yr. = 80 Certified Instructor/counseling intern @ $20/hr x 60 contact hrs. Equine specialist staff@ $15/hr x 60 contact hrs. Equine useage @ $15/hr x 60 contact hrs. TOTAL REQUEST + USE OF FUNDS Requested Support $24,000.00 Requests made $2,000 $1,000 $2,000 $8,000 $24,000.00 16,000 $1,200.00 $900 900 Deschutes Cty 0.46% 11,000.00 11,000 $11,000.00 HRTRC BOARD OF DIRECTORS 2014 Robin Kenney, President 22380 McArdle Road, Bend, OR 97702 541- 326-7081 (cell) jnkenneybend@gmail.com Moe Carrick, Vice President Partner, Moementum, Inc. 3802 Summerfield, Bend, OR 97701 541-382-0778 (work) 541-408-6654 (cell) mcarrick(@moementum.com John Ogan, Secretary Partner, Karnopp Petersen 14419 Crossroads Loop, Sisters, OR 97759 541-382-3011 (work) Lwo@karnopp.com Kathie Gedde, Treasurer Partner, SGA 499 SW Upper Terrace (SGA CPAs), Bend, OR 97702 541-388-7888 (work) 541-388- 0739 (fax) kgedde@resultscpa.com Geoff Babb Fire Ecologist, Central Oregon Fire Mgmt. Service 20841 West View Dr., Bend, OR 97702 541-383-5521 (work) 541-408- 0424 (cell) babbfamily@bendbroadband.com Lee Legowik Brigadier General U.S. Army (Ret) 20973Miramar Dr., Bend, OR 97702 541- 388-6769 (home) leelegowik@gmail.com Gunnar Hansen Chief Operating Officer, GetG5 21950 Butte Ranch Rd., Bend, OR 97702 541-610-9042 (cell) 541-633-7568 (work) Gunnar.Hansen@getg5.com Barbara Newman, MD Medical Director, St. Charles OB/GYN Redmond 213 NW Larch Ave., Redmond, OR 97756 925-487-4367 (cell) 541-526- 6635 (work) jrsygrinw@aol.com Mindy Laidlaw, OTR -L Acute & Rehab Therapy Supervisor, St. Charles Health System 2500 NE Neff Road, Bend, OR 97701541-706- 5804 (work) mlaidlawc stcharleshealthsystem.org Keith Krueger, DMD Oral & Maxillofacial Surgeon 1192 NW Redfield Circle, Bend, OR 97701 541-617-3993 (work) 541-617-9855 (cell) jawzdr@aol.com Lori Slaughter Regional Philanthropy Advisor Excellence In Giving 5093 SW Quarry Ave. Redmond, OR 97756 (310) 926.3841 Islaughter@excellenceingiving.com ADVISORY BOARD (Past Members) Debbie Amerongen EVP & Chief Deposits Officer, BOTC 541-617-3572 (work) debbiea@botc.com Michel A. Boileau, MD Chief Clinical Officer, St. Charles Health System 541-382-4321 (work) michelboileau@gmail.com Pam Steinke Chief Nurse Executive, St. Charles Health System 541-760-5840 (work) psteinke@stcharleshealthcare.org Robin Tomb Independent Business Owner 415-852-8216 (cell) spurranchllc@gmail.com STAFF Dita Keith, Executive Director 60078 Edmonton Dr., Bend, OR 97702 541-382-9410 ext. 11 (work) 541-419-8709 (cell) ditak@healingreins.org Polly Cohen, Program Director 61870 Ward Road, Bend, OR 97701 541-382-9410 ext. 10 (work) 541-639-6835 (cell) pollyc@healingreins.org HREIN 03/07/2014 4:27 PM Form 990 Department of the Treasury Internal Revenue Service Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation) ► The organization may have to use a copy of this return to satisfy state reporting requirements. A For the 2012 calendar year, or tax year be> inninc 7/01 /12 , and ending 06/30/13 B Check if applicable: C Name of organization HEALING REINS THERAPEUTIC RIDING 1 l Address change CENTER, INC . 1 Warne change Initial return Terminated Amended return Application pending Doing Business As OMS s,iitai 201 Open to Public Inspection D Employer identification number Number and street (or P.O. box it mail is not delivered to street address) PO BOX 5593 Room/suite City, town or post office, state, and ZIP code BEND OR 97708 F Name and address of principal officer: SANE AS C ABOVE 1 Tax exernpl status: ;X1 501tc)(3( L 501(C) ( ) 1 (insert nn.) • wabauo ► WWW . HEALINGRE INS . ORG K Form of orgarazetien. Corporation I Trust 1 1 Association 1 1 Other Part! Summary Activities & Governance 0) w > cc m a) rn w 0- X w 4917(a)(1) or 527 93-1279550 E Telephone number 541-382-9410 G Crossrmewls5 301, 705 H(a) Is this a group return for affiliates? - I Yes XI No H(b) Are all affiliates included? I Yes I .1 No 11 "No," attach a list. (see instructions) II( cj Group exemption number ► L Year of formation 1 Briefly describe the organization's mission or most significant activities: SEE SCHEDULE 0 1 M Stale 01 legal danlicda OR 2 Check this box ►[ I if the organization discontinued its operations or disposed of more than 25% of its net assets. 3 Number of voting members of the governing body (Part VI, line 1 a) 3 4 Number of independent voting members of the governing body (Part VI, line 1 b) 1 4 5 Total number of individuals employed in calendar year 2012 (Part V, line 2a) 6 Total number of volunteers (estimate if necessary) 7a Total unrelated business revenue from Part VIII, column (C), line 12 b Net unrelated business taxable income from Form 990-T, line 34 7b 8 Contributions and grants (Part VIII, line 1 h) 9 Program service revenue (Part VIII, line 2g) 10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 12 Total revenue — add lines 8 through 11 (must equal Part VI 11, column (A), line 12) 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 14 Benefits paid to or for members (Part IX, column (A), line 4) 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 16aProfessional fundraising fees (Part IX, column (A), line 11e) b Total fundraising expenses (Part IX, column (D), line 25) ► 49,414 17 Other expenses (Part IX, column (A), lines 11a -11d, 11 f -24e) 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 19 Revenue less expenses. Subtract line 18 from line 12 Prior Year 5 6 7a 10 10 9 70 0 237,464 123, 433 2,469 33,889 397,255 11, 196 232, 652 0 Current Year 118, 453 117, 732 2, 885 25, 366 264,436 10, 786 0 240, 499 0 110, 883 354,731 criTs Y� 20 Total assets (Part X, line 16) 21 Total liabilities (Part X, line 26) 22 Nei assets or fund balances. Subtract line 21 from line 20 42,524 Beginning of Current Year 249, 315 97,314 348,599 —84, 163 End of Year 173, 381 24, 520 148'x, 861 25, 215 Part II Signature Black Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. 224,100 Sign Here Signature of ollicer DITA KEITH Type or print name and title Date EXECUT IVE DIRECTOR Paid Preparer Use Only Print/Type preparer's name CATHERINE M. GEDDE Preparers signature Date Check IXI if sell -employed PTIN P00362084 rirm'e name ( SGA CPAS & CONSULTANTS, LLP 499 SW UPPER TERRACE DR Firm's address ► BEND, OR 97702 Flrm'sEtN20-1592634 May the IRS discuss this return with the preparer shown above? (see instructions) For Paperwork Reduction Act Notice, see the separate instructions. DAA Phone no, 541-388-7888 IXC Yes No Form 0 (2012) HREIN 03/07/2014 4:27 PM Form990(2412) HEALING REINS THERAPEUTIC RIDING 93-1279550 Part 111 Statement of Program Service Accomplishments Check if Schedule 0 contains a response to any question in this Part 111 1 Briefly describe the organization's mission: SEE SCHEDULE 0 Page 2 2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990 -EZ? II Yes X! No If "Yes," describe these new services on Schedule O. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services? . Yes IXi No If "Yes," describe these changes on Schedule O. 4 Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported. 4a (Code: ) (Expenses $ 254,211 including grants of $ 1 t) , 7 8 6 ) (Revenue $ 117,732) PROVIDED OVER 200 DISABLED, EMOTIONALLY CHALLENGED OR BEHAVIORALLY AT—RISK CHILDREN AND DISABLED ADULTS RIDING EXPERIENCES DESIGNED TO ENHACE PHYSICAL FUNCTION, IMPROVE SELF ESTEEM AND REDUCE STRESS. 4b (Code: ) (Expenses $ including grants of $ ) (Revenue $ ) 4c (Code: ) (Expenses $ including grants of$ (Revenue $ ) 4d Other program services. (Describe in Schedule 0.) (Expenses $ . _., including grants of $ 4e Total program service expenses 1 254, 211 DAA Form 990 (2012) ) (revenue $ Applicant: Deschutes County Community Grant Program 2014-15 Application Review Rating Worksheet Children's Vision Foundation Category/Grant Amount: Title: Health, Mental Health, Addictions / $11,000 Classroom Visual Abilities Screenings Review Criteria: 1. Organization: • Stable and positive history of providing services in Deschutes County. • Experience delivering similar programs, projects, or activities as those proposed. • Mission and goals are consistent with proposed program, project, or activity. • Stable and experienced Board of Directors or other leadership group. • Adequate staff and/or volunteers to implement proposed program, project, or activity. Points awarded for this section (maximum of 25). 2. Financial Status: • Adequate financial resources available to conduct and sustain operations. • Broad and diverse base of funding sources. • Financial need for a Community Grant to implement proposed program, project, or activity. • Proposed budget is consistent with and appropriate for the fixed grant amount available in the selected Community Grant category. Points awarded for this section (maximum of 25). 3. Program, Project, or Activity: • Program, project, or activity does not address emergency food, clothing, or shelter. (These activities are supported by Deschutes County through a separate grant program in conjunction with United Way's Emergency Food and Shelter program.) • Request is consistent with the fixed dollar amounts indicated in the category/grant amount description at the top of this form. • Number of individuals to be served is appropriate to the budget and scale of proposed program, project or activity. • Serves vulnerable and/or underserved populations and/or communities. • Positively impacts welfare of the community. • Complements, but does not duplicate, existing Deschutes County services. • Implementation strategy is suitable to achieving the stated goals and objectives of proposed program, project, or activity. • Partnerships or collaboration with other agencies are included in implementation strategy. • Other sources of funds or in-kind support are available to supplement Community Grant funds. Points awarded for this section (maximum of 35). 4. Performance Management: • Stated outputs are relevant and reasonable to the scale of the proposed program, project, or activity. • Stated outcomes are relevant and reasonable to the scale of the proposed program, project, or activity. Points awarded for this section (maximum of 15). TOTAL NUMBER OF POINTS AWARDED: COMMENTS: NAME OF RATER: Deschutes County Fiscal Year 2014-15 Community Grant Application Submittal Instructions and Cover Sheet A complete application will consist of the following: 1. This cover sheet, signed and dated. 2. Narrative responses to the attached questions on no more than four single -sided, single-spaced pages. 3. Attachments: a. Proof of the organization's 501(c)(3) tax-exempt status in the form of a letter from the Internal Revenue Service (IRS). b. The first two pages of the organization's most recently submitted IRS 990 or 990 EZ form or, if the organization is not required to file either form with the IRS, a financial statement that provides equivalent information concerning activities and governance, revenue, expenses, and net assets or fund balances. c. An operating budget specific to the proposed operations, program, project, or activity. d. A roster of the organization's Board of Directors. Submit the complete application electronically to judithu@deschutes.org no later than 5:00 p.m. on October 24, 2014. Incomplete and/or late applications will not be reviewed or considered. Please complete the following: Contact Name: Julie Bibler Organization Name: Address: City: Children's Vision Foundation 61451 Rock Bluff Ln Bend Telephone Number: Email Address: State: OR Zip Code: [ 97702 541-330-3907 www.childrensvisionfoundation.org Application is being submitted to which Community Grant Program funding category*? deV Health, Mental Health, and Addictions Services Arts and Culture Other Essential Services: Includes services to youth; underserved, indigent, and/or vulnerable populations; animal welfare; or the environment. * Please refer to the funding guidelines for more information. Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 1 of 11 Certification: On behalf of the organization specified above, I certify the following: 1. All information included in this application is accurate. 2. I am authorized by the governing board to submit this grant application. 3. This organization is located in Deschutes County. 4. If awarded, Community Grant funds will be used in support of Deschutes County residents only. 5. This organization is in good standing with the U.S. Internal Revenue Service and is currently designated as a 501(c)(3) tax-exempt entity. Si gnature: Print Name: Julie Bibler Title: Executive Director Date: ID/' 5/1.?1 y Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 2 of 11 Organization 1. Describe the history of the organization, including the year the organization was established. Continuing the work began by the National Children's Vision Foundation, the Children's Vision Foundation (CVF) was established in 2005. Since 2001, nearly 50,000 children's seven -step vision screenings have been provided in more than 36 communities, primarily in Central and Eastern Oregon. National Research shows that: • 80% of a student's learning is done visually • 15-25% of our children have vision problems, many undetected. • 60% of children with learning difficulties and • at least 70% of our nation's juvenile delinquents have vision challenges. All students are screened at their school according to grade level, regardless of age, nationality, gender, specific ethnic group and economic factors. CVF's screenings provide important information regarding children's visual abilities at no cost to their school or families. This program benefits many families who have no insurance, are unemployed and/or cannot afford a professional vision exam. 2. State the organization's mission, goals, and programs or services provided. The mission of the Children's Vision Foundation is to identify children who have potential visual barriers to learning, to encourage families and schools to seek professional eye care for identified children, and to raise awareness about the importance of early detection of vision problems. CVF project goals include- • Conducting screenings that includes an in-depth assessment of children's visual abilities • Providing families and school staff with information that will facilitate appropriate vision care referrals • Educating communities about learning related vision problems. CVF provides this essential service to thousands of children, including underserved and indigent populations, with specific results given to children's families, schools and teachers. CVF Uses an evidence -based, modified, national screening battery designed to identify all the classroom vision skills students need. Specific results from Deschutes County screenings and other counties have provided a profile supporting the importance of and need for these screenings. For example, during the 2013-14 school year, 2,483 2nd and 4t grade Deschutes County children were screened. 523 (21%) of those students were identified with potential vision problems. 3. Describe the leadership and structure of the organization. CVF's Director, Julie Bibler, has over 16 years of vision screening experience and has more than 24 years of state and Deschutes County community involvement and leadership. In addition, CVF has a part time program assistant/volunteer coordinator. CVF is governed by an experienced, committed board of directors (Attachment D). In Deschutes County, we also have a dedicated group of trained community volunteers who are essential to the success of our program. These community volunteers include retired nurses, educators, and administrators. Program, Project, or Activity 1. Provide a title of the proposed initiative for which funds are being requested. "Classroom Visual Abilities Screenings" 2. Describe the goals and objectives of the proposed initiative. CVF plans to vision screen more than 3,000 children in Deschutes County. These screenings will be done in more than 18 primarily elementary schools. CVF will provide three sets of reports including- • School reports will be done for every school, listing each student identified with their potential vision problem. • Individual student reports will be created for every student identified in one or more areas of the screening. An individual student report (in either English or Spanish) will be sent to the students' families so that they can pursue follow up professional care. • Teachers will also receive a list of students in their classes who were identified with potential vision problems. This three point communication system has proven to be very effective. In addition to school screenings, CVF will provide vision training and screenings to COCC first year college nursing students. Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 3 of 11 3. Identify the target population which will be served. Primarily elementary school students, at risk Oregon Youth Challenge Program (OYCP) High School and COCC nursing students will be served in Deschutes County. 4. Identify the geographic area(s) of Deschutes County which will benefit. Students in Bend, La Pine, and Sunriver schools, at risk OYCP high school students and COCC nursing students throughout Deschutes County will benefit from our vision screenings. 5. Describe how the proposed initiative will positively impact the community and complement existing services currently provided by Deschutes County. CVF's program complements existing school and community services and programs including school district nurses, school administrators, teachers, Supported Education, English Language Learner Program, FAN advocates, COCC nursing department, eye care professionals and Deschutes County Health Services. Bend La Pine Lead School Nurse, Marylou Patterson writes: "The Children's Vision Foundation has provided an exceptionally valuable service to the students of Bend La Pine schools. In cooperation with the school nurses we are able to make vouchers available to pay for eye exams and glasses for children who require further care. As so much of education is visually based, the ability to pick up vision problems at an early age is essential to a successful school experience. The screenings provided by the Children's Vision Foundation have become an integral part of the services provided in our school district..." Furthermore, CVF was honored in March, 2008 to receive recognition as the Public Health Hero by Deschutes County Public Health Advisory Board here in Central Oregon. The acknowledgment is: "In grateful recognition of your unwavering commitment, exceptional service and leadership in promoting and protecting the health and vision of school children. Thanks to your efforts in assuring good vision for children they will lead healthier, more productive lives. You are indeed Public Health Heroes!" 6. Describe in detail how the proposed initiative will be implemented. CVF's Deschutes County screening project will be implemented for the 2014-2015 school year, beginning in August and continuing throughout the school year. School screenings will take place at 18 schools in Bend, Sunriver, La Pine and include approximately 3,000 students from throughout Deschutes County. For each screening, a team of trained volunteers led by CVF's director and volunteer coordinator will screen students using CVF's seven -step screening process. Following the screening, CVF's leaders will deliver individual student's reports, class reports and school reports. Screenings will be completed and follow-up data will be collected by June 2015. 7. Describe specifically how the requested funds will be used. Our request of $11,000 from the 2014-15, Deschutes County Community Grant will fund: • Staff time for scheduling, training of school and community volunteers, and coordinating each school screening; • Cost and staff time for procuring vision screening materials; • Help fund a one-time expense for "Spot Screener" equipment; • Staff time for scheduling schools and communicating with families, nurses, and school administrators; • Staff time for providing students' families, teachers and schools reports; • Cost of marketing and information materials; • Cost and staff time for providing volunteer lunches, transportation, and other screening needs. CVF operates an efficient budget by utilizing a group of experienced volunteers, and averages a $10 cost per student per screening here in Deschutes County. Our paid staff includes our executive/program director and one part-time program assistant/ volunteer coordinator. With a new investment and use of "Spot Screener" equipment technology, we will reduce screening time in half, and eliminate false positive referrals, especially for younger age students (see at: www.voutube.com/watch?v=m2TfRnfNfWE). 8. Identify any partner agencies which will collaborate to implement the proposed initiative. Collaborative partners include Bend -La Pine School District, individual school staffs, school district nurses, Family Access Network (FAN) advocates, the COCC Nursing Department, Oregon Youth Challenge Program, PTA's and PTOs. CVF collaborates with these partner agencies to set up the screening schedules, recruit and coordinate volunteers, communicate student results, and provide specific information. School and community volunteers receive on-site training by CVF to administer a particular part of the screening. These volunteers have been essential to the vision screening Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 4 of 11 program and have contributed to the sustainability of CVF through community "networking". More than 1,747.75 hours were contributed by parents, community leaders and volunteers during the 2013-2014 school year alone! Bend -La Pine School District has committed student access, parent permission, and staff support through a Memorandum of Understanding. In a letter by superintendent Ron Wilkinson, he states: "Our staff has a strong belief that the vision screening program is benefitting many children in our schools and community. I encourage your support to help the Children's Vision Foundation so that it may continue the vision screening program..." Family Access Network (FAN) advocates have requested that CVF screen students prior to using FAN community group scholarships and donations for professional care. FAN advocate, Robert Currie commented: "As a family advocate charged with connecting families to resources they need, I know that a child referred by the CVF has demonstrated significant vision problems, the kind that require a professional exam and glasses. This allows me to use efficiently and effectively the limited community resources available." In addition, we provide FAN advocates with student reports, which they use to help children who are struggling to learn. With this resource advocates are able to offer support for needed professional treatment for children identified with vision challenges. COCC's Associate Professor of Nursing, Kiri Simning, provides the following comment: "We in our COCC nursing program, feel that health promotion is an integral thread to the nursing curriculum. We cannot truly prepare the next generation of nurses without helping them to understand the importance of health promotion in children..." Since 2009, CVF has been educating nursing students on the importance of children's vision and learning. CVF provides an interactive presentation, followed by students rotating through each screen station, learning that station's tools and methods, and screening each other. Students with vision problems have been identified in the process, and have also chose to volunteer in nearby school screenings. CVF stresses to nursing students how they can use this experience in their nursing careers including hospitals, medical offices, schools, and in their personal lives. 9. Describe other sources of funding that will support the proposed initiative. CVF's proposed initiative has received partial support from several sources: Funding that has been received or secured include: Oregon Community Foundation Trust Management Services The Ford Family Foundation Other pending or planned support requests include: $10,000 $ 9,000 $ 5,000 $24,000 received to date for this project RBC Wealth Management Foundation $5,000 Shopko Foundation $1,000 Private business and individual donations- $3,000 Performance Measurement 1. Identify quantifiable outputs anticipated to be achieved through the proposed initiative (examples: number of persons served, programs or events held, animals rescued, acres restored or protected). CVF anticipates screening roughly 3,000 students in Deschutes County, identifying approximately 20% or 600 student's with potential vision problems. CVF will provide screenings at 18 Deschutes County schools, Oregon Youth Challenge Program high school students and first year COCC nursing students will be screened. Identified students families will receive an informational packet including their student results and information, recommending them for a professional eye exam. The following statistics are a summary of the results of thirteen years of vision screenings performed on second and fourth graders throughout the Bend -La Pine School District. These figures contain nearly the entire population of second and fourth grade students, including those with major medical and vision problems and students with learning disabilities. Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 5 of 11 Bend -La Pine School District School Year # Schools Tested 2nd Grade 4th Grade School Totals S R % S R % S R %_ 2001-2 13 927 195 21.0% 1006 177 17.6% 1933 372 19.2% 2002-3 14 982 220 22.4% 992 186 18.8% 1974 406 20.6% 2003-4 14 1025 218 21.3% 1019 133 13.1% 2044 351 17.2% 2004-5 15 1071 229 21.4% _ 1121 163 14.5% 2192 392 17.9% 2005-6 15 1081 219 20.3% 1117 194 17.4% 2198 413 18.8% 2006-7 15 1151 254 22.1% 1196 194 16.2% 2347 448 19.1% 2007-8 15 1194 261 21.9% 1208 158 13.1% 2402 419 17.4% 2008-9 16 1179 238 20.2% 1217 173 14.2% 2396 411 17.2% 2009-10 12 841 156 18.5% 852 145 17.0% 1693 301 17.8% 2010-11 16 1096 249 22.7% 1063 177 16.7% 2159 426 19.7% 2011-12 15 1068 236 22.1% 1013 157 15.5% 2081 393 18.9% 2012-13 17 1203 263 21.9% 1248 220 17.6% 2451 483 19.7% 2013-14 17 1258 315 25.0% 1225 208 16.9% 2483 523 21.0% Total 194 14,076 3,053 21.6% 14,277 2,285 16.0% 28,353 5,338 18.8% R = Number of students identified with potential vision problems S = Number of students screened = Percent of students with problems to the total students Results Summary The thirteen -year collection of data on students within the Bend -La Pine School District reflects two important facts: First, there is a need for comprehensive vision screenings for second and fourth grade students: approximately 21 percent of second grade students were referred to professionals each year, and 13 -18 percent of all fourth grade students were referred each year. Second, the vision -screening program has been effective: there is a reduction in the percentage of referrals in each two-year cycle of students from the second to the fourth grades. 2. Describe the anticipated outcomes of the proposed initiative (examples: fewer persons institutionalized, greater knowledge and understanding of local history, fewer animals in shelter care, more natural areas available for wildlife and recreation). Identifying students with vision challenges can dramatically improve both a child's education and long-term life success. Studies show that children with vision challenges frequently become withdrawn and/or have discipline problems. We increase awareness of the variety of vision challenges and identify a correctable reason why some of the students are struggling in school. An anticipated outcome from this project is that CVF will identify more than 600 students with potential vision problems, providing parents and educators with student -specific information to increase school success. In collaboration with FAN Coordinators and school nurses, more children will able to receive professional vision care to correct vision problems. Our success has, and will be reflected in the success of Deschutes County's schools and communities, as seen in annual Bend -La Pine School District district -wide report cards, Wellness and Education of Central Oregon reports, and Central Oregon Health Council community benchmarks. CVF will continue to measure this program's outcome performance in numerous ways including: • Identifying students with vision problems. • Decreased percentages of students identified with continuing vision problems in 4th versus 2nd grades. • Post survey anecdotal comments from teachers, parents and students about results of our work. This project has made and will continue to make a significant improvement in many Deschutes County children's lives! Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 6 of 11 CVF Bend- La Pine Schools Protect Budget (1) July 1 2014 to June 30 2015 Attachment C Income Contributed Support Individual/business contribution 1,300.00 Deschutes County Community Grant 11,000.00 Nonprofit organization grants 24,000.00 Subtotal 36,300.00 Earned Revenues Fundraisers 2,000.00 Program service fees 200.00 Subtotal 2,200.00 TOTAL INCOME 38,500.00 Expense Salaries & Related expenses Assistants wages paid 3,800.00 Directors salary 15,850.00 Payroll taxes 2,500.00 Subtotal 22,150.00 Insurance Expenses Directors & Officers Insurance 50.00 Work Comp Expense 125.00 Subtotal 175.00 Business expenses Organizational (corp) 50.00 Taxes - other 25.00 Subtotal 75.00 Program Expenses Postage, shipping, copying, delivery 150.00 Screening supplies 250.00 Spot Screen Equipment (2) 8,500.00 Telephone & telecommunications 700.00 Subtotal 9,600.00 Occupancy Expenses Rent 1,900.00 Subtotal 1,900.00 Professional Fees Accounting fees 300.00 Professional fees 300.00 Subtotal 600.00 Misc Expenses Office/fundraiser supplies 200.00 Subtotal 200.00 Travel & Meetings Expenses Conf, Conv., & Meeting 200.00 Mileage 2,750.00 Lodging and Meals 50.00 Subtotal 3,000.00 Volunteer Support Expenses Food & Beverage 800.00 Subtotal 800.00 TOTAL EXPENSE (3) 38,500.00 (1) Average cost per student formula = $10 X 3,000 students to be served = $30,000 base budget (2) One-time expense = $8,500 "Spot Screener" equipment (3) In -Kind Match: 1,747.75 volunteer screening hours X $21 per hour value = $36,702.75 Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 10 of 11 Children's Vision Foundation Board of Directors October 2014 Mickey Lumetta- President, outgoing Retired optician, 35 years experience in vision care 3038 NW Kenwood Court- Bend, Oregon 97701 (541) 550-7483 (mckyzinbendbroadband.com) Suzie Abbott- Treasurer HR management, advanced computer/accounting skills 18700 River Woods Drive- Bend Oregon, 97702 (541) 388-3807 (heyabbottcentury Iink.net) Debby Golonka, MPH- Secretary, outgoing Medical content specialist for Healthwise 206 S. 8th Ave- Yakima WA 98902 (503) 780-3634 (2debzemail c( gmail.com) Kathy Blake -member/ past CVF board chair Retired Librarian and CVF assistant 61521 Sunny Breeze Lane- Bend, Oregon, 97702 (541) 382-7375 (kblake(a�bendbroadband.com) Theresa Mayer- member Bank of the Cascades Vice President/bank manager- Redmond 154 SW. 6th Street- Redmond, Oregon 97756 (541) 617-3627 (tmayer(a�botc.com) Dave Deeks- member Retired teacher, Bend-LaPine School District, tutors students 61225 Mt. Vista Dr- Bend Oregon 97701 (541) 382-4929 (judadeeks(a,gmail.com) Robert Currie- member, incoming secretary English Language Learning teacher, Family Access Network (FAN) advocate 71 SE Myrtlewood St- Bend, Oregon 97702 (541) 388-1129(logancurriebendbroadband.com) Cindy Harvey- member, incoming president Retired School Administrator and teacher, Chance to Grow teacher trainer 64103 Tumalo Rim Dr- Bend Oregon 97701 (541) 921-2124 (charvey111@gmail.com) Attachment D All of these board members volunteer or have volunteered at school and/or community screenings. Several help or have helped write grants. All members have helped with fundraising. In addition, CVF has an advisory board. Several are past members of the board and/or provide professional advice or information. Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 11 of 11 Form 990—EZ Department of the Treasury Infernal Revenue Service Attachment B Short Form Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except privatefoundations) • Do not enter Social Security numbers on this form as it may be made public. ► Information about Form 990 -EZ and its instructions is at www.lrs.gov/form990. OMB No 1545-1150 2013 Open to Public Inspection A For the 2013 calendar year, or tax year beginning 7/01 , 2013, and ending 6/ 30 r 2014 Check d applicable: r C Address change Name change CHILDRENS VISION FOUNDATION Initial return 61451 ROCK BLUFF LANE Terminated BEND, OR 97702-2000 Amended return Application pending D Employer identification number 20-3161992 E Ta phone number 591-330-3907 F Group Exemption Number G Accounting Method: ® Cash U Accrual Other (specify) I Website: • N/A J Tax-exempt status (check only one) — ® 501(cX3) ® 501(c) ( ) (insert no.) ❑ 4947(aX1) or 527 K Form of organization: Corporation Trust [ Association fl Other H Check ► El if the organization is not requi ed to attach Schedule B (Form 990, 990 -EZ, or 990 -PF)„ Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part 11, column (B) below) are $500,000 or more, file Form 990 instead of Form 990 -EZ ► $ 105 023 Part 1 'Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part 1) Check if the organization used Schedule 0 to respond to any question in this Part I 1 Contributions, gifts, grants, and similar amounts received ...... 2 Program service revenue including government fees and contracts 3 Membership dues and assessments .... 4 Investment income. .. . R E N u E 5 a Gross amount from sale of assets other than inventory 5a b Less: cost or other basis and sales expenses .. - 5 b c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) 6 Gaming and fundraising events a Gross income from gaming (attach Schedule G if greater than $15,000) .. , . I 6 al b Gross income from fundraising events (not including $ of contributions From fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceeds $15,000) .. . . ... ..... I 6b c Less: direct expenses from gaming and fundraising events . . f 6c d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c)... . .... ..... . 7 a Gross sales of inventory, less returns and allowances . b Less: cost of goods sold. c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a). 8 Other revenue (describe in Schedule 0) . . 9 Total revenue. Add lines 1. 2, 3, 4, 5c, 6d, 7c, and 8 E x P E N S E s A NS ES TT s BAA 7a1 7b 1 2 1511 103,637. 650. 3 4 5c 736. 29. 6d 707. 7c 8 9 104,994. 10 Grants and similar amounts paid (list in Schedule 0). 11 Benefits paid to or for members 12 Salaries, other compensation, and employee benefits . 13 Professional fees and other payments to independent contractors 14 Occupancy, rent, utilities, and maintenance 15 Printing, publications, postage, and shipping 16 Other expenses (describe in Schedule 0) See Schedule 0 17 Total expenses. Add lines 10 through 16 .... ' 18 Excess or (deficit) for the year (Subtract line 17 from line 9) 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end -of -year figure reported on prior year's return) . - . - .... . 20 Other changes in net assets or fund balances (explain in Schedule 0) 21 Net assets or fund balances at end of year. Combine lines 18 through 20 ..... " For Paperwork Reduction Act Notice, see the separate Instructions. TEEA0803L 11/27/13 10 11 12 13 14 38,412. 692. 2,400. 15 16 17 18 106. 93,239. 84,849. 20, 145. 19 9,349. 20 21 29,494. Form 990 -EZ (2013) Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 8 of 11 1 1 r 1 1 1 1 1 1 u 1 1 1 1 1 1 1 1 1 Four -19%42 (2013) CHILDRENS VISION FOUNDATION 20-3161992 Page 2 Part Balance Sheets (see the instructions for Part II) Check If the organization used Schedule 0 to respond to any question in this Part I 01) (A) beginning of yea1 End of year 22 Cash, savings, and investments ...... 23 Land and buildings.... .......,., . .. 24 Other assets (describe in Schedule 0)... ............... ..... 25 Total assets. 26 Total liabilities (describe in Schedule O) .. . See _ScheduleP .., 27 Net assets or fund balances (line 27 of column (R) must agree with line 21)... .... 11 Part 111 1 SCreek 16nt of Progra1 the organ zationervice ed Sch edule f hedule0 ognts (see the re pond to any Quesltion ins nfths Part 111 what is the ergamralion's primary rcempt purpose' See Schedule U Describe the organization's program service accomplishments 101 each of Its three largest program services, as measured by glees el. In al cleinfoar and dion concise acs manner, dm escribe the services provided, the number of persons TRT -SERVED STUDENTS FROM SCHOOLS AROUND THE STATE OF OREGON, IDENTIFYING WITILPOTENTIAL VISION PROBLEMS. 10, 399. 22 32, 643. 23 24 10,399. 25 2643- 1,050. 9,349 (Grants , '5 If This amount includes foreign grants, check here 26 3,149 27 29,494 Expenses (Required for section 501 ()(3) and 501(c)(4) organizations and section 4947(a)(t) trusts; optional for others.) 28 a 67,459. (Grants ) If this amount includes foreign grants, check here (Grants • 'TT 294 ) If this amount includes foreign grants, check here. 31 Other program serlmes (describe in Schedule 0) (Grants $ ) If this amount includes foreign grants, check here, 32 Total prograrvIce expenses (add lines 283 through 3la).. ' 32 67,459. [Part IV j List of Officers, Directors, Trustees, and Key Employees(fnf each one even if not compensated — see the estrudlions for Pad IV) LJ i1 the organization used Schedule 0 to respond la ally question in this Part IV 3 El 31 a (a) Name and Title MICKEY LUMETTA President DAVID MCKAY Director JUNE SCHEROCMAN Director DOROTHY WRIGHT Secretary MARYLOU PATTERSON RN Director KATHY BLAKE Director JULIE BIBLER Executive Direc. SUZIE ABBOTT Treasurer (b) Average hours per week devoted 10 pospbon 1 1 1 1 1 1 20 1 (c) Reportable compensation (Forms nal P d, ) anter -0-) 0. 0. 0. 0. 0. 0. o. 0. Id) 1-440 benems, Konbobot ] ie empipyee haneld plans, and dale rtlM BWnperridhon 0. 0. 0. 0. 0. 0. o. 0. (a) Estimated amount of other compensation 0. 0. 0. 0.. 0. 0. 0. 0. BAA 1rEA091& 1112)113 Form 990.EZ (2013) Children's Vision Foundation -Deschutes Community Proposal 2014-15 Page 9 of 11