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DocuSign Envelope ID: 1640431D- 872F- 4BC9- ACA1- 2226D9788920 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br />CLAUSE <br />Are any of the Board Members or employees of the agency which will be carrying out this program or <br />members of their immediate families, or their business associates... <br />YES NO <br />® ❑ a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br />Chapel Hill, or Orange County? <br />® ❑ b) Members of or closely related to members of the governing bodies of the Town of Carrboro, <br />the Town of Chapel Hill, or Orange County? <br />❑ ❑ c) Current beneficiaries of the program for which funds are being requested? <br />❑ ❑ d) Paid providers of goods or services to the program or having other financial interest in <br />the program? <br />If you have answered YES to any question, please provide a full explanation below. <br />Orange County Commissioner Mia Burroughs is a board member, appointed by the County <br />Commissioners to the OCPYC Board of Directors; Board member designee Coby Austin is <br />an employee of the Orange County Health Department; Board member Lucinda Munger <br />leads the Orange County Library; Todd Wirt, superintendant of Orange County Schools, and <br />Kerry Moore, director of CHCCS Head Start and Pre -K, serve on the board; Emily Bivins is <br />an employee of the CHCCS. <br />NON - DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the <br />parties hereto for themselves, their agents, officials, employees and servants agree not to <br />discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, <br />religion, sexual orientation, gender identity /expression, familial status or veterans status with <br />reference to any activities carried out by the grantee, no matter how remote. The parties hereto <br />further agree in all respects to conform to the provision and intent of Orange County Civil Rights <br />Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is <br />enforced by action for specific performance, injunctive relief, or other remedy as by law <br />provided; this provision shall be binding on the grantees, the successors and assigns of the <br />parties hereto with reference to the above subject manner. <br />AGENCY INFORMATION 1/22/2018 6:18:22 PM . age 5 of 22 <br />