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Certified by:________________________ Title: ____________________ Date: ____________ <br /> (Provider’s Electronic Signature) <br />**You will sign this document electronically with your performance agreement. <br />EXHIBIT “B” <br />Scope of Services – FY 2020-21 <br />Outside Agency Performance Agreement <br />Agency Name: <br />Program Name: <br />Funding Award: <br />Outline how the agency will spend Orange County’s funding award. <br />Program Services <br />Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2021. <br />x <br />x <br />x <br />Anticipated Outcomes <br />The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange <br />County, only (all Towns and municipalities). <br />If you use percentages, you must also provide the total number of participants within that measure’s description or for an <br />earlier performance measure. <br />Performance Measures Anticipated <br />Results <br />Expense Description Amount <br />Supplies $ 700 <br />Grief Activities $ 134 <br />Salary $ 300 <br />We will waive the registration fee of $35 for any family requesting the waiver. <br />100% of <br />requests <br />made <br />Participants will report a positive experience from their participation in <br />camp. <br />95% <br />Camper surveys are completed prior to the conclusion of camp. 95% <br />Duke Homecare & Hospice <br />Camp ReLEAF <br />$1,134 <br />Activities designed to assist in the development of grief coping skills <br />interactive activities designed to enhance the connection to the deceased <br />Opportunities to learn about grief process and learn from peers. <br />DocuSign Envelope ID: B433F56A-34C6-4EFE-BD1E-7683C2CA0514 <br />7/1/2021