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HomeMy WebLinkAboutMINUTES - 01051993 - 1.67 1 . 67 TO: BOARD OF SUPERVISORS FROM: Mark Finucane, Health Services Director .� I Contra By: Elizabeth A. Spooner, Contracts AdministratCnsla DATE: December 15, 1992 County SUBJECT: Approval of Unpaid Student Training Agreement #22-153-3 with San Francisco State University SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION I. RECOMMENDED ACTION: Approve and authorize the Chair to execute on behalf of the County, Unpaid Student Training Agreement #22-153-3 with San Francisco State University for the period July 1, 1992 through June 30, 1995 for field experience for public health nursing students. II. FINANCIAL IMPACT: None. III. REASONS FOR RECOMMENDATIONS/BACKGROUND: The purpose of this agreement is to provide San Francisco State University nursing students with the opportunity to integrate academic knowledge with application skills and attitudes at progres- sively higher levels of performance requirements and responsibility. Supervised field work experience is considered an integral part of both the educational and professional preparation. The Department can provide the requisite field education, while at the same time, taking advantage of the students' services to clients. On July 21, 1987, your Board approved Unpaid Student Training Agreement #22-153-2 with San Francisco State University for the period July 1, 1987 through June 30, 1992, in order to provide field instruction in public health nursing. Contract #22-153-3 continues this service through June 30, 1995. The Chair should sign four copies of the agreement, three of which should be returned to the Contracts and Grants Unit for delivery to the San Francisco State University. CONTINUED ON ATTACHMENT: YES SIGNATURE: ! / RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMEN ATI N OF BOARD C MMITTEE APPROVE OTHER SIGNATURE(S) ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A TRUE AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD Contact: Wendel Brunner, M.D. (313-6712) OF SUPERVISORS ON THE DATE SHOWN. CC: Health Services (Contracts) ATTESTEDl-, 3 Risk Management Phil helot,Clerk the Board of Auditor-Controller Supervisors and County Administrator Contractor M382/7-e9 BY , DEPUTY Contia ,costa county $ 1 Standard . 67 form UNPAID STUDENT TRAINING AGREEMENT 1. Contract Identification. Number 22-153-3 County Department: Health Services (Public Health Division) subject: unpaid student training with Department, sponsored by Contractor 2. Parties. The County of Contra Costa, California (County) , for its Department named above, and the following named Contractor mutually agree and promise as follows: Contractor: SAN FRANCISCO STATE UNIVERSITY Capacity: State Educational Institution Address: 1600 Holloway Avenue, San Francisco, California 94132 3. Term. The effective date of this Agreement is July 1. 1992 and it terminates June 30, 1995, unless sooner terminated as provided herein. 4. Termination. This Agreement may be terminated by either party, at its sole discretion, upon seven-day advance written notice thereof to the other, or canceled immediately by written mutual consent, subject to termination conditions (if any) set forth in the Program Plan attached hereto and incorporated herein by reference. 5. Program. By this Agreement County agrees to permit unpaid student training by persons (participants) sponsored by Contractor under the conditions set forth in Paragraph 1. of the Proaram Plan, attached hereto and incorporated herein by reference. 6. Independent Contractor Status. This Agreement is by and between two independent contractors and is not intended to and shall not be construed to create the relationship of agent, servant, employee, partnership, joint venture, or association. 7. Indemnification. Except for those activities of participants covered by the County's Volunteer policy, each party and its employees, agents and officers shall be indemnified and held harmless against any and all claims, demands, or causes of action allegedly arising out of any act or omission arising as a result of the services provided in this agreement, of any officer, agent, or employee of the other party, or resulting from the conditions of any property owned or controlled by the other party. 8. Legal Authority. This Agreement is entered into under and subject to the following legal authority: California Government Code Sec. 26227. 9. Signatures. These signatures attest the parties' agreement hereto: COUNTY OF CONTRA COSTA. CALIFORNIA CONTRACTOR By Designee Reoo=ft�p a t t 0-te— _Lt4me -bapacity) (Designate official By JDesignee (Form approved by County Counsel) 1 e 6 I Contra Costa County Standard Form UNPAID STUDENT TRAINING AGREEMENT 1. Contract Identification. Number. 22-153-3 County Department: Health Services (Public Health Division) Subject: Unpaid student training with Department, sponsored by Contractor 2 . Parties. The County of Contra Costa, California (County) , for its Department named above, and the following named Contractor mutually agree and promise as follows: Contractor: SAN FRANCISCO STATE UNIVERSITY Capacity: State Educational Institution Address: 1600 Holloway Avenue, San Francisco, California 94132 3 . Term. The effective date of this Agreement is July 1, 1992 and it terminates June 30, 1995, unless sooner terminated as provided herein. 4 . Termination. This Agreement may be terminated by either party, at its sole discretion, upon seven-day advance written notice thereof to the other, or canceled immediately by written mutual consent, subject to termination conditions (if any) set forth in the Program Plan attached hereto and incorporated herein by reference. 5. Program. By this Agreement County agrees to permit unpaid student training by persons (participants) sponsored by Contractor under the conditions set forth in Paragraph 1. of the Program Plan, attached hereto and incorporated herein by reference. 6. Independent Contractor Status. This Agreement is by and between two independent contractors and is not intended to and shall not be construed to create the relationship of agent, servant, employee, partnership, joint venture, or association. 7. Indemnification. Except for those activities of participants covered by the County's Volunteer policy, each party and its employees, agents and officers shall be indemnified and held harmless against any and all claims, demands, or causes of action allegedly arising out of any act or omission arising as a result of the services provided in this agreement, of any officer, agent, or employee of the other party, or resulting from the conditions of any property owned or controlled by the other party. 8. Legal Authority. This Agreement is entered into under and subject to the following legal authority: California Government Code Sec. 26227. 9. Signatures. These signatures attest the parties' agreement hereto: COUNTY OF CONTRA COSTA, CALIFORNIA CONTRACTOR (J () By By 00-IVX Designee D Recomm d by D partment 1. ,re�c-i`� t"1�h.� Lr (Designate official apacity) P By Designee (Form approved by County Counsel) Contra Costa County Standard Form UNPAID STUDENT TRAINING PARTICIPANT AGREEMENT The County of Contra Costa and the Participant named below agree as follows: 1. Participant will engage in training for a Contra Costa County Department pursuant to a contract between the County and a contractor sponsoring the participant. 2. Participant agrees that in connection with such training, participant is a volunteer, subject to the County's volunteer policy and regulations, and will obtain no employment rights or employment benefits from the County and waives any claim to any employment rights or benefits from Contra Costa County based upon participant's training services, whether or not authorized under such contract. 3. Participant further agrees: "I have read the Resolution adopted by the Contra Costa County Board of Supervisors on volunteer programs. In return for the benefits provided by Contra. Costa County in case of my illness, injury, death, or third party liability while providing, or resulting from acts or occurrences within the scope of my authorized volunteer services, and for my right to authorized expense reimbursement, i waive any claim on my behalf and on behalf of my heirs, representatives, and assigns against the County of Contra Costa or any of its agents, servants or employees for illness, injury, debts or other harm arising from my volunteer services, whether or not authorized. " 4. Participant has read and understands the Unpaid Student Training Agreement (identified below) between the County and participant's sponsoring contractor and agrees to and is bound by the terms of that contract. 5. County or participant may terminate this agreement upon three day's notice or without prior notice, for cause; or by mutual consent; otherwise this agreement terminates upon termination of the agreement between the County and participant's sponsoring contractor. 6. This agreement is made in consideration of the County accepting participant for training. 7. Neither the County nor any agent, officer, servant, or employee of the County shall undertake or incur any liability or other responsibility respecting the quantity, quality, kind, or value of the training of participant and no warranty, express or implied shall exist in that regard. 8. Entire Contract. This Agreement contains all the terms and conditions agreed upon by the parties. Except as expressly provided herein, no other understandings, oral or otherwise, regarding the subject matter of this Agreement shall be deemed to exist or to bind any of the parties hereto. 9. Identification of Unpaid Student Training Agreement: Number 22-153-3 Contractor SAN FRANCISCO STATE UNIVERSITY County Department HEALTH SERVICES - PUBLIC HEALTH DIVISION CONTRA COSTA COUNTY PARTICIPANT (Printed Name) By (Designee) (Signature) PROGRAM PLAN FOR FIELD INSTRUCTION IN PUBLIC HEALTH NURSING Number 22-153-3 1. Purpose of the Program. San Francisco State University, San Francisco, California, conducts an educational program in public health nursing for its students. The University desires to have students, enrolled in this program, receive clinical instruction from the County, and the County is willing to provide such instruction under the terms and conditions hereinafter set forth. Therefore, the parties will undertake a program whereby such instruction and experience will be provided in accordance with a plan mutually agreed to by the parties. 2 . University' s Obligations. In participating in this program, Contractor shall: a. Designate students for participation in the clinical experience conducted pursuant to this Agreement. b. Suggest dates for the clinical experience periods, and cooperate with County's Department in establishing assignment schedules consisting of specific dates for the placement of a specific number of students with the County for training, which shall be established by mutual agreement of the respective representatives of the County and the University. C. Assign for field instruction only those students who are prepared to a degree considered adequate by mutual agreement of the parties hereto; d. Make all necessary arrangements so that each student will: (1) Have completed all the necessary courses required by the University as preparation for said clinical experience; (2) Agree to execute the County's Unpaid Student Training Participant Agreement upon referral to the training program; (3) Arrange for their own transportation to and from the Health Services Department and for, maintenance and housing during field instruction; (4) Channel educational problems to the University; (5) Promptly report illnesses and absence from duty; and Initials: Contractor County Dept. 1 PROGRAM PLAN FOR FIELD INSTRUCTION IN PUBLIC HEALTH NURSING Number 22-153-3 (6) Comply with regulations and standards of conduct governing professional occupational therapists in the County Health Services Department. e. Furnish County with such evidence as County may require that each student assigned for training hereunder is physically fit. f. Verify, at request of County, that the University has in full force and effect during the term of this Agreement, professional liability insurance for students designated for participation pursuant to this Agreement with a coverage of at least One Million Dollars ($1, 000, 000) for the activities of the student pursuant to this Agreement. 4. County's Obligations. In participating in this program, County shall: a. Comply with all State statutes and regulations applicable to the training of public health nurses enrolled in the University' s program; b. Accept for clinical experience those students assigned by the University for such a period and in such numbers as may be mutually agreed; C. Provide the student with learning experiences needed to meet the objectives of the training program mutually agreed to by the parties in accordance with the plan referenced in Paragraph 1. , above; and d. Have the right to terminate the participation of any student in the clinical experience for failure to follow the instructions of County, or for any other reason deemed adequate by County. In the event of such termination, County shall give prompt written notice to the University. 5. Joint Obligations. County and Contractor shall jointly: a. Plan a student training program including course content and student assignment schedule so as to provide a sound and effective educational program; b. Review the program at the end of each training period in order to evaluate progress and recommend changes for the next consecutive training period; and C. Plan for periodic review of this Agreement. Initials: ✓►�' ��� Contractor County Dept. 2 PROGRAM PLAN FOR FIELD INSTRUCTION IN PUBLIC HEALTH NURSING Number 22-153-3 6. Participants, Obligations. Participants shall: a. Execute the County's Unpaid Student Training Participant Agreement upon referral to the training program; b. Abide by County policies and regulations; C. Conduct themselves in an appropriate professional manner consistent with responsibility; d. Observe and respect patient' s rights, privacy and dignity; and e. Comply with applicable County, State and Federal regulations respecting disclosure of patients ' heath information and access to, and removal of, medical records and/or information contained therein. 7. University, County and Participant Agreement. Notwithstanding the authorization for reimbursement for actual and necessary expenses (including a flat mileage rate of $0. 15 per mile for use of personal vehicles) of authorized volunteer services set forth in the final paragraph of attached Contra Costa County Policy Statement on Volunteers, participant shall be entitled to no reimbursement by County for said expenses while engaged in the training program covered by this Agreement. Initials: Contractor County Dept. 3 CONTRA COSTA cc=1 Y PCLIC'i STATEXTITT ON VOLUNTEER PROGRA.'QS The use of volunteers in performi.lg specific ser-vices is a valuable rescur�-e and provides an avenue for citizenparticipation in varic s CCL'nty programs wil_C is recognized as being of pLylic benefit. In recccniticr. of th e benefits whic'n may be derived fro= vcl nteer services, it is hereby declared teat it sl-all be Ccul-ity policy to encourage and promote volunteer programs detar=Lned to be in the public interest. It is CcuntjT policy that volunteers will not replace County employees but W ill provide services to supple=ent or enrich regular Ccunli nr programs an d services . This :olicy statement is designed to provide the framework for all Ccunt-.- 44 volunteer programs and activit_es . The fcllcw_ng guidelines are adc=ted _cr Vciu:t=er pr a-f a-1S : VOL�'TEER PRCGRA'•!S A cc. et-- des cr _t4 C_ of each volunteer program shall be s�:::m_tted by the depa=zmenL read to the County Adm_nisz.ratcr for review and preseritation tC the 'card of Supervisors with his recc=endaticn. Factors to be considered in evaluating programs are the need for and public benefit to be derived from the volunteer program, associated County cast and staff effort required for such * a program, the potential for injury to volurteers, and the possibility for injury to others including injuries giving rise to possible liability claias. Regulations and procedures including, but not limited to, such matters as eligibility, training, supervision and roster control, may be promulgated by the County Administrator for guidance of departments to assure proper administration and control of volunteer services. VOLUNTEERS A volunteer is defined as a person who renders services gratuitously and has been accepted in the volunteer program. The volunteer is not an employee of the County. In recognition of the benefit to the County derived from volunteer services, authorized volunteers serving in programs approved by the Board of Supervisors shall be provided the benefits indicated below. I CONTRA COSTA COUNTY PCLIC'? ST-ATT'MMN- m— ON Q0LUN7_rrZ:Z PROGRAMS I. in-4=7 tc Volunteer. i'-.ut Cr�ze� volunteers are nct under the purJ_ew of the wcr'te__ ' c=ersat_cn laws cf California. In 1__u 4-exec= and '_.. raturr: for the vc_UMMS-ers wa_Ver Of a.-.,/ claim against the C=,,::-.- r^ illness, inn ur,- Or other ha_:aa aris.rC from acts Cr occur=anC swhll prcviC1ing VClura-aer services, the County shall provide, In the Casa c= aL'thCrized Volunteer seiiices, t==.^ugh self-insurance, for reimh rse=ent C= ama ed_cal ex"-•ensas and aura_ ui.l pe-_-aren. d_Sa i 11tV C:LZpe.^.sat1CP. _ e��a_ to af=crded L'nde= the workers c=..=ensat_cn laws C= Cal_fcr::_a, CV_ded, however, t.at no t:. c_ Crar"; d_Sa __tv c= ensaticn shall be ;aid an'd .:.ad_ca_ e:{^.enSas s`.'1a=1 .ti'.c� l].M--ad to rei_..:L'rsement for e:i'C'enditL'res ct-her'w_Sz l re eyed the vo_ t s a;_3 '.vC h a_ ZCt covered bV ...�.... _ p.an, Cthe- a'ia_-;.,leli'surarse CCVerage, Or Other t:�].r: =a--,- (_. e , =ceral, State ..ate cr cth_= pay:,,ent) - 2 . P',hl_c Lia::1:t-7 The County through its self-insurance _ _cc=am i S ha_ def_nd and VC1 ..-aer5 LDC% reCLes- agan5� i _s^i� _- - i C a_=:5 atad LV th__ Ca--=e5 a-_S CL't CL' ac-S or cm=SS_CnS Cc.^.::____ _ W-=_M the scc_:,e c= a?.:-..c__zad vc_—,,i—t___ se=-�_cas , unless the vol�rtee= acted c= =a__ed to act zecausa c= ac-_a_ malice, fraud, ccrr'�-_ora c_ cross neg__Cenca. Vc_,,--a_-s L'S_ng z:erscia= au-..uc i les in per=ci_._nga =:Cr_-ad sCrJiceS must :mi..' a_n, l_a..___- ins'.-rance a- l_:u'_LS which as a uii:il=Lyi. CCM=-, v wit the Ca,_=.._.._a Financia_ Respcnsi..il_tV law and mL:s- ha-'re a va.14 drive='s l=c--nSa. -:e D-oleo-_Ci^ of=„=ded bV the Count- ,- shall be in exces_ Cr.IV of any,- C-h ar -valid and C: :le publ_C li ab_l_t'J C: liab_lity in5:1rance ma_:ta_ned C: w:-c h provides Cove-ace =cr t.-_e volunteer. Volunteers may he permitted to operate County vehicles iia -the performance of au-herized volunteer services . 3 . E.sense Reimbursement. Volunteers shall be reimbursed for actual and necessary e:-•eases in perfcr-ance c authorized volunteer seryices at the same rates and ira accordance With regulat-ions and procedures esta:.l-Shed fC_ County employees, except that a flat mileage rate of $0 . 15 per .mile for use of personal vehicles will he allowed. No reimbursement will be made for aray child care er_.:enses, mileage from the personal residence of the volunteer to the County facility or service location or for damage to personal vehicles of volunteers used when performing authorized volunteer services. 2 Administrative Bulletin Contra Number c Replaces Office of We County Administrator Costa Date 7—_26—7 R Count)/ Section PPrg onn P 1 SUBJECT: Rules and Procedures to be Followed by County Departments for Authorized Volunteer Programs I . GENERAL This bulletin provides the rules and procedures to be followed by County departments governing entrance, training, and supervising of volunteers under County authorized volunteer programs, including the policies and procedures for reimbursement of expenses ; medical and permanent disability benefits ; and legal defense and indemnification against liability claims initiated by third parties . These regulations and procedures are promulgated in accordance with the policy adopted by the Board of Supervisors . II . RULES AND PROCEDURES County departments shall submit to the Office of the County Administrator a description of each volunteer program, the number of volunteers to be assigned, County staff requirements for coordination and County expenditures and funding involved. Such volunteer program definition, following review by the Office of the County Administrator, shall be forwarded to .the Board of Supervisors for approval. After Board approval, rules and procedures, as follows , shall be adopted, and copies forwarded to the County Administrator: A. County departments sponsoring volunteer programs shall have a staff member assigned as a volunteer coordinator, who will be respon- sibile for the selection and acceptance of volunteers . Personnel matters regarding the volunteers will be referred to the volunteer coordinator. Volunteers will work directly with other staff members and will be under their supervision for each assignment . Each County department will forward to the County Administrator the name and telephone number of the employee (s) assigned as the volunteer coordinator. Volunteers will be provided with initial orientation and training by the c. . volunteer coordinator . Where appropriate, confidentiality requirements shall be explained, reading materials assigned and discussion groups held .on a regular basis with the volunteers. B. The volunteer coordinator will also be respon- sible for requiring volunteers to fill out, read and sign the application form, and if such volunteer is accepted, the volunteer coordinator will fill out the registration form (just below the application form) showing acceptance of the volunteer, date services commence and terminate , any remarks he may wish to include with respect to the capability of the volunteer and limitations as to tasks to be performed, and lastly the service authorized to be performed by the volunteer. If the volunteer is a minor, the parental consent form shall be completed and signed by the parent or legal guardian. Forms to be used by departments are attached. Departments may continue to use forms developed for volunteer programs which include information needed by the department in addition to that indicated on the attachments . Any obvious or suspected disabilities of a volunteer shall be discussed with the County Safety Officer. If reimbursement of actual and necessary expenses in performing volunteer services is contemplated, volunteer must .sign .Oath of Allegiance form in accordance with established department procedures when registering to perform authorized volunteer services with the County. The volunteer coordinator shall be responsible for mainte- nance of a log listing pertinent information with respect to all authorized volunteers, including date services commenced and . terminated. Records are to be retained at least five years from the date of the last volunteer service for subsequent reference on claims which may be presented by either the volunteer or any third party allegedly injured. 3. If a volunteer is to use his personal vehicle in the course of authorized volunteer services, he will be required to fill out the "Volunteer Auto Insurance Declaration" form. Volunteers must check with their insurance agent or broker to make certain that liability insurance is extended under their policy while their vehicle is being used for volunteer activities . Auto insurance is required for all volunteers who will use their personal automobile - while performing authorized volunteer services with at least the following limits : $15 , 000 for injury to or death to one person $30, 000 for injury to. or death to two or more persons in one accident $5 , 000 for property damage The volunteer must furnish a valid California motor vehicle operators license if he is to use a vehicle and the license number together with insurance .policy number duly noted on the Auto Insur- ance Declaration (form attached) . A Certificate of Insurance or other evidence of insurance may be requested and placed on file . III . PROCEDURE IN CASE OF ACCIDENT OR INJURY When a volunteer is injured while performing authorized volunteer services , the supervisor shall arrange for medical care as necessary and appropriate in accordance with normal departmental operating procedures . The volunteer' s supervisor shall immediately thereafter complete the Supervisor' s Report of Occupational Injuries or Illness (Form AK-30) . The supervisor shall then forward the form to the volunteer cordinator who within 24 hours shall submit the report through department channels to the Safety Division of the Civil Service Office . The form shall indicate that the injured party is a volunteer. A copy of the report must be forwarded to the Office of the County Administrator. All medical bills received by the volunteer not otherwise covered by health insurance, other insurance, or third party pay- mens shall be forwarded to the Office of the County Administrator. Such bills must be itemized and indicate the date of injury. County payments will be made. jointly to the volunteer and to the medical provider. Any claims for permanent disability compensation shall be referred to the Office of the County Administrator for review and adjustment . Prior to final settlement and payment of any such claim, the volunteer shall execute an appropriate form releasing the County from any further liability and agreeing that such compensation shall be the sole and exclusive remedy with respect to the injury sustained. 4. When there is an accident resulting in third party personal injury or property damage, the appropriate accident report form shall be completed by the supervisor and forwarded to the volunteer coordinator. The subsequent procedure to be followed shall be identical to thatapplicable as in acciden ts' involving County employees. IV. LIABILITY The County under its self-insurance program upon request shall defend and indemnify the volunteer against liability claims initi- ated by third parties arising from acts or omissions occuring within the scope of authorized services, unless the volunteer acted or failed to act because of actual fraud, corruption, malice or .gross negligence. . However, the County shall provide automotive liability insur- ance protection as excess only of the limits under the volunteer' s personal automotive liability policy. Such County insurance protection does not cover any damages to t e vehicle of the volun- teer, including any deductible provision which must Ee pai . Maintenance of such records as determined necessary to assure that adequate insurance .protection is afforded shall be a respon- sibility of the department ' s volunteer coordinator. V. REIMBURSEMENT OF EXPENSES Volunteers are eligible to receive reimbursement from the County for certain actual and necessary expenses incurred in the performance of authorized volunteer services . In order to claim expenses , the volunteer must have signed the Oath of Allegiance before any County officer authorized to administer oaths and meet previously described insurance requirements . Volunteers are governed by general County reimbursement policies established for County employees with the exception of mileage which will be reimbursed at a flat rate of $0. 15 per mile . The County will not reimburse volunteers for child care expenses , mileage from the volunteer' s residence to the County designated facility or service location or damage. to _t7e volunteer-'s ersonal vehicle , including any deductible provisions which are ai the volunteer. The volunteer must provide information to the volunteer coordinator with respect to the automobile liability insurance coverage maintained prior to use of the personal vehicle for volunteer services and reimbursement of mileage claims . 5. Volunteers are recognized as a valuable resource in perform- ing services which are not provided by the County. The Board of Supervisors has expressed its strong support of volunteer programs. These policies and procedures have been developed for the information and guidance of .County staff and volunteers . Acting County Administrator CONTRA COSTA COUNTY VOLUNTEER APPLICATION AND REGISTRATION FORM Name Age Social Security No. Home Address Home Phone Business Address Business Phone Driver ' s License No. , If Any Service Preference Acceptable Location Do you have a health problem we should be aware of in an emergency? Yes No (Describe - such as a history of back trouble , heart, epilepsy, diabetes , fainting, etc . ) Is there a medication you must take? Yes No Is there a medication to which you are allergic? Yes No If yes, medication is : Medical, Hospital or Other Insurance Person to Call in Emergency Address Phone No . Interviewed by I have been informed against and accept responsibility for any breach on my part respecting confidential information. I have read the Resolution adopted by the Contra Costa County Board of Supervisors Signature on volunteer programs . In return for the benefits provided by Contra Costa County Date in case of my illness, injury, death, or third party liability while providing, or resulting from acts or occurrences within the scope of my authorized volunteer services , and for my right to authorized expense reimbursement, I waive any claim on my behalf and on behalf of my heirs, representatives, and assigns against the County of Contra Costa or any of its agents, servants or employees for illness , injury, debts or other harm arising from my volunteer services , - whether or not authorized. Signature Date CONTRA COSTA COUNTY VOLUNTEER SERVICES AUTO INSURANCE, DECLARATION Date This is to certify that I, the undersigned, am in possession of a valid California Driver' s License , , (Number) My car , Expiration Date (Make) to e ear License No. is insured with , Company (Policy No . Expiration Date I further certify that I have minimum liability insurance coverage as follows : $15 , 000 for injury to, or death of, one person; a $30, 000 for injury to, or death of, two or more persons in one accident; $5 , 000 for property damage . Signature CONTRA COSTA COUNTY PARENTAL CONSENT FORM VOLUNTEER PROGRAM Name of Minor : Address : Birthdate : Volunteer Activity: The above person, a minor, desires to perform volunteer services for the County in accordance with the attached application form. As parent/guardian of this minor, permission is hereby granted for him/her to participate in the volunteer program. My child does not have any physical or medical problems which would prohibit or limit participation in the volunteer program, except: In case of illness or emergency, please call : Telephone Number : I have reviewed the volunteer application and registration form and give my consent for to participate in the volunteer program subject to the terms and conditions expressed therein. Signed by Parent/Guardian: Date: