HomeMy WebLinkAboutMINUTES - 10041994 - 1.39 TO: BOARD OF SUPERVISORS � ' 1
FROM: Mark Finucane, Health Services Director
�, - 14 Contra
By: Elizabeth. A. Spooner, Contracts AdministratorCosta
DATE: September 19, 1994 County
SUBJECT: Approval of Unpaid Student Training Agreement #22-473 with
Pacific Union College
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Health Services Director, or his designee
(Wendel Brunner, M.D. ) , to execute on behalf of the County, Unpaid
Student Training Agreement #22-473 with Pacific Union College, for the
period from September 1, 1994 through December 31, 1997 , for provision
of field instruction in the Department' s Home Health Agency for the
Contractor' s nursing students.
II. FINANCIAL IMPACT:
None
III . REASONS FOR RECOMMENDATIONS/BACKGROUND:
The purpose of this agreement is to provide Contractor' s nursing
students with the opportunity to integrate academic knowledge with
application skills and attitudes at progressively higher levels of
performance requirements and responsibility. Supervised field work
experience for students is considered to be an integral part of both
the educational and professional preparation. County' s Home Health
Agency can provide the requisite field education, while at the same
time, taking advantage of the students' services to patients.
Approval of this Unpaid Student Training Agreement will provide
clinical experience for Contractor' s nursing students through December
31, 1997 .
CONTINUED ON ATTACHMENT: YES SIGNATURE: `
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMME DATI N OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON0-CT 4 1994 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
OF SUPERVISORS ON THE DATE SHOWN.
Contact: Wendel Brunner, M.D. (313-6712)
cc: Health Services (Contracts) ATTESTED OCT 4 1
Contractor
Phil Batchelor, Clerk of the Board of
SupejvWrs vd Gounty Admini*aW
M382/7-83 BY J ► �J.111 ���,� DEPUTY
�. 39
Cgatra �;.Osta--rw unty UNPAID STUDENT TRAINING AGREEMENT
Number 22-473
1. Contract Identification.
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: PACIFIC UNION COLLEGE
Capacity: Educational Institution
Address: Department of Nursing, Angwin, California 94508-9797
3. Term. The effective date of this Agreement is September 1. 1994 and it terminates
December 31. 1997 unless sooner terminated as provided herein.
-20
4. Termination. This Agreem m' be terminated by either party, at its sole discretion,
upon one hundred and tw t ys dvance written notice thereof to the other, or canceled
immediately by wr' 1 c sent, subject to termination conditions (if any) set
forth in the P ached hereto and incorporated herein by reference.
5. Program. By th3- r ement County agrees to permit unpaid student training by persons
(participants) s sored by Contractor under the following conditions:
a. Services provided under this Agreement are volunteer services, and participants
obtain no employment rights with, or employment benefits from, the County, by virtue of
this Agreement or service hereunder. Agreement, in the form attached hereto, is required
of every participant.
b. Upon approval by County's Board of Supervisors this Agreement shall be an authorized
volunteer program. The County's volunteer policy and the County Administrator's rules
and procedures for authorized volunteer programs attached hereto, are applicable with
respect to this Agreement, and are incorporated herein by reference together with any
amendments thereto, subject nevertheless to the terms of this Agreement.
c. Other contract terms and conditions are expressed in 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 constd to create the relationship
of agent, servant, employee, partnership, joint ventu on association.
7. Indemnification. Except for those activities pants covered by the County's
Volunteer policy, each party and its employe. a d officers shall be indemnified
and held harmless against any and all clai m ds, or causes of action allegedly
arising out of any act or omission arising 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 CONTRACT
By BY
Designee LO-1 V
Recommended by Department AGadem,'c. PCan
(Designate official capacity)
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 Contra Costa County Policy Statement 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.
S. 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 22-473
Contractor Pacific Union College
County Department Health Services - Public Health Division
CONTRA COSTA COUNTY PARTICIPANT
(Printed Name)
By
(Designee) (Signature)
PROGRAM PLAN
Number 22-473
1. Purpose of the Program. Pacific Union College (hereinafter
referred to as Contractor) conducts a student nursing training program, in
cooperation with County' s Department. The Contractor desires to have
students, enrolled in this program, receive clinical nursing experience and
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 the plan mutually agreed to by the
parties.
2 . Contractor' 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 Contractor;
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
Contractor 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 appropriate
instructor(s) in Contractor's school;
(5) Promptly report illnesses and absence from duty; and
(6) Comply with regulations and standards of conduct
governing professional personnel in the County Health
Services Department.
Initials:
Contractor County Dept.
1
PROGRAM PLAN
Number 22-473
1. Purpose of the Program. Pacific Union College (hereinafter
referred to as Contractor) conducts a student nursing training program, in
cooperation with County's Department. The Contractor desires to have
students, enrolled in this program, receive clinical nursing experience and
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 the plan mutually agreed to by the
parties.
2. Contractor' 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 Contractor;
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
Contractor 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 appropriate
instructor(s) in Contractor's school;
(5) Promptly report illnesses and absence from duty; and
(6) Comply with regulations and standards of conduct
governing professional personnel in the County Health
Services Department.
Initials:
Contractor County Dept.
1
PROGRAM PLAN
Number 22-473
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 Contractor 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 Five Hundred Thousand Dollars
($500, 000) for the activities of the student pursuant to this Agreement.
3 . County's Obligations. In participating in this program, County
shall:
a. Comply with all State statutes and regulations applicable to
the training of students enrolled in the Contractor's program;
b. Accept for clinical experience those students assigned by the
Contractor 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 Contractor.
4 . 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.
5. 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;
Initials:
Contractor County Dept.
2
PROGRAM PLAN
Number 22-473
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.
6. Contractor, 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 COUNTY
POLICY STATEMENT ON VOLUNTEER PROGRAMS
The use of volunteers in performing specific services is a valuable resource
and provides an avenue for citizen participation in various County programs
which is recognized as being of public benefit. In recognition of the
benefits which may be derived from volunteer services, it is hereby declared
that it shall be County policy to encourage and promote volunteer programs
determined to be in the public interest.
It is County policy that volunteers will not replace County employees but
will provide services to supplement or enrich regular County programs and
services.
This policy statement is designed to provide the framework for all County
volunteer programs and activities. The following guidelines are adopted for
volunteer programs:
VOLUNTEER PROGRAMS
A complete description of each volunteer program shall be submitted by the
department head to the County Administrator for review and presentation to
the Board of Supervisors with his recommendation.
Factors to be considered in evaluating programs are the need for and public
benefit to be derived from the volunteer program, associated County cost and
staff effort required for such a program, the potential for injury to
volunteers, and the possibility for injury to others including injuries
giving rise to possible liability claims.
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.
1
CONTRA COSTA COUNTY
POLICY STATEMENT ON VOLUNTEER PROGRAMS
1. Iniury to Volunteer. Authorized volunteers are not under the
purview of the workers ' compensation laws of California. In lieu thereof and
in return for the volunteers waiver of any claim against the County for
illness, injury or other harm arising from acts or occurrences while
providing volunteer services, the County shall provide, in the case of
authorized volunteer services, through self-insurance, for reimbursement of
medical expenses and minimum permanent disability compensation equal to that
afforded under the workers ' compensation laws of California, provided,
however, that no temporary disability compensation shall be paid and medical
expenses shall be limited to reimbursement for expenditures otherwise
qualified for reimbursement which are not covered by the volunteer' s health
plan, other available insurance coverage, or other third party (i.e. ,
Federal, State or other payment) .
2 . Public Liability. The County through its self-insurance program
shall defend and indemnify volunteers upon request against liability claims
initiated by third parties arising out of acts or omissions occurring within
the scope of authorized volunteer services, unless the volunteer acted or
failed to act because of actual malice, fraud, corruption or gross
negligence. Volunteers using personal automobiles in performing authorized
services must maintain liability insurance at limits which as a minimum
comply with the California Financial Responsibility law and must have a valid
driver' s license. The protection afforded by the County shall be in excess
only of any other valid and collectible public liability or automobile
liability insurance maintained by or which provides coverage for the
volunteer. Volunteers may be permitted to operate County vehicles in the
performance of authorized volunteer services.
3 . Expense Reimbursement. Volunteers shall be reimbursed for actual
and necessary expenses in performance of authorized volunteer services at the
same rates and in accordance with regulations and procedures established for
County employees, except that a flat mileage rate of $0. 15 per mile for use
of personal vehicles will be allowed. No reimbursement will be made for any
child care expenses, 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 321
Replaces
Office of the County Administrator _Costa Date 1 2-26-7,q
u "J Section 'Dorcnnnol
SUBJECT: Rules and Procedures to be Followed
by Comity Departments for Authorized
Volunteer Programs
I. G E NER.0
ThJ,s bulletin. provides the rules and procedures to be
followed by Co=ty departments governing entrance , training, and
supervising of volunteers under County a-uthorized volunteer
programs, including the policies and procedures for reimbursement
of expenses ; medical and pe=.:anent disability benefits; and legal
defense and i�7GellTi__�Cation. agains- liability Claims initiate` by
third parties . These regulations and D-ocedures are p-omu,lg=ted
in accordance wit: t:-±e policy adopted by the Board of Supervisors.
IT RULES AuND PROCEDURES
County departments shall submit to the Office of the Cour--L--,,-
Administrator
ountyAdministrator a description of each volunteer program, the n=-.ber
C. volunteers to be assigned, County staff requirements for
coordination and County e:-penditures and funding involved. Such
volunteer grogram definition, following review by the Office o=
the County Administrator, sinall 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
2 .
volunteer coordinator . Where appropriate,
confidentiality requirements shall be
explained, reading materials ass4 7ned and
discussion groups held an a regular basis with
the volunteers.
B. The volunteer coordinator will also be respon-
sible for requiring vciunteers to fill out,
read and sign the application fora, and if
such volunteer is accepted, the volunteer
coordinator will fill cut the registration
fern (just below the a-:-�lication fcrn) showing
acceptance of the volunteer, date services
commence and tenni nate , any remar--s he may
wish to include with respect to t--e capability
of the volunteer and I'mitalions as to tasks
to be perfor-sed, and lastly the service
authorized to be performed by the volunteer.
if the volunteer is a �:�inor, the parental
consent fern shall be completed and signed by
the parent or legal v_,a=dian. Fo�-.ms to be
used by departments ar=_ attached. Departments
may continue to use forms developed for
volunteer programs which include information
needed by the department in additign 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 coT;rse
of authorized volunteer ser7i.ces, he will be required to fill out
the "Volunteer Auto Insurance Declaration" form. Volunteers =:st
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 auto:.:cbile
while performing authorizer volunteer ser,74ces with at least the
following limits :
$15 , 000 for injury to or death to one person
$30, 000 for injur-y 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 t e license number
together with insurance pclicy number dul,7 noted on the Auto Insur-
ance Declaraticn (form attached) . A Certificate of Insurance or
other evidence of insurance may be requested and placed on file .
III. PROCEDURE IN CASE Or r CCIM.—I OR LTJURT
When a volunteer is injured while performing authorized
volunteer serv-'ces , the s=e-_--r_sor 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
oxesto the volunteer cordinator who within 24 hours shall submit theme
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-
ment 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 that applicable as in acciden-_s involving County
employees .
IV. LIABILIT'
.The County under its self-insurance program upon request shat:
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 , =less 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 volT.mteer ' s
personal automotive liability policy. Such County insurance
protection does not cover anv daa:aaes to the vehicle of the volun-
teer,
olun-
teer, including any aeauc_zo_e a.rovislon wa cn must e paid.
Maintenance of such records as determined necessa=J to assure
that adequate insurance protection is afforded shall be a respon-
sibility sof the department ' s volunteer coordinator.
V. REIMBURSEMNT OF E UENSES
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 sigped 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,
m ea a from the volunteer's residence to the County designate
facility or service location or damage to the volunteer' s personal
veRicle , including any deductible provisions which are paid by the
volunteer. The vo =teer must provide ifirormation 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 perfarm-
ing services which are not provided by the Count?. The Board cf
Supervisors has expressed its strong support of volunteer
programs. These policies ar_d procedures have been developed for
the information and guidance of COUn 7 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 Phcne
Driver' s License No. , If Any
Service Preference
Acceptable Location
Do you have a health problem we should be aware of in an eme:genc ?
Yes No (Describe - such as a history of back troub ' o ,
heart, epilepsy, diabetes , fainting, etc. )
Is there a med_cation you must take? Yes No
Is there a medication to which you are allergic? Yes No
If yes, medication is :
Medical, Hosp-ital 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
t my volunteer services, . whether or not
�•
authorized .
Signature
I
CONTRA COSTA COUNTY
VOLUNTEER SERVICES
AUTO INSURAi10E DECLARATION
�- Date
This is to certify that I, the undersigned, am in possessiori
of a valid California Driver' s License ,
• Number
My car
Expiration Date Mace
(i•:oael) (Ye ar7License No . )
is insured with
(Company)
(Policy No . ) (Expiration Date)
I further certify that I have minim„ 1-ability inSL:ranCe CO J?=awe
as follows : $15 , 000 for injury to, or death of, one person ;
$30 , 000 for injury to, or death of, t-wo or more perscns in ons
accident; $5 , 000 for property damage .
Signature
C0NTRA COSTA COUNTY
PARENTAL CONSENT FORM
VOLUNTEER PROGRALM
Name of Minor:
Address .
Birthdate :
Volunteer Activity:
The above :erscn, a minor, desires to perfor:i1 volunteer se v;ces
for the County in accordance with the attached application fcr-.1.
As parent/guardian of this minor, permission is heresy c=anto_
for him/her to participate in the volunteer program. My child does
not have anv 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: