HomeMy WebLinkAboutMINUTES - 10041994 - 1.4 (3) TO: BOARD OF SUPERVISORS //
FROM: Mark Finucane, Health Services Director Contra
By: Elizabeth A. Spooner, Contracts Administrator COSta
DATE: September 19, 1994 oio County
SUBJECT: Approval of Unpaid Student Training Agreement #22-507 with
the Regents of the University of California
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 #22-507 with the Regents of the University
of California (on behalf of its Berkeley Campus School of Social
Welfare) , for the period from August 1, 1994 through June 30, 1997 , to
provide field instruction in the Department's AIDS Program for the
University's social work students.
II. FINANCIAL IMPACT:
None
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
The purpose of this agreement is to provide Contractor' s social work
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. The County's AIDS
Program can provide the requisite field education, while at the same
time, taking advantage of the students ' services to clients.
Approval of this Unpaid Student Training Agreement will provide
clinical experience for Contractor' s social work students through June
30, 1997 .
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMME ATI OF BOARD CO MITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON r APPROVED AS RECOMMENDED OTHER
WWI
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) OCT � 4
CC: health Services (Contracts) ATTESTED
Risk Management Phil Batchelor,Clerk of the Board of
Auditor—Controller Supervisors and County Administrator
Contractor
1
M3e2/7•e3 BY DEPUTY
l- �d
ConCra-.Coata County UNPAID STUDENT TRAINING AGREEMENT Standard Form
Number 22-507
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: THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Capacity: State Educational Institution
Address: Berkeley Campus, School of Social Welfar
131 University Hall, Berkeley, California 4720
3. Term. The effective date of this Agreement is Au ust 1 1and it terminates
June 30, 1997 , unless sooner terminated as provided her
4. Termination. This Agreement may be terminated by either party, at its ole discretion,
upon seven-day advance written notice thereof to the other, or canceled ediately by
written mutual consent, subject to termination conditions (if any) set f th 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 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 contrac terms and conditions are expressed in the Program Plan attached
hereto and incorpora derein by reference.
6. Independent Contractor S This Agreement is by and between two independent
contractors and is not in ended to and shall not be construed to create the
relationship of agent, servant, mployee, partnership, joint venture, or association.
7. Indemnification. Except for those ac 'vities of participants covered by the County's
Volunteer policy, each party, and it 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 By
Designee
Recommended by Department
(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.
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 22-507
Contractor The Re tents of the University of California. Berkeley School of Social Welfare
County Department Health Services - Public Health Division
CONTRA COSTA COUNTY PARTICIPANT
(Printed Name)
By
(Designee) (Signature)
PROGRAM PLAN
Number 22-507
1. Purpose of the Program. The Regents of the University of
California, on behalf of the Berkeley Campus School of Social Welfare,
(hereinafter referred to as Contractor or University) conducts a training
program for its Social Work students, in cooperation with County' s
Department. The Contractor desires to have students, enrolled in this
program, receive clinical 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
Initials:
Contractor County Dept.
1
PROGRAM PLAN
Number 22-507
(6) Comply with regulations and standards of conduct
governing professional personnel 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 Contractor has in full
force and effect during the term of this Agreement, general 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;
Initials:
Contractor County Dept.
2
PROGRAM PLAN
Number 22-507
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.
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. Injury 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, th=ough 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 ctherwise
qualified for reimbursement whicia 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 inde:rni`y volunteers upon request against liability claims
initiated by third parties arising out of acts or omissions occurring within
the scope of authcrized volunteer services, unless the volunteer aced or
failed to act because of actual malice, fraud, corruption c= gross
negligence. Volunteers using personal automobiles in performing authorized
services must maintain liability insurance at limits which as a minimum
comply with the Califcrnia 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
321
Administrative Bulletin Contra Number
Costa Replaces
Office of the County Administrator y, ' Date 12-26—78
County Section PPYCm1T1
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
2 .
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-
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 jointlyvto 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 accidents 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 the vehicle of the-volun-
teer, including any deauctible provision which must be paM.
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
tacility or service location or damage to the volunteer's personal
vehicle , including any Ueductible provisions which are 2aid by. the
vn1untizp-r. : The volunteer must provide information to the volunteer
c5ordina r with respect to the automobile liability .:hnsurance
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.
V
Acting County Administrator
CONTRA COSTA, COUNTY
VOZ.GNT: R A_MPIz'C k_;ON AND c'Z..-GIST.ItA ION FORM
Naume Ace Social Secsr,t i vc .
Horne Address Home Phone
Bus_Hess :add=ass 3usi.;ess P:gree
L_ae Se VO. , 7- .=-:l
S Cir J_^ie .Prez. e-ence
cc vcu l=ave a we should: be a'+vaze of La an
Yes VC (Lescr_:e - s z—:: as a _S-cry C- lac:{ t t.:^_= ,
d=ear- , ez:? -,, =-_Z:?
is t:ere a r.,e__caticr vcu must ta'{e? Yes Nc
_s t:ere a ,;,=decd=icr_ tc '�- c :rcu a=c aller7.c? 'jos N_-
7
icIyes, iAe:i Cat Oa. i5 :
uec_ca=, gids_.t=_ or C]-he=
�crsOP. :: cal"_ _n zmercre nc AGGress C n :'y T.
IT�te=T,e*�JeC 'J 1 have bee= li.COr:ueG aca_.'ls t aI:G aCC- t
res-zCAS' ^_lity .6 an, bread on =nr t.a=
rescectinc can_iden tialforza. c r .
have read the Resolution adopted by t =
Contra Costa County Bcar:! of Supe=JiSv:s
Sicr_atur e oa volunteer prograMS . Iz rete:= for t e
ben e=its provided by Contra Costa Ccu:=v
Li case o= my illness, i,�jury, death, c:
Datet:ire gar-t_J liability while prov_c.:,c, c=
resulting from acts or cccurrer_ces wit:i
the scope of my authorized volunteer
ser7ices, and for my right to auto crizec
expense reimbursement, I waive any cla:.,i
on my behalf and on behalf of my heirs,
representatives, and assigns agai:zst t e
County of Contra Costa or any of its
agents, servants or employees for illness
injury, debts or other harm arising f_cr.:
my volunteer services,. whether or not
authcrized.
S igna tur e
Date
C0N'_-R:A. COSMA. COU=
VOLUNTEz3 SERVICES
AUTO IVSUR-,`IC'a DECLARATION
Date
at I, the =.dezai�ed, am ii. gossess4o::
�.is is to ca,ti�7 t=
Of a Valid Cal__c=—Ja Dr;'Te:r'S L ce.se
My Ca=
l =J 1+.1C= 52 :Vv .
rd
1 :e: Com_as :o::cws . S15 , 000 fcr _ ?L-- to, c= death. of, cme e=scr- ;
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J gna e
CONTP COSTA CGU.'==_Z
PA_ MTTAL CONSENL T r GRP4
VGLiiTT r3 PRCC�s�
Name of Minor :
Ad d=e s s :
Vo_u.n__e_ Ac.._ v_`v:
':he a1=17a ^.eZsc'. :, a VC7.untae=
---a C^.�n-_ Lim acc.,..z __ wit'-_ -621a a=mac ed a:
VCI___ e cr'CC:Zil. '�_i c
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act ___-,-a z y __:%s_c=_ cr ,:. =_ca_ prc1: s w _ci wcu,
BYcaC�..
-i. case ct i?lzeas or e—�erce nc•7, r-I.eaSa cai�.
Teles%one Nw-ti:e_
I have reviewer the vcluntee_ aPglicat'_cn and registrat'_cn fo— and
give my consent for to participate i tze ve_Lr.tee;
pros;_"I subject to the ter..s and conez.t_ons e_.=ressed therein.
Signer by Parent/Guardian:
Date: