HomeMy WebLinkAboutMINUTES - 03021993 - 1.35 �' 1M 1 • 3 5
TO: BOARD OF SUPERVISORS /n /
FROM: Mark Finucane, Contra
Health Services Director U v- ontra
fi:A
By: Elizabeth A. Spooner, Contracts Administrator NSl�
DATE: February 16, . 1993VPW County
SUBJECT: Approval of Unpaid Student Training Agreement #26-254 with ConCorde Career
Institute
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Chair, Board of Supervisors, to execute on behalf of the
County, Unpaid Student Training Agreement #26-254 with ConCorde Career Institute,
for the period February 15, 1993 through June 30, 1994 for the provision of clinical
experience for respiratory therapy students.
II. FINANCIAL IMPACT:
None
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
The purpose of this agreement is to provide respiratory therapy 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 in respiratory therapy is considered to be an
integral part of both the educational and professional preparation. As a teaching
hospital, Merrithew Memorial Hospital can provide the requisite field education,
while at the same time, taking advantage of the students' services to patients.
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMM D ION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON APPROVED AS RECOMMENDED >< OTHER
VOTE OF SUPERVISORS
UNANIMOUS (ABSENT ) 1 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: Frank Puglisi, Jr. (370-5100) OF SUPERVISO ON THE DATE SHOWN.
CC: Health Services (Contracts) ATTESTED
Risk Management Phil Batchelor,Cleric of the 803rd of
Auditor-Controller Supervisors and County Administrator
Contractor
M382/7-83 �'y
BY DEPUTY
Contra Costa County 3 5 Standard Form
UNPAID STUDENT TRAINING AGREEMENT
Number 26-254
1. Contract Identification.
County Department: Health Services (Hospital and Clinics 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: CONCORDE CAREER INSTITUTE
Capacity: Private Educational Institution
Address: 1290 North First Street, San Jose, California 95112
3. Term. The effective date of this Agreement is February 15. 1993 and it terminates
June 30. 1994 , 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 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 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
By1 v�aal By
Designee
Reco374Department
(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 26-254
Contractor Concord Career Institute - Respiratory Therapy Program
County Department Health Services - Hospital and Clinics Division
CONTRA COSTA COUNTY PARTICIPANT
(Printed Name)
By
(Designee) (Signature)
PROGRAM PLAN
FOR
CLINICAL EXPERIENCE FOR RESPIRATORY THERAPY
Number 26-254
1. Purpose of the Program. ConCorde Career Institute conducts an
educational course in respiratory therapy for its students enrolled in the
Respiratory Therapy Program. The Contractor 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. 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 Contractor;
Initials:
Contfhctor Co y Dept.
1
PROGRAM PLAN
FOR
CLINICAL EXPERIENCE FOR RESPIRATORY THERAPY
Number 26-254
(5) Promptly report illnesses and absence from duty; and
(6) Comply with regulations and standards of conduct
governing professional respiratory 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 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 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 respiratory therapists 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 l. , 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.
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;
Initials: _
Contractor Cou y Dept.
2
PROGRAM PLAN
FOR
CLINICAL EXPERIENCE FOR RESPIRATORY THERAPY
Number 26-254
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.
6. Participantst 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. 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:
Cont ctor Co Dept.
3
CON'T'RA C:S'='A CO MMT
POL2CY STATYM '`1- ON VOLUNI"E R PROGRA_'!s
The use of volunteers in performing specific services is a valuable resource
and provides an avenue for citizen participation in various County prcr,-a=s
w:.ic is recognized as being of public benefit. In recogniticr, of the
benefits which may be derived from volunteer services, it is hereby declared
,—at it shall be County policy to encourage and promote volunteer proarars
detern:ned to be in the public interest.
It is Coup -- policy that volunteers will not replace County employees bit
w il? provide services to suppleWent or enrich regular County precr a=s and
s e=77-cos.
.ia_s pclicv statement is designed to provide the framework fcr all Ccun-v
vc_..::teer prcc=ams are- activit_es . The following guidelines are adopted
vc_:...-eer procraWs
A c=lete description_ of each volunteer program shall be s-�:bmitted by t
dep a_^ent head to the County Ad-.inistrator for review and preseritat:;Cr. tJ
the Board of Suoervisers with his recommendation.
Factors to be considered in evaluating programs are the need for and pu l:c
benefit to be derived from the volunteer program, associated County cost and
staff effort reruired for such a program, the potential for injury to
vclunteers, and the possibility for injury to others including injuries
92vi--g rise to possible liability claims.
Rea Mations and procedures including, but not limited to, such matters as
eligibility, training, supervision and roster control,- may be promulgated by
the County AdWinist_rator for guidance of depart=ents to assure proper
administration and control of volunteer services.
yOLUNT�ERS
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 cf
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 CCL":+ZY
PCL_Ci STA^_'rM 'NT ON VCLUY"_"_4'=R PRCGPA'!S
1. In4iur7 to Volunteer. Authorized volunteers are not u:'.der the
pure,:.-_ of the workers ' cc=nensation laws of California. In lieu t::er_cf a-C:
in return fcr the volunteers waiver of any claim against the Ccu:.ty for
illness, in4ur'y or other harm arisi.^.s f_c.:a acts c: occurrences w1_1e
providing volunteer services, the County shall provide, in the case c'
authorized volunteer seryices, through self-_Agin-ance, for reiMbursemert of
medical expenses and minimum permanent disability compensation ecua_ to than
affcr-4ed under the workers ' ccmcensation laws of California, provided,
however, that no tem-craps disability compensation shall be paid and medical
expenses shall be limited tc re4mburseme-:_ for ex--end ct er-«'sa
crcalified for rei=.!^u=sement which are not covered by the volunteer ' s heat___
plan, other available insurance coverage, cr other thin.. party ( i .e. ,
Federal, State or other payment) .
2 . P_ :__c Lia____ _v. The Courter �.. „u_:Z its se .. ^sem ance prcc_ _.,
s::a__ defend and In defJ volunteers u:.cn request against 1=abi1 i-:i
n:-_ate d by thin^ pa=--'_'_es arising Cut Cf acts or cIIiss:cns cc:=-,
the SCcp e cf at:thor=zed volunteer ser':_ces, unless the Volunteer acted oz-
.4r
r
fa_1=_d tc act because of act :a_ malice, fraud, Cort _ tion c= c=c=_s
negliCe:lCe. VC1L:^atE'er5 115"nC perSCnal aL'tc^Cb_les 11: perfCrIIi::CJ
serV_cas mus-_ =ainta-, n Iiabil=t'✓ insurance at limits which as a
CCM-_`� With 4: Cal.4. r _ .i%anC:al :ceSpCllSr.:l1t,J law an G� WL'St have a Va_4,4
driver's an :e -rotec-- on af_crced b the C urty✓ *- ' 1 _..
l C 52. t. �_ y :. a S a. be ' " ex.....55
only of any other va=id andca='_ect�le pu ilio liab:lity oz-
a--I_. --ty
rab:__ty insu=ance =a-;n-.a ra•-. "'ed b v Cr which prov=des coverage for tie
volunteer. Volunteers may be permitted to operate County vehicles in 4"".e
perfc=ance of authorized volunteer ser✓ices .
3 . Extense Re;_-1-ursement. Volunteers shall be reim u=sed for act--al
and necessary expenses in performance of authorized volunteer services at 'the
saWe 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 rein:-:urseme.^.t w:11 be made for a,-,,.r
child care expenses, mileage from the personal residence of the volurtee= to
the Ccunty facility or service location or for damage to personal vehicles cf
volunteers used when performing authorized volunteer services.
2
\\.111111 IIV l!k"U I •V -' •v.•. _
costaMepiaces
l
Office of the County Administrator ^ ��
Date I ) -26-7;
(Co Section D•o c r`rs-,0 1
SUBJEECT: Rules and Procedures to be Followed
by County Departments for Authorized
Volunteer Programs
I . GE NERAL
This bulletin provides the rules and procedures to be
followed by Co=ty 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 pa-ties. i:ese reg-Mations and procedures are promulgated
in accordance w_t the policy adopted by the Board of Supervisors .
II . RMLES 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 a---d Cou:-*:ty 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 .
vclu::teer coordinator . Vnere appropriate,
confidentiality requirements shall. be
explained, reading materials assigned and
discussion groups held on a reg-u-ar bas= s with
the volunteers.
B. The vol=nteer coordinator will also be respon-
sible for recu_ri_^o volunteers to fill- out,
read and sig?" the appl-cation forte, and if
such vol, tee- is accepted, the volunteer
coordinator will fill out the registration
form (just below the application form) showing
acceptance of the vol•.:rteer, data services
commence and terminate , any remarks he may
wisp: to i ncludz with respect to the capability
of the volunteer and 7 .4..-itations as to� tasks
to be performed, and lastly the service
authcrized to be performedy by the volunteer.
I_ the volunteer is a miner, the parental
consent form shall be completed and signed by
the parent or legal gaardian. Forms to be
used by departyents are attached. Departments
may continue to use terms developed for
volunteer pro-ams 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 Cou`ty Safety Officer.
If reimburseme,.t of actual and necessary
expenses in performing volunteer services is
contemplated, volunteer must sign Oath of
Alle'aiance form in accordance with established
department procedures when registering to
perform authorized volunteer services with the
County.
The volunteer coordinator shall be res-oonsible 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 voluTteer =ust furnish a valid California motor vehicle
operators license if he is to use a vehicle and the license number
together wit': 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 or. file .
III . PROCEDURE IN CASE OF ACCIDENT OR INJURY
When a volunteer is injured while performing authorized
volunteer serv-_ces , the supervisor stall 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-
meet 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 accidents involving County
employees .
IV. LI?? LITY
The Co=1C-v under its self-insurance program upon request shall
derend and indemnify the volunteer against liability claims initi-
ated by t:gird parties arising from acts or omissions occuring
within the scope of aut':orized services , unless the volunteer acted
or failed to act because of actual fraud, corruption, malice or
,Cross negligence .
kcwe-rer , the Cc=ty shall provide automotive liability insur-
ance protection. as excess only o- the limits under the vol teen' s
personal automotive liability policy. Such Cou-*ity insurance
protect'c- does not cover ary damazes to the vehicle or the volun-
teer, i^C'd4-.-- any deducciD1e provision w icn must 'De Uald.
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. REIT URSMENT OF EMNSES
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 Countv will not reimburse volunteers for child care expenses ,
Mileage fnom, the vo unteer s residence to the County esignate
ace ity or service location or damage to vo unteer s personal
venic e , includin any Ueductible provisions which are paid t e
vo unteer. The volunteer must provide information to a vo unteer
coordinator with respect to the automobile liability '.nnsurance
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
PARENTAL CONSENT FORM
VOLUNTEER PROGPAdX
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:
CONTRA COSTA COUNTY
VOLUNTEER SERVICES
AUTO INSURANCh 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)
1•10 de 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 ;
$30 , 000 for injury to, or death of, two or more persons in one
accident; $5 , 000 for property damage .
Signature —
:.�:;=mss
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