12-001 Martha EngberJanuary 24, 2014
Martha Engber
Re: Agreement
OFFICE OF THE CITY CLERK
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
TELEPHONE: (408) 777 -3223 • FAX: (408) 777 -3366
WEBSITE: www.cupertino.crg
Enclosed is an original copy of the second amendment to your agreement with the City of
Cupertino. If you have any questions or need additional information, please contact the
Parks and Recreation Department at 408-777-3120..
Sincerely,
LQcAa74 &'��
Dorothy Stee fott
Senior Office Assistant
Enclosure
cc: Parks & Recreation
No: 57704
FY 13 -14
SECOND AMENDMENT TO AGREEMENT BETWEEN THE CITY OF CUPERTINO
AND MARTHA ENGBER FOR CONTRACT SERVICES
This Second Amendment to the Agreement between the City of Cupertino and Martha
Enp,ber, for reference dated December 2, 2013, is by and between the CITY OF CUPERTINO, a
municipal corporation (hereinafter "City ") and Martha Engber a sole proprietor, whose address
is (hereinafter referred to as "Contractor "), and is
made with reference to the following:
RECITALS:
A. On July 1, 2012,the City and Contractor - entered into an Agreement; and
B. On May 1, 2013, the City and Contractor entered into a First Amendment to the
Agreement between the City and Contractor (collectively, the Agreement and First
Amendment are hereafter referred to as "Agreement "); and
C. City and Contractor desire to modify the Agreement on the terms and conditions set forth
herein. NOW, THEREFORE, it is mutually agreed by and between and undersigned
parties as follows:
1. The term of the Agreement as set forth in Paragraphlshall be extended six
months, from January 1, 2014 until June 30, 2014, unless terminated earlier as set
forth in the Agreement; and
2. Contractor shall receive additional compensation under Paragraph 3 of the
Agreement as follows: $37 per class. The total compensation under the
Agreement is not to exceed the following: $10,000 (total), $5,000 for the term of
July 1 2012 to June 30 2013,$2150.0, -for the term of_July 1,, 2013 to December
a
31, 2013; and $2�SOo "rwthe term �fJanuary -l- ,12014 taJune 3.0,_2014..
3. On or before the term of this Second Amendment, Contractor shall provide the
City with a certificate of insurance and additional insured endorsement
demonstrating Contractor's ongoing compliance with the Agreement's insurance
obligations and naming the City as an additional named insured,; and
4. Contractor represents, warrants, and declares that the Agreement Exhibit "C" the
"City of Cupertino Consultant Declaration" remains accurate and current.
5. Except as expressly modified herein, all other terms, covenants and conditions set
forth in the Agreement shall remain the same and shall be in full force and effect.
IN WITNESS WHEREOF, the parties hereto have caused this modification of
Agreement to be executed.
Martha Engber CITY OF CUPERTINO
A Municipal Corporation
By
Title: Fitness Instructor
Date:_
By A '-olleen Ferris Recreation Coordinato
RECOMMENDED FOR APPROVAL:
Recreation Supervisor
TO FORM:
(, City Attorney
CgrEST: j2g—,City Clerk
CUPERTINO
July 1, 2013
Martha Engber
Re: Agreement
OFFICE OF THE CITY CLERK
CITY HALL
10300 TORRE AVENUE; • CUPERTINO, CA 95014 -3255
TELEPHONE: (408) 777 -3223 • FAX: (408) 777 -3366
WEBSITE: www.cupertino.org
Enclosed is an original copy of your agreement with the City of Cupertino. If you have any
questions or need additional information, please contact the Parks and Recreation
department at 408 - 777 -3120.
Sincerely,
Brittany Care
Senior Office Assistant
City Clerk's Office
Enclosure
cc: Parks & Recreation
No: 57704
FY 13 -14
1 S` AMENDMENT TO AGREEMENT BETWEEN THE CITY OF CUPERTINO AND
Martha Engber FOR Contract Services
This 1 sc Amendment to the Agreement between the City of Cupertino and Martha
Engber , for reference dated May 1, 2013, is by and between the CITY OF CUPERTINO, a
municipal corporation (hereinafter "City ") and _Martha Engber a sole proprietor whose address
is (hereinafter "referred
to as Consultant "), and is made with reference to -the following:
RECITALS:
A. On May 1, 2012, an agreement was entered into by and between City and Martha
Engber (hereinafter "Agreement ").
B. City and Consultant desire to modify the Agreement on the terms and conditions
set forth herein.
NOW, THEREFORE, it is mutually agreed by and between and undersigned parties as
follows:
1. Paragraph 1 of the Agreement is modified to read as follows:
"The term of this Agreement shall commence on July 1, 2012, and shall terminate
on December 31, 2013, unless terminated earlier as set forth herein."
2. Paragraph 3 of the Agreement is modified to read as follows:
"Consultant shall be compensated for services performed pursuant to this
Agreement in the amount set forth below.
Compensation: '$37 per class. Compensation shall not exceed a total amount of
five thousand dollars from 7/1/12 - 6/30/13 and $2,500 from 7/l/13- 12/31/13 for a
total not to exceed $7500.
Payment by the City to the Consultant for services: Consultant will be paid on a
monthly basis based on the rates."
3. Except as expressly modified herein, all other terms and covenants set forth in the
Agreement shall remain the same and shall be in Rill force and effect.
IN WITNESS WHEREOF, the parties hereto have caused this modification of
Agreement to be executed.
Martha Engber CITY OF CUPERTINO
A Municipal Corporation
By:
Date: RECOMMENDED FOR APPROVAL:
By Recreation Su ervisor
APPRO EDy,AS TO FORM:
By / ''� .City Attorney
A ST:
,City Clerk
CUPERTINO
July 5, 2012
Martha Engber
Re: Agreement
OFFICE OF THE CITY CLERK
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
TELEPHONE: (408) 777 -3223 • FAX: (408) 777 -3366
WEBSITE: www.cupertino.crg
Enclosed is an original copy of your agreement with the City of Cupertino. If you have any questions
or need additional information, please contact the Parks and Recreation department at 408 - 777 -3120.
Sincerely,
Brittany Morales
Acting Senior Office
City of Cupertino
Enclosure
cc: Parks & Recreation
stant
VL�
FI' I� -t3
AGREEMENT BETWEEN THE CITY OF CUPERTINO AND
DMartha Engber FOR CONSULTANT SERVICES
FOR Group Exercise Instructor
THIS AGREEMENT, for reference dated May 1, 2012, is by and between CITY OF
CUPERTINO, a municipal corporation (hereinafter referred to as "City "), and Martha Engber
a California State, SOLE PROPRIETORSHIP whose address is
(hereinafter referred to as "Consultant "), and is made
with reference to the following:
RECITALS:
A. City is a municipal corporation duly organized and validly existing under the laws
of the State of California with the power to carry on its business as it is now being conducted
under the Constitution and the statutes of the State of California and the Cupertino Municipal
Code.
B. Consultant is specially trained, experienced and competent to perform the special
services which will be required by this Agreement:; and
C. Consultant possesses the skill, experience, ability, background, certification and
knowledge to provide the services described in this Agreement on the terms and conditions
described herein.
D. City and Consultant desire to enter into an agreement for
upon the terms and conditions herein.
NOW, THEREFORE, it is mutually agreed by and between the undersigned parties as
follows:
1. TERM:
The term of this Agreement shall commence on July 1, 2012, and shall terminate on June
30, 2013, unless terminated earlier as set forth herein.
2. SERVICES TO BE PERFORMED:
Consultant shall perform each and every service set forth in Exhibit "A" which is
attached hereto and incorporated herein by this reference.
3. COMPENSATION TO CONSULTANT:
Consultant shall be compensated for services performed pursuant to this Agreement in
the amount set forth below.
Compensation: $37 per class.
Payment by the City to the Consultant for services: Consultant will be paid on a monthly basis.
4. ACKNOWLEDGEMENT OF MANDATED REPORTING REQUIREMENTS:
Consultant shall comply with the requirements of California Penal Code 11164 - 11174.3
and as set forth in Exhibit "B" which is attached hereto and incorporated herein by this reference.
5. FINGERPRINT AND TB CONSULTANT DECLARATION:
Consultant agrees that all individuals covered under this Agreement shall provide
fingerprints for criminal background test purposes and results of TB screening, pursuant to the
requirements as set forth in Exhibit "C" which is attach hereto and incorporated herein by this
reference.
6. TIME IS OF THE ESSENCE:
Consultant and City agree that time is of the essence regarding the performance of this
Agreement.
7. STANDARD OF CARE:
Consultant agrees to perform all services hereunder in a manner commensurate with the
prevailing standards of like professionals in the San Francisco Bay Area and agrees that all
services shall be performed by qualified and experienced personnel who are not employed by the
City nor have any contractual relationship with City.
8. INDEPENDENT PARTIES:
City and Consultant intend that the relationship between them created by this Agreement
is that of employer - independent contractor. The manner and means of conducting the work are
under the control of Consultant, except to the extent they are limited by statute, rule or regulation
and the express terms of this Agreement. No civil service status or other right of employment
will be acquired by virtue of Consultant's services. None of the benefits provided by City to its
employees, including but not limited to, unemployment insurance, workers' compensation plans,
vacation and sick leave are available from City to Consultant, its employees or agents.
Deductions shall not be made for any state or federal taxes, FICA payments, PERS payments, or
other purposes normally associated with an employer - employee relationship from any fees due
Consultant. Payments of the above items, if required, are the responsibility of Consultant.
9. IMNIIGRATION REFORM AND CONTROL ACT (IRCA):
Consultant assumes any and all responsibility for verifying the identity and employment
authorization of all of his/her employees performing work hereunder, pursuant to all applicable
IRCA or other federal, or state rules and regulations. Consultant shall indemnify and hold City
harmless from and against any loss, damage, liability, costs or expenses arising from any
noncompliance of this provision by Consultant.
10. NON - DISCRIMINATION:
Consistent with City's policy that harassment and discrimination are unacceptable
employer /employee conduct, Consultant agrees that harassment or discrimination directed
toward a job applicant, a City employee, or a citizen by Consultant or Consultant's employee or
subcontractor on the basis of race, religious creed, color, national origin, ancestry, handicap,
disability, marital status, pregnancy, sex, age, or sexual orientation will not be tolerated.
Consultant agrees that any and all violations of this provision shall constitute a material breach
of this Agreement.
11. HOLD HARMLESS:
A. Consultant shall, to the fullest extent allowed by law, with respect to all services
performed in connection with the Agreement, indemnify, defend, and hold harn -less the
City and its officers, officials, agents, employees acid volunteers from and against any and
all liability, claims, actions, causes of action or demands whatsoever against any of them,
including any injury to or death of any person or damage to property or other liability of
any nature, whether physical, emotional, consequential or otherwise, arising out,
pertaining to, or related to the performance of this Agreement by Consultant or
Consultant's employees, officers, officials, agents or independent contractors. Such costs
and expenses shall include reasonable attorneys' fees of counsel of City's choice, expert
fees and all other costs and fees of litigation.
B. Claims for Other Liability. Consultant shall, to the fullest extent allowed by
law, with respect to all services performed in connection with the Agreement, indemnify,
defend, and hold harmless the City and. its officers, officials, agents, employees and
volunteers against any and all liability, claims, actions, causes of action or demands
whatsoever from and against any of them, including any injury to or death of any person
or damage to property or other liability of any nature, that arise out of, pertain to, or relate
to the negligence, recklessness, or willful misconduct of Consultant or Consultant's
employees, officers, officials, agents or independent contractors. Such costs and
expenses shall include reasonable attorneys' fees of counsel of City's choice, expert fees
and all other costs and fees of litigation. Consultant shall not be obligated under this
Agreement to indemnify City to the extent that the damage is caused by the sole or active
negligence or willful misconduct of City, its agents or employees.
C. Claims involving intellectual property.. In addition to the obligations set forth in (A)
and (B) above, Consultant shall indemnify, defend, and hold the City, its elected and
appointed officers, employees, and volunteers, harmless from and against any Claim in
which a violation of intellectual property rights, including but not limited to copyright or
patent rights, is alleged that arises out of, pertains to, or relates to Consultant's
negligence, recklessness or willful misconduct under this Agreement. Such costs and
expenses shall include reasonable attorneys' fees of counsel of City's choice, expert fees
and all other costs and fees of litigation.
12. INSURANCE:
On or before the commencement of the term of this Agreement, Consultant shall furnish
City with certificates showing the type, amount, class of operations covered, effective dates and
dates of expiration of insurance coverage in compliance with paragraphs 12 A, B, C, D and E.
Such certificates, which do not limit Consultant's indemnification, shall also contain substantially
the following statement: "Should any of the above insurance covered by this certificate be
canceled or coverage reduced before the expiration date thereof, the insurer affording coverage
shall provide thirty (3 0) days' advance written notice to the City of Cupertino by certified mail,
Attention: City Manager." It is agreed that Consultant shall maintain in force at all times during
the performance of this Agreement all appropriate coverage of insurance required by this
Agreement with an insurance company that is acceptable to City and licensed to do insurance
business in the State of California. Endorsements naming the City as additional insured shall be
submitted with the insurance certificates.
A. COVERAGE:
Consultant shall maintain the following insurance coverage:
(1) Workers' Compensation:
Statutory coverage as required by the State of California.
`2 Liabilitr
Co=crcial gc -neral l abili.�7 coverage, in the followilIg r EM MUM line ts:
Bodily Injury: $500,000 each occurrence
$1,000,000 aggregate - all other
Property Damage: $100,000 each occurrence
$250,000 aggregate
If submitted, combined single limit policy with aggregate limits in the
amounts of $1,000,000 will be considered equivalent to the required
minimum limits shown above.
(3) Automotive:
Proof of automobile insurance required at the California statutory
minimums.
(4) Professional Liability:
Professional liability insurance which includes coverage for the
professional acts, errors and omissions of Consultant in the amount of at
least $1,000,000.
B. SUBROGATION WAIVER:
Consultant agrees that in the event of loss due to any of the perils for which he /she has
agreed to provide comprehensive general and automotive liability insurance, Consultant shall
look solely to his/her insurance for recovery. Consultant hereby grants to City, on behalf of any
insurer providing comprehensive general and automotive liability insurance to either Consultant
or City with respect to the services of Consultant herein, a waiver of any right to subrogation
which any such insurer of said Consultant may acquire against City by virtue of the payment of
any loss under such insurance.
C. FAILURE TO SECURE:
If Consultant at any time during the term hereof should fail to secure or maintain the
foregoing insurance, City shall be permitted to obtain such insurance in the Consultant's name or
as an agent of the Consultant and shall be compensated by the Consultant for the costs of the
insurance premiums at the maximum rate permitted by law and computed from the date written
notice is received that the premiums have not been paid.
D. ADDITIONAL INSURED:
City, its City Council, boards and commissions, officers, employees and volunteers shall
be named as an additional insured under all insurance coverages, except any professional liability
insurance, required by this Agreement. The naming of an additional insured shall not affect any
recovery to which such additional insured would be entitled under this policy if not named as
such additional insured. An additional insured named herein shall not be held liable for any
premium, deductible portion of any loss, or expense of any nature on this policy or any extension
thereof. Any other insurance held by an additional insured shall not be required to contribute
anything toward any loss or expense covered by the insurance provided by this policy.
E. SUFFICIENCY OF INSURANCE:
The insurance limits required by City are not represented as being sufficient to protect
Consultant. Consultant is advised to confer with Consultant's insurance broker to determine
adequate coverage for Consultant.
13. CONFLICT OF INTEREST:
Consultant warrants that it is not a conflict of interest for Consultant to perform the
services required by this Agreement. Consultant may be required to fill out a conflict of interest
form if the services provided under this Agreement require Consultant to make certain
gove=nental decisions or serve in a staff capacity as defined in Title 2, Division 6, Section
19 700 of the California Code of Regulations.
14. PROHIBITION AGAINST TRANSFERS:
Consultant shall not assign, sublease, hypothecate, or transfer this Agreement, or any
interest therein, directly or indirectly, by operation of law or otherwise, without prior written
consent of City. Any attempt to do so without said consent shall be null and void, and any
assignee, sub - lessee, hypothecate or transferee shall acquire no right or interest by reason of such
attempted assignment, hypothecation or transfer. However, claims for money by Consultant
from City under this Agreement may be assigned to a bank, trust company or other financial
institution without prior written consent. Written notice of such assignment shall be promptly
furnished to City by Consultant.
The sale, assignment, transfer or other disposition of any of the issued and outstanding
capital stock of Consultant, or of the interest of any general partner or joint venture or syndicate
member or cotenant, if Consultant is a partnership or joint venture or syndicate or co- tenancy,
which shall result in changing the control of Consultant, shall be construed as an assignment of
this Agreement. Control means fifty percent (50 %) or more of the voting power of the
corporation.
15. SUBCONTRACTOR APPROVAL:
Unless prior written consent from City is obtained, only those people and subcontractors
whose names and resumes are attached to this Agreement shall be used in the performance of
this Agreement.
In the event that Consultant employs subcontractors, such subcontractors shall be
required to furnish proof of workers' compensation insurance and shall also be required to carry
general, and professional liability insurance in reasonable conformity to the insurance carried by
Consultant. In addition, any work or services subcontracted hereunder shall be subject to each
provision of this Agreement.
16. PERMITS AND LICENSES:
Consultant, at his/her sole expense, shall obtain and maintain during the term of this
Agreement, all appropriate permits, certificates and that may be required in connection with the
performance of services hereunder.
17. REPORTS:
A. Each and every report, draft, work product, map, record and other document,
hereinafter collectively referred to as "Report", reproduced, prepared or caused to be prepared by
Consultant pursuant to or in connection with this Agreement, shall be the exclusive property of
City. Consultant shall not copyright any Report required by this Agreement and shall execute
appropriate documents to assign to City the copyright to Reports created pursuant to this
Agreement. Any Report, information and data acquired or required by this Agreement shall
become the property of City, and all publication rights are reserved to City. Consultant may
retain a copy of any report furnished to the City pursuant to this Agreement.
B. All Reports prepared by Consultant may be used by City in execution or
implementation of:
(1) The original Project for which Consultant was hired;
(2) Completion of the original Project by others;
(3) Subsequent additions to the original project; and/or
(4) Other City projects as appropriate.
C. Consultant shall, at such time and In such form as City may require, furnish
reports concerning the status of sen7ices required under this Agreement.
D. All Deports acquired is 5-- provided by his Agreement shall be printed on
recycled paper. All Reports shall be copied on both sides of the paper except for one original,
which shall be single sided.
E. No Report, information or other data given to or prepared or assembled by
Consultant pursuant to this Agreement shall be made available to any individual or organization
by Consultant without prior approval by City.
18. RECORDS:
Consultant shall maintain complete and accurate records with respect to sales, costs,
expenses, receipts and other such information required by City that.relate to the performance of
services under this Agreement.
Consultant shall maintain adequate records of services provided in sufficient detail to
permit an evaluation of services. All such records shall be maintained in accordance with
generally accepted accounting principles and shall be clearly identified and readily accessible.
Consultant shall provide free access to such books and records to the representatives of City or
its de- signees at all proper times, and gives City the right to examine and audit same, and to
make transcripts therefrom as necessary, and to allow inspection of all work, data, documents,
proceedings and activities related to this Agreement. Such records, together with supporting
documents, shall be kept separate from other documents and records and shall be maintained for
a period of three (3) years after receipt of final payment.
If supplemental examination or audit of the records is necessary due to concerns raised by
City's preliminary examination or audit of records, and the City's supplemental examination or
audit of the records discloses a failure to adhere to appropriate internal financial controls, or
other breach of contract or failure to act in good faith, then Consultant shall reimburse City for
all reasonable costs and expenses associated with the supplemental examination or audit.
19. NOTICES:
All notices, demands, requests or approvals to be given under this Agreement shall be
given in writing and conclusively shall be deemed served when delivered personally or on the
second business day after the deposit thereof in the United States Mail, postage prepaid,
registered or certified, addressed as hereinafter provided.
City at:
All notices, demands, requests, or approvals from Consultant to City shall be addressed to
City of Cupertino
10300 Torre Ave.
Cupertino CA 95014
Attention: Director of Parks and Recreation
All notices, demands, requests, or approvals from City to Consultant shall be addressed to
Consultant at:
Martha Engber
20. TEEMINA.TION:
In the event Consultant fails or rcf zses to perfo= any of the provisions hereof at the ti-
and in the manner required hereunder, Consultant: shall be deemed in default in the performance
of this Agreement. If such default is not cured within the time specified after receipt by
Consultant from City of written notice of default, specifying the nature of such default and the
steps necessary to cure such default, City may terminate the Agreement forthwith by giving to
the Consultant written notice thereof.
City shall have the option, at its sole discretion and without cause, of terminating this
Agreement by giving thirty (30) days' prior written notice to Consultant as provided herein.
Upon termination of this Agreement, each party shall pay to the other parry that portion of
compensation specified in this Agreement that is earned and unpaid prior to the effective date of
termination.
21. COMPLIANCES:
Consultant shall comply with all state or federal laws and all ordinances, rules and
regulations enacted or issued by City.
22. CONFLICT OF LAW:
This Agreement shall be interpreted under, and enforced by the laws of the State of
California excepting any choice of law rules which may direct the application of laws of another
jurisdiction. The Agreement and obligations of the parties are subject to all valid laws, orders,
rules, and regulations of the authorities having jwisdiction over this Agreement (or the
successors of those authorities.)
Any suits brought pursuant to this Agreement shall be filed with the courts of the County
of Santa Clara, State of California.
23. ADVERTISEMENT:
Consultant shall not post, exhibit, display or allow to be posted, exhibited, displayed any
signs, advertising, show bills, lithographs, posters or cards of any kind pertaining to the services
performed under this Agreement unless prior written approval has been secured from City to do
otherwise.
24. WAIVER:
A waiver by City of any breach of any term, covenant, or condition contained herein shall
not be deemed to be a waiver of any subsequent breach of the same or any other term, covenant,
or condition contained herein, whether of the same or a different character.
22. INTEGRATED CONTRACT:
This Agreement represents the full and complete understanding of every kind or nature
whatsoever between the parties hereto, and all preliminary negotiations and agreements of
whatsoever kind or nature are merged herein. No verbal agreement or implied covenant shall be
held to vary the provisions hereof. Any modification of this Agreement will be effective only by
written execution signed by both City and Consultant.
25. INSERTED PROVISIONS:
Each provision and clause required by law to be inserted into the Agreement shall be
deemed to be enacted herein, and the Agreement shall be read and enforced as though each were
included herein. If through mistake or otherwise, any such provision is not inserted or is not
correctly inserted, the Agreement shall be amended to make such insertion on application by
either party.
26. CA.P'I'rONS:
The captions in this Agreement are for convenience only, are not a part of the Agreement
and in no way affect, limit or amplify the terms or provisions of this Agreement.
IN WITNESS WHEREOF, the parties have caused the Agreement to be executed.
CONSULTANT CITY OF CUPERTINO
A Municipal Corporation
B / By Colleen Ferris
Title �F fr'0s-j Title Recreation Coordinator
Date / i Date May 8, 2012
RECOMMENDED FOR APPROVAL:
APPROVED AS TO FORM:
City Attorney
ATTEST:
.�-t
City Clerk
EXPENDITURE DISTRIBUTION:
570- 6450 -7014
Account Number
$5,000.00
Amount
r0►:v
CONSULTANT SERVICES TO BE PERFORMED
The CONSULTANT will provide Group Fitness Instruction in, but not limited to,
the following programs:
Aerobics, Body Sculpting, TRX
Location and Time of CONSULTANT Services:
Refer to current Fitness Schedule for agreed upon dates, times, and class locations. By
Mutual agreement of both parties, class schedule may change.
Eligible Participant Minimum and Maximums for CONSULTANT Services:
Minimum: 10
Maximum: 45
In the event that less than the required minimum number of participants shall request and
pay for services prior to the agreed upon time for the commencement of services to be
performed by Consultant, City may cancel and withdraw from this Agreement.
Performance of CONSULTANT Services:
City shall have no right of control as *to the manner Consultant performs the services to be
performed. Nevertheless, City may, at any time, observe the manner in which such
services are being performed by the consultant.
The Consultant shall follow all guidelines pertaining to registration procedures as listed
in the passholder contract. Participants may not take part in the program unless they are
members or have paid a drop in fee. All participants and volunteers need to complete the
City's Waiver of Liability form prior to taking part in the program. Contractors are
responsible for supervising minors after class until a parent of legal guardian has arrived.
In the event of an injury occurring to a participant, the Consultant will notify the City
within 1 hour and complete an ABAG Incident Report. The ABAG Incident Report must
be submitted to the City within 24 hours of the injury occurring.
L,>; l ill'
A-CIC, TO WL ED;GEHENT OF 1\1 , NTA-TED I IP:OL T ING RE, QU=I TENTS, .
RE, CELP'T OF TER- A- ENING, AND R.ECELFT OF 1" ENAL, CODES STATUTES
A mandated reporter is an individual who is obligated by lavJ to report suspected cases of
child abuse and neglect. In general, any individual who, in the ordinary course of their
employment, has contact with children is a mandated reporter. Mandated reporters include
child care workers, teachers and coaches. (California Penal Code 11165.7).
If your job duties as an employee or an independent contractor ofC��
include contact with children, you are a Mandated Reporter. Prior to commencing
employment and as a prerequisite of that employment, California law requires that you sign a
statement to the effect that you have knowledge of the provisions of the Mandated Reporter
Law, and will comply with those provisions. (California Penal Code 11166.5).
The following are the Mandated Reporter responsibilities under California law. You are also
being provided with a separate informational document which includes the text of the
California Mandated Reporter Law and contact information for Child Abuse and Neglect
Reporting for the County of Santa Clara. Please review this information carefully and
acknowledge your receipt and understanding where indicated. If you have questions or
concerns about this form or your Mandated Reporter responsibilities, please contact the
Recreation Supervisor at 405 -777 -3120.
I understand that:
• By virtue of my employment or independent contractor status with—_ � F
and because my employment requires me to have contact with children, I am a
Mandated Reporter as defined by California Penal Code 11165.7.
• The following situations trigger mandatory reports: a) Physical Abuse (willful
harming of a child); b) Sexual abuse including sexual assault, child exploitation,
pornography, and trafficking; c) Severe or General Neglect; and d) Extreme
Corporal Punishment (resulting in injury). (Cal. Pen. Code 11165 et. seq.) I
further understand that I may, but am not required to, report suspected Emotional
Abuse.
• If I reasonably suspect that a child is being abused, I must immediately make a
telephone report. I must follow up with a written report within 36 hours. This
report may be made to local law enforcement, or County Sheriff's Department,
Probation Department or Child Welfare Agency. (Cal Pen. Code 11166(a)).
• I anz not required to, but I may, share information about suspected abuse with my
supervisor or management or the parents of the alleged victim.
C a__1.....::Ll , c l -��U'1 L� - �I___ ..
T11y 1deTltTty vJ1�1 L' e l_el3t COr1f1Cent- ur css I e-1 -,r Consent to CTsciositl'G- 01" TI t1iG-
disclosure is made p -L suaI!t to a (,o d-t order. F L11Lhcr, agencies investlga in- tle
mandated report may disclose my Tde1!tlty to one another. (Lai 1�e1i. Co'
11167(d)).
® The following agencies and indi� iduals receiving or investigating mandated
reports may disclose my identity to one another:
o Prosecutors in a criminal prosecuting or in an action initiated under
section 602 of the Welfare, and Institutions Code arising from alleged child
abuse;
• Counsel appointed pursuant to subdivision (c) of Section 317 of the
Welfare and Institutions Code;
• A licensing agency when abuse or neglect in out -of -home care is
reasonably suspected. (Cal Pen. Code 11167.5)
1 may not be disciplined, dismissed, retaliated against, discriminated against or
harassed for malting a mandated report of reasonably suspected child abuse.
e As a Mandated Reporter, I have civil and criminal immunity when making a
report (Cal Pen. Code 11172).
® As a Mandated Reporter, it is a misdemeanor to fail to comply with
Mandated Reporting laws and I can be held criminally liable for failing to
report suspected abuse. The perialty for this is up to six months in County jail, a
fine of not more than $1000, or both. I further understand I could be civilly liable
for failure to report. (Cal. Pen. Code 11166(c)).
I have been provided with a copy of California Penal Code sections 11164- 11174.3
undated Reporter Law).
I understand that I am a legally Mandated Reporter. I am aware of and understand
my responsibilities under the Mandated Reporter laws of this state and am willing and
able to comply. I understand that a copy of this Acknowledgement will be kept in my
personnel file.
1\Tame Signature)
Name (Print)
�?
Date
Qit T of Cupei7dno Consultant D,edarafku
The iTnCL I eC ao IieTej7y CeIt11jT tllc_t:
1. 1 am a representative of � �V Q77 "(consultant or company name); that I
p p y
am familiar with the facts herein and am authorized and qualified to execute this declaration.
2. 1 declare that L /V `� xANe_��b�onsultant or company name) has complied with
fingerprinting and criminal background investigation requirements with respect to all
Consultant's employees who may have contact with minors in the course of providing services
pursuant to the Agreement, and the California Department of Justice has determined that none of
those employees has been convicted of a felony, as that term is defined in California Penal Code
Section 11105.3.
3. That a complete and accurate list of Consultant's employees, who may come in contact with
minors during the course and scope of the Agreement, are included below.
4. All of the below mentioned employees have tested negative for TB, or X -ray results for TB, and
have current documentation on file with Consultant.
5. All of the below mentioned employees have received training and understand their
responsibilities under the Mandated Reporter laws of this state and are willing and able to
comply.
A List of all Consultant Employees Working for the City of Cupertino:
6. The City of Cupertino will be notified by Consultant in writing of any new employees and will
be added to the above list prior to beginning work for the City of Cupertino.
I declare under penalty of penury that the foregoing is true and correct:
7-11, Z— -C, 1A
Date Place Consultant Signa4tdre of
Staff Title: