13-001 Clap ArtsOctober 30, 2013
Clap Arts
1194 8thStreet
San Jose, CA 95112
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
)3•ool
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,
Dorothy Ste fott
Senior Office Assistant
Enclosure
cc: Parks & Recreation
NO.�?�-�
- -14
AGREEMENT BETWEEN THE CITY OF CUPERTINO D
CLAP Arts FOR CONSULTANT SERVICES
THIS AGREEMENT, for reference dated October 1, 2013, is by and between CITY OF
CUPERTINO, a municipal corporation (hereinafter referred to as "City"), and CLAP Arts. a
California, LLC, whose address is 1194 8th Street San Jose, 95112;hp one (408) 564-6067. email
sharon desouzagclaparts.org (hereinafter referred to as "Consultant"), and is made with
reference to the following:
RF.CTTAT.S-
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
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 October 1, 2013, and shall terminate on
June 30, 2014, 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: 70% of Final Roster fees minus a $10.00 administrative fee per student.
Payment by the City to the Consultant for services: Payments will be made one week after the
half -way point and one week after the conclusion of the courses.
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 harmless the
City and its officers, officials, agents, employees and 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 irrvolvina intelleetuaL re r
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.
form if the services provided under this Agreement require Consultant to make certain
governmental decisions or serve in a staff capacity as defined in Title 2, Division 6, Section
18700 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
20. TERMINATION:
In the event Consultant fails or refuses to perform any of the provisions hereof at the time
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 party that portion of
compensation specified in this Agreement that is earned and unpaid prior to the effective date of
termination.
21. COMPLUNCES:
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 jurisdiction over this Agreement (or the
successors of those authorities.)
�brought�ursuant to-th s�reemen� shall be of tllu Cozm-ty 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.
25. 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.
26. 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
EXHIBIT A
CONSULTANT SERVICES TO BE PERFORMED
The CONSULTANT will provide youth theater, dance, and art classes in, but not
limited to, the following programs:
Center Stage, Hip Hop, Get Up and Dance, Act One, Musical Revue, Origami
Location and Time of CONSULTANT Services:
Refer to current Recreation 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: 6
Maximum: 15
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 quarterly recreation schedule. Participants may not take part in the program unless
they are listed on the class roster or can show proof of enrollment. 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.
EXIIIBIT B
ACKNOWLEDGEMENT OF MANDATED REPORTING REQUIREMENTS,
RECEIPT OF TRAINING, AND RECEIPT OF PENAL CODES STATUTES
A mandated reporter is an individual who is obligated by law 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 of _CLAP Arts_ 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 408-777-3120.
I understand that:
• By virtue of my employment or independent contractor status with CLAP Arts,
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 am not required to, but I may, share information about suspected abuse with my
supervisor or management or the parents of the alleged victim.
EXHIBIT C
City of Cupertino Consultant Declaration
The undersigned does hereby certify that:
1. I am a representative of _CLAP Arts (consultant or company name); that I
am familiar with the facts herein and am authorized and qualified to execute this declaration.
2. I declare that CLAP Arts (consultant 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
A List of all Consultant Employees Working for the City of Cupertino:
Niki Braman
Clara Hirsh Walker
_Anna Torraca
Frankie Mendoza
Rachel B arnett
Katherine Goldman
_Paige Lewis
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 perjury that the foregoing is tnie and correct:
_10/11/13
Date Place Consultant Signature
Consultant Title: Partner
OFFICE OF THE CITY CLERK
CITY HALL
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
TELEPHONE: (408) 777-32:23• FAX: (408) 777-3366
WEBSITE: www.cupertino.org
CUPERTINO
August 8, 2013
Clap Arts
Re: Agreement
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,
LC�94 zj-"�
Dorothy Steen ott
Senior Office Assistant
Enclosure
cc: Parks & Recreation
CITY OF AGREEMENT
CITY OF CUPERTINO >
10300 Torre Avenue i
Cupertino, CA 95014
408-777-2:200 0 � NO. QW� Y
CUPERTINO FY 13-14
I�
THIS AGREEME , made and entered into this 1st day of July is by and between the CITY OF
CUPERTINO (Hereinafter "CITY") and (1) CLAP Arts Address:
Hereinafter "CONSULTANT"), in consideration of their mutual covenants, the parties agree as
follows:
CONSULTANT shall provide or furnish the following specified services and/or materials: Youth
theater and dance classes.
Check box if services are further described in an Exhibit.FW
EXHIBITS: The following attached exhibits hereby are made part of this Agreement: Exhibit A,
Exhibit B, & Exhibit C.
TERM: The services and/or materials furnished under this Agreement shall commence on July 1,
2013 and shall be completed no later than December 31, 2013.
COMPENSATION: For the full performance of this Agreement, CITY shall pay CONSULTANT:
CLASSES
$8 per student per class date based on final rosters
CAMPS
$120 per student for half-day camps based on final rosters
$245 per student for full-day camps based on final rosters
Payments shall be issued to consultant no more than 2 times per quarter.
GENERAL TERMS AND CONDITIONS
Hold Harmless. Consultant shall, to the fullest extent allowed by law, indemnify, defend, and hold
harmless the City and its officers, officials, agents, employees and volunteers against any and all
liability, claims, stop notices, 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, arising out of, pertaining to, or rellated to the performance of this Agreement by
Consultant or Consultant's employees, officers, officials, agents or independent Consultants.
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. 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.
Subcontracting. Consultant has been retained due to their unique skills and Consultant may not
substitute another, assign or transfer any rights or obligations under this Agreement. Unless prior
written consent from City is obtained, only those people whose names are listed this Agreement
shall be used in the performance of this Agreement.
Page 1 of 7
Short Form Agreement
Assignment. Consultant may not assign or transfer this Agreement, without prior written consent
of CITY.
Insurance. Consultant shall file with City a Certificate of Insurance consistent with the following
requirements
Coverage:
Consultant shall maintain the following insurance coverage:
(1) Workers' Compensation:
Statutory coverage as required by the State of California.
(2) Liability:
Commercial general liability coverage in the following minimum limits:
Bodily Injury: $1,000,000 each occurrence
$2,000,000 aggregate - all other
Property Damage: $500,000 each occurrence
$1,000,000 aggregate
If submitted, combined single limit policy with aggregate limits in the amounts of$2,000,000 will be
considered equivalent to the required minimum limits shown above.
(3) Automotive:
Comprehensive automobile liability coverage in the following minimum limits:
Bodily injury: $500,000 each occurrence
Property Damage: $500,000 each occurrence
or
Combined Single Limit: $1,000,000 each occurrence
Subrogation Waiver. Consultant agrees that in the event of loss due to any of the perils for which
it has agreed to provide comprehensive general and automotive liability insurance, Consultant
shall look solely to its 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.
Termination of Agreement. The City reserves the right to terminate this Agreement with or
without cause with a thirty (30)-day notice. The Consultant may terminate this Agreement with or
without cause with a thirty (30)-day written notice.
Non-Discrimination. No discrimination shall be made in the employment of persons under this
Agreement because of the race, color, national origin, ancestry, religion, gender or sexual
orientation of such person
Interest of Consultant. It is understood and agreed that this Agreement is not a contract of
employment in the sense that the relationship of master and servant exists between City and
Page 2 of 7
Short Form Agreement
undersigned. At all times, Consultant shall be deemed to be an independent Consultant and
Consultant is not authorized to bind the City to any contracts or other obligations in executing this
Agreement. Consultant certifies that no one who has or will have any financial interest under this
Agreement is an officer or employee of City. 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 comply with all applicable Federal, State, and local laws and ordinances
including, but not limited to, unemployment insurance benefits, FICA laws, and the City business
license ordinance.
Changes. No changes or variations of any kind acre authorized without the written consent of the
City.
CONTRACT COORDINATOR and representative for CITY shall be:
NAME: Rachelle Sander DEPARTMENT: Parks and Recreation
This Agreement shall become effective upon its execution by CITY, in witness thereof; the parties
have executed this Agreement the day and year first written above.
CONSULTANT: CITY OF CUPERTINO:
Title: Recreation Coordinator
APPROVALS EXPENDITURE DISTRIBUTION
T HEAD DATE -ACCOUNT NUMBER AMOUNT
4—e. – 580-6349-7014 $5,000.00
ATMMRN Y APPROVED AS TO FORM DATE
CI JERK: ATTEST DATE
Page 3 of 7
Short Form Agreement
EXHIBIT A
CONSULTANT SERVICES TO BE PERFORMED
The CONSULTANT will provide youth parent participation art class instruction in,but not limited to,
the following programs:
Hip Hop, Dance Act Perform, Hogwarts camps
Location and Time of CONSULTANT Services:
Refer to current Recreation 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: 8
Maximum: 16
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 quarterly
recreation schedule. Participants may not take part in the program unless they are listed on the class roster or
can show proof of enrollment. 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.
Page 4 of 7
Short Form Agreement
EXHIBIT B
ACKNOWLEDGEMENT OF MANDATED REPORTING REQUIREMENTS,RECEIPT OF
TRAINING,AND RECEIPT OF PENAL CODES STATUTES
A mandated reporter is an individual who is obligated by law 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 of Sharon DeSouza 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 408-777-3120.
I understand that:
• By virtue of my employment or independent contractor status with Sharon DeSouza,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(,0).
• I am not required to,but I may, share information about suspected abuse with my supervisor
or management or the parents of the alleged victim.
• When I make a mandated report, I will be required to give my name. However, my identity
will be kept confidential unless I either consent to disclosure or if the disclosure is made
pursuant to a court order. Further, agencies investigating the mandated report may disclose
my identity to one another. (Cal Pen. Code 11167(d)).
Page 5 of 7
Short Form Agreement
• The following agencies and individuals receiving or investigating mandated reports may
disclose my identity to one another:
• 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)
• I may not be disciplined, dismissed,retaliated against, discriminated against or harassed for
making a mandated report of reasonably suspected child abuse.
• 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 penalty 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,via e-mail,with a copy of California Penal Code sections 11164-11174.3
(Mandated 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.
Name (Signature) Date
Name (Print)
Page 6 of 7
Short Form Agreement
EXHIBIT C
City of Cupertino Consultant Declaration
The undersigned does hereby certify that:
1. I am a representative of Avg (consultant or company name); that I am
familiar with the facts herein and am authorized and qualified to execute this declaration.
2. 1 declare that CA-09 (consultant 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:
pQ " _
A-1�Jr!4. _N Zc _
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 perjury that the foregoing is true and correct:
Date Place Consultant Signature
Consultant Title:
Page 7 of 7
Short Form Agreement