15-001 Polly Hu (2) CITY OF
SHORT FORM AGREEMENT
(Less than$5,000)
CITY OF CUPERTINO
[1 1 10300 Torre Avenue
CUPERTINO Cupertino,CA 95014 s
408-777-3200 NO. 1 , "
This Agreement,made and entered into this 2 day of June,2015,(the"Effective Date")is by and between the
City of Cupertino (hereinafter"City")and Polly Hu hereinafter
"Contractor"),in consideration of their mutual covenants,the parties agree as follows:
A. SCOPE OF SERVICES. Contractor shall provide or furnish the following specified services and/or
materials:Fitness instructor Services are further described in Exhibit"A".
B. TERM. The services and/or materials furnished under this Agreemenf shall commence on July 1,2015
and shall be completed no later than June 30,2016.
C. COMPENSATION. For the full performance of this Agreement,CITY shall pay Contractor a total
amount not to exceed five thousand dollars($5,000). Consisting of the following:$35 per 60 minute class.
D. EXHIBITS. The following attached exhibits hereby are made part of this Agreement:
❑Exhibit"A"-Scope of Services
❑Exhibit`B"-Acknowledgement of Mandated Reporting Requirements,Receipt of Training,and Receipt of Penal
Code Statutes Exhibits"B"and"C"are for anyone working with minors
El Exhibit"C"-City of Cupertino,Consultant Declaration
GENERAL TERMS AND CONDITIONS
1.Hold Harmless. Contractor shall, to the fullest extent allowed by law and without limitation of the provisions of
this Agreement related to insurance, 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
Contractor or Contractor'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. The acceptance of the Services by City shall not operate as a waiver of the right of indemnification.
The provisions of this Section survive the completion of the Services or termination of this Contract.
2. Subcontracting. Contractor has been retained due to their unique skills and Contractor 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.
3. Assignment. Contractor may not assign,transfer, or subcontract this Agreement or any portions thereof, without
prior written consent of City.
4. Insurance. Contractor shall maintain the following insurance coverage, with the City as an additional named
insured, and provide a Certificate of Insurance and Additional Insured Endorsement consistent with the following
requirements:
(a)Workers' Compensation: Statutory coverage as required by the State of California.
(b)Liability: Commercial general liability coverage,without an exclusion for sexual abuse and
molestation, in the following minimum limits:
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.
F
(c)Automotive:Comprehensive automotive liability coverage in the following minimum limits:
Bodily Injury: $500,000 each occurrence r
Property Damage: $100,000 each occurrence
or
Combined Single Limit: $500,000 each occurrence
5.Subrogation Waiver.Contractor 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, Contractor shall look solely to its insurance for
recovery. Contractor hereby grants to City, on behalf of any insurer providing comprehensive general and
automotive liability insurance to either Contractor or City with respect to the services of Contractor herein,a waiver
of any right to subrogation which any such insurer of said Contractor may acquire against City by virtue of the
payment of any loss under such insurance.
6. Termination of Agreement. In the event Contractor fails or refuses to perform any of the provisions hereof at
the time and in the manner required hereunder, Contractor shall be deemed in default in the performance of this
Agreement. If Contractor fails to cure the default within the time specified and according to the requirements set
forth in City's written notice of default, and in addition to any other remedy available to the City by law, the City
Manager may terminate the Agreement by giving Contractor written notice thereof, which shall be effective
immediately. The City Manager shall also have the option, at its sole discretion and without cause, of terminating
this Agreement by giving seven (7) calendar days' prior written notice to Contractor as provided herein. Upon
receipt of any notice of termination,Contractor shall immediately discontinue performance.
7. Non-Discrimination. Contractor shall not discriminate against a job applicant, employee, City employee, or a
citizen on the basis of race, color, national origin, ancestry, religion, gender, sexual orientation or other protected
class of such person.
8. Interest of Contractor. It is understood and agreed that this Agreement is not a contract of employment and, at
all times, Contractor shall be deemed to be an independent contractor and Contractor is not authorized to bind the
City to any contracts or other obligations in executing this Agreement. Contractor 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 Contractor performs the services to be performed. Nevertheless, City may, at any time,
observe the manner in which such services are being performed by the contractor. Contractor 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.
9. Permits and Licenses. Contractor, at his/her own expense, shall obtain and maintain during the term of this
Agreement,all appropriate permits,licenses, and certificates including but not limited to a City business license,that
may be required in connection with the performance of services under this Agreement.
10.Reports and Records.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 Contractor pursuant to or in
connection with this Agreement, shall be the exclusive property of City. Contractor 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. Contractor may retain a copy of any
report furnished to the City pursuant to this Agreement.
Contractor 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, 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. Contractor shall provide free
access to such books and records to the representatives of City or its designees 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 Contractor receives final payment from City for all services required under this agreement.
11. Changes. No changes or variations of any kind are authorized without the written consent of the City.
CONTRACT CO-ORDINATOR and representative for CITY shall be: Colleen Ferris, Recreation and Community
Services
In witness thereof,the parties have executed this Agreement the day and year first written above.
CONTRACTOR:
By:
Title: C-60
Tax I.D:. �(,
CITY OF CUPERTI O:
By: Colleen Ferris
Title:Recreation Coordinator
APPROVALS EXPENDITURE DISTRIBUTION (z"'
DEPARTMENT HEAD DATE ACCOUNT NUMBER AMOUNT
XT� ,.r A10pd Chj3lj 570-63-621-700-702 $5,000.00
CITYA,�'O Y PRO D AS'TO FORM DATE
C�
CITY ERK: ATTE DATE
EXHIBIT A
CONSULTANT SERVICES TO BE PERFORMED
The CONSULTANT will provide insert what the consultant is to do, like "provide youth
camps" in, but not limited to, the following programs:
Instruct Fitness Classes
Location and Time of CONSULTANT Services:
Refer to the Recreation Schedule dated Insert date of Rec Schedule or official title of that
document 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: 50
If less than the required minimum number of participants enroll in and pay for a particular class
as identified in the schedule before the class is scheduled to start,the City may cancel the
particular class and/or terminate this Agreement without additional notice or payment to
Consultant.
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 Incident Report in the form approved by the City. The Incident Report
must be submitted to the City within 24 hours of the injury occurring.
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 CONTRACTOR. 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:
o By virtue of my employment or independent contractor status with
CONTRACTOR, 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 Sheriffs 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.
® 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)).
e The following agencies and individuals 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;
o Counsel appointed pursuant to subdivision(c) of Section 317 of the
Welfare and Institutions Code;
o 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 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 (Signatur• ) Date
Name (Print) 61
EXHIBIT C
City of Cupertino Consultant Declaration
The undersigned does hereby certify that:
1. I am a representative of Polly Hu; that I am familiar with the facts herein and am
authorized and qualified to execute this declaration.
2. I declare that Polly Hu 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 at the City of Cupertino.
I declare under penalty of perjury that the foregoing is true and correct:
Vie-
Date Place Consultarx Signature Title