LOS ANGELES UNIFIED SCHOOL DISTRICT



LOS ANGELES UNIFIED SCHOOL DISTRICT

Student Health and Human Services Division

MEMORANDUM OF UNDERSTANDING

AGREEMENT FOR VOLUNTEER MENTAL AND/OR HEALTH SERVICES ON SCHOOL SITES

| This agreement is entered into between |      |

hereinafter referred to as “Provider,” and LOS ANGELES UNIFIED SCHOOL DISTRICT hereinafter referred to as “District,” for the purpose of providing selected health services on school site(s) of the District. It is recognized that the provisions of this agreement shall be construed in a manner not inconsistent with the California Education Code and other laws of the State of California.

In furtherance of the foregoing purpose, Provider and District agree as follows:

| 1. Term of Agreement. This agreement shall be in effect on |      |

|and shall remain effective through |      |This agreement is subject to |

cancellation on twenty (20) calendar days written notice by either party. Renewal of agreement may occur on execution of an amendment to the agreement approving such extension.

2. Location. The delivery of services by Provider will be on the premises of______________

|      | school and any additional sites listed |

(Lead School Only)

in the School Site Service Delivery Plan which shall be attached hereto and made a part hereof. Additional sites may be added by completion and submission of a School Site Service Delivery Plan executed by both parties. Services shall be delivered on days and at times mutually agreed to by the parties.

3. Staffing. Provider shall be solely responsible for staff providing services under this agreement. Provider certifies that staff and/or trainees providing the services are adequately trained and prepared according to prevailing professional standards for providing such services and that

personnel providing clinic and/or counseling services are licensed or otherwise legally qualified. Provider certifies that it shall provide adequate supervision of the staff and/or trainees. Provider certifies that staff/trainees will follow legal guidelines on reporting child abuse/neglect. Provider certifies that all personnel in contact with students are adequately screened so as to prevent the assignment of personnel who may pose a threat to the safety and welfare of students. All personnel shall provide evidence of freedom from tuberculosis within six months prior to the commencement of service.

4. Equipment. Provider will be responsible for the cost and care of equipment.

4. Conflict Resolution. Should any problems or conflicts arise in the course of the delivery of services, it is understood that the authorized representative of District will work with the parties in conflict to accomplish an effective resolution through mediation.

5. Description of Service. The Provider shall be responsible for the services described in the Service Delivery Plan, a copy of which is attached and made a part hereof. Parent/guardian written consent is required in accordance with Section §11, below.

6. Billing. Services will be provided at no cost to the District or students served. No Pre-K through 12-grade student enrolled in a traditional educational program otherwise eligible for services shall be denied such services due to inability to pay for same. Medi-Cal, Healthy Families, CHDP and other third party payers may be billed for eligible patients.

7. Insurance. Provider shall present District with an original Certificate of Insurance evidencing insurance coverage for General Liability, Medical Malpractice and Workers’ Compensation. Evidence of insurance covering vehicles will also be required if Provider’s services involve use of vehicle(s) on District site(s) or providing transportation to District students.

Provider’s general liability and medical malpractice and vehicle coverage shall, at a minimum, provide for limits of $1,000,000/$3,000,000 per claim/occurrence. District shall be named as an additional insured. Provider shall maintain the aforementioned insurance in effect at all time during the life of this agreement. District warrants that it is self-insured with a reserve in excess of $3,000,000.

8. Liability. Provider shall defend and indemnify District, its officers, agents and employees against all claims, regardless of form, and lawsuits for damages for death or injury to persons or property arising from or connected with services rendered by Provider, its officers, agents or employees under this agreement.

District shall defend and indemnify Provider, its officers, agents and employees against all claims regardless of form, and lawsuits for damages for death or injury to persons or property arising from or connected with services rendered by District, its officers, agents or employees under this agreement.

10. Independent Contractor. While engaged in performance of this agreement, Provider is an independent contractor and is not an officer, agent, or employee of District.

11. Parent Consent for Services. Should services by Provider include any form of medical or psychological services, including diagnostic services, treatment, or counseling, Provider shall obtain written parent/guardian consent on District approved form prior to providing service(s) to a minor.

12. Confidentiality of Records. Provider and District recognize that records maintained by them respectively relative to pupils are confidential pursuant to related provisions of federal and state law.

13. Notice. Any notice pursuant to this agreement shall be deemed given when deposited in certified mail, all charges prepaid, and addressed to District personnel/Provider listed below.

John Di Cecco, Director

Integrated Student Health Partnership Programs

644 W. 17th Street, Bungalow B

Los Angeles, CA 90015

IN WITNESS HEREOF, THE PARTIES HERETO HAVE CAUSED THIS AGREEMENT TO BE DULY EXECUTED.

1) DISTRICT LOS ANGELES UNIFIED SCHOOL DISTRICT

|      |

DATED BY_____________________________________

S. THAIS ROTHMAN

Contracts Supervisor

2) LEAD SCHOOL

|      |

DATED ____________________________________ School Principal

3) PROVIDER

|      |

DATED BY______________________________________

Authorized Signature

_______________________________________

PROVIDER NAME

_______________________________________

Title

_______________________________________

Address

_______________________________________

|      |

Federal ID Number:

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Ref. 5

Ref. 4

Ref. 3

AGREEMENT NO.

Rev. 10/99

Agency

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