Background Check Certification

Organizations that provide classes, camps, or other services involving interaction with or supervision of minors under the age of 18, or other vulnerable populations are required to complete this certification.

Organization Information

Organization Name:

Authorized Representative:

Title:

Email:

Phone:

Certification

Please certify the following:

Employees, instructors, or service providers of the Organization, 18 years of age or older, who provide instruction or other services to the City of Palo Alto, have passed (cleared) a Livescan background check at a minimum service level of the California Department of Justice (DOJ), prior to providing services to the City.

Employees, instructors, or service providers of the Organization, 18 years of age or older, who provide instruction or other services to the City of Palo Alto have not been convicted of a serious crime or violent felony as defined by Education Code Section 45122.1 and Penal Code Sections

667.5 and 1192.7.

Organization adheres to California AB 506 requirements for youth service organizations, including mandated reporter training, policies to prevent child abuse, and background check requirements for administrators, employees, and regular volunteers who have direct contact with minors.

Please accept the following:

The Organization shall submit a roster of individuals who have completed LiveScan clearance, based on records maintained in the Organization’s in-house records system. The roster shall include only the individual’s full name and LiveScan clearance date. No other information shall be submitted.

Submit the completed roster to the City of Palo Alto by email to: risk@paloalto.gov

Organization will promptly notify the City if any certification information changes or if an individual becomes ineligible to provide services.

mailto:risk@paloalto.gov

Background Check Certification

Waiver of Liability / Indemnification

Please accept the following terms and conditions:

To the fullest extent permitted by law, Organization acknowledges that the City is relying on Organization’s certifications regarding Livescan clearance, eligibility, and compliance with applicable laws, including AB 506 where applicable.

Organization agrees to defend, indemnify, and hold harmless the City of Palo Alto, its officers, officials, employees, agents, and volunteers from and against any and all claims, demands, losses, liabilities, damages, costs, or expenses, arising out of or related to Organization’s failure to conduct required background checks, failure to comply with applicable law, misrepresentation of eligibility or clearance status, or assignment of any individual who is not eligible to provide services.

This provision does not waive any protections, immunities, or defenses available to the City under law. This provision does not waive any protections, immunities, or defenses available to the City under law.

Signature:

Full Name:

Title:

Date