Common use of COMPENSATION CERTIFICATION Clause in Contracts

COMPENSATION CERTIFICATION. Labor Code Section 3700 in relevant part provides: Every employer except the State shall secure the payment of compensation in one or more of the following ways: • By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State. • By securing from the Director of Industrial Relations a certificate of consent to self-insure, which may be given upon furnishing proof satisfactory to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to its employees. I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the Services of this Agreement. Date: Proper Name of Contractor: Boys & Girls Clubs of Kern County Signature: Print Name: Xxxx Xxxxx Title: Executive Director (In accordance with Article 5 – commencing at Section 1860, Chapter 1 part 7, Division 2 of the Labor Code, the above certificate must be signed and filed with the District prior to performing any Services under this Agreement.) FINGERPRINTING/CRIMINAL BACKGROUND INVESTIGATION CERTIFICATION One of the boxes below must be checked, with the corresponding certification provided, and this form attached to the Independent Contractor Agreement for Special Services (“Agreement”): [To be completed by the authorized District employee only.] The Boys & Girls Clubs of Kern County’s (“Contractor”) employees, agents and volunteers will (1) have only limited contact, if any, with District students and the District will take appropriate steps to protect the safety of any students that may come in contact with the Contractor’s employees so that the fingerprinting and criminal background investigation requirements of Education Code Section 45125.1 shall not apply to the Contractor for the Services under their Agreement; or (2) be under the immediate supervision and direction of certificated personnel of the District so that the fingerprinting and criminal background investigation requirements of Education Code Section 49024 shall not apply to the Contractor for the Services under this Agreement. As an authorized District official, I am familiar with the facts herein certified, and am authorized to execute this certificate on behalf of the District. (Education Code Section 45125.1 [c]) Date: District Representative’s Name and Title: Signature: The fingerprinting and criminal background investigation requirements of Education Code Section 49024 apply to the Contractor’s Services under this Agreement and Contractor certifies its compliance with these provisions as follows: The Contractor certifies that the Contractor has complied with the fingerprinting and criminal background investigation requirements of Education Code Section 49024 with respect to all the Contractor’s volunteers, employees, subcontractors, agents, and subcontractors’ employees or agents (“Contractor Parties”) regardless of whether those Contractor Parties are paid or unpaid, concurrently employed by the District, or acting as independent contractor of the Contractor, who may have contact with District pupils in the course of providing Services pursuant to the Agreement, and the California Department of Justice AND the Federal Bureau of Investigation have determined that none of those Contractor Parties has been convicted of a felony, as that term is defined in Education Code Section 45122. A complete and accurate list of all Contractor Parties who may come in contact with District pupils during the course and scope of the Agreement is attached hereto. I am an authorized representative of the Contractor entering into this Agreement with District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf of the Contractor. Date: Name of Contractor or Company: Boys & Girls Clubs of Kern County Signature: Print Name and Title: Xxxx Xxxxx, Executive Director The undersigned does hereby certify to the Governing Board of the District as follows: I am a representative of the Boys & Girls Clubs of Kern County (“Contractor”) currently entering into this Agreement with the District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf of the Contractor. The Contractor’s responsibility for tuberculosis clearance extends to all of its employees, subcontractors, and employees of subcontractors coming into contact with District students regardless of whether they are designated as employees or acting as independent contractors of the Contractor. The Contractor certifies that at least one of the following items applies to the Services that are the subject of the Agreement: The Contractor has complied with the tuberculosis requirements of Education Code Section 49406.1 with respect to all Contractor’s employees all of its subcontractor’s employees who may have contact with District students in the course of providing Services pursuant to the Agreement, and the California Department of Justice has determined that none of those employees has active tuberculosis, as that term is defined in Education Code Section 45122.1. A complete and accurate list of the Contractor’s employees and of all of its subcontractors’ employees who may come in contact with District students during the course and scope of the Agreement is attached hereto; and/or The Contractor’s Services under the Agreement are to be provided at an unoccupied school site only and/or will not be done on any District property and no employee and/or subcontractor or supplier of any tier of Agreement shall come in contact with District students. Name of Contractor or Company: Boys & Girls Clubs of Kern County Date: Signature: Print Name and Title: Xxxx Xxxxx, Executive Director PARENT PERMISSION FROM FOR STUDENT TO PARTICIPATE IN FIELD TRIP, WAIVER OF LIABILITY AND CONSENT FOR MEDICAL TREATMENT I, (Parent/Guardian of Student), by signing below agree to the following with respect to my daughter/son’s, , (“Student”) participation in the voluntary activity described in this Consent and Release Form. Student has my consent to participate in the field trip described below and may participate in all activities associated with the field trip or school-related trip (hereinafter, “Field Trip”).

COMPENSATION CERTIFICATION. Labor Code Section 3700 in relevant part provides: Every employer except the State shall secure the payment of compensation in one or more of the following ways: • By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State. • By securing from the Director of Industrial Relations a certificate of consent to self-insure, which may be given upon furnishing proof satisfactory to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to its employees. I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the Services of this Agreement. Date: Proper Name of Contractor: Boys & Girls Clubs of Kern County Signature: Print Name: Xxxx Xxxxx Title: Executive Director (In accordance with Article 5 – commencing at Section 1860, Chapter 1 part 7, Division 2 of the Labor Code, the above certificate must be signed and filed with the District prior to performing any Services under this Agreement.) FINGERPRINTING/CRIMINAL BACKGROUND INVESTIGATION CERTIFICATION One of the boxes below must be checked, with the corresponding certification provided, and this form attached to the Independent Contractor Agreement for Special Services (“Agreement”): [To be completed by the authorized District employee only.] The Boys & Girls Clubs of Kern County’s (“Contractor”) employees, agents and volunteers will (1) have only limited contact, if any, with District students and the District will take appropriate steps to protect the safety of any students that may come in contact with the Contractor’s employees so that the fingerprinting and criminal background investigation requirements of Education Code Section 45125.1 shall not apply to the Contractor for the Services under their Agreement; or (2) be under the immediate supervision and direction of certificated personnel of the District so that the fingerprinting and criminal background investigation requirements of Education Code Section 49024 shall not apply to the Contractor for the Services under this Agreement. As an authorized District official, I am familiar with the facts herein certified, and am authorized to execute this certificate on behalf of the District. (Education Code Section 45125.1 [c]) Date: District Representative’s Name and Title: Signature: The fingerprinting and criminal background investigation requirements of Education Code Section 49024 apply to the Contractor’s Services under this Agreement and Contractor certifies its compliance with these provisions as follows: The Contractor certifies that the Contractor has complied with the fingerprinting and criminal background investigation requirements of Education Code Section 49024 with respect to all the Contractor’s volunteers, employees, subcontractors, agents, and subcontractors’ employees or agents (“Contractor Parties”) regardless of whether those Contractor Parties are paid or unpaid, concurrently employed by the District, or acting as independent contractor of the Contractor, who may have contact with District pupils in the course of providing Services pursuant to the Agreement, and the California Department of Justice AND the Federal Bureau of Investigation have determined that none of those Contractor Parties has been convicted of a felony, as that term is defined in Education Code Section 45122. A complete and accurate list of all Contractor Parties who may come in contact with District pupils during the course and scope of the Agreement is attached hereto. I am an authorized representative of the Contractor entering into this Agreement with District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf of the Contractor. Date: Name of Contractor or Company: Boys & Girls Clubs of Kern County Signature: Print Name and Title: Xxxx Xxxxx, Executive Director The undersigned does hereby certify to the Governing Board of the District as follows: I am a representative of the Boys & Girls Clubs of Kern County (“Contractor”) currently entering into this Agreement with the District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf of the Contractor. The Contractor’s responsibility for tuberculosis clearance extends to all of its employees, subcontractors, and employees of subcontractors coming into contact with District students regardless of whether they are designated as employees or acting as independent contractors of the Contractor. The Contractor certifies that at least one of the following items applies to the Services that are the subject of the Agreement: The Contractor has complied with the tuberculosis requirements of Education Code Section 49406.1 with respect to all Contractor’s employees all of its subcontractor’s employees who may have contact with District students in the course of providing Services pursuant to the Agreement, and the California Department of Justice has determined that none of those employees has active tuberculosis, as that term is defined in Education Code Section 45122.1. A complete and accurate list of the Contractor’s employees and of all of its subcontractors’ employees who may come in contact with District students during the course and scope of the Agreement is attached hereto; and/or The Contractor’s Services under the Agreement are to be provided at an unoccupied school site only and/or will not be done on any District property and no employee and/or subcontractor or supplier of any tier of Agreement shall come in contact with District students. Date: Name of Contractor or Company: Boys & Girls Clubs of Kern County Date: Signature: Print Name and Title: Xxxx Xxxxx, Executive Director PARENT PERMISSION FROM FOR STUDENT TO PARTICIPATE IN FIELD TRIP, WAIVER OF LIABILITY AND CONSENT FOR MEDICAL TREATMENT I, (Parent/Guardian of Student), by signing below agree to the following with respect to my daughter/son’s, , (“Student”) participation in the voluntary activity described in this Consent and Release Form. Student has my consent to participate in the field trip described below and may participate in all activities associated with the field trip or school-related trip (hereinafter, “Field Trip”).

COMPENSATION CERTIFICATION. Labor Code Section 3700 in relevant part provides: Every employer except the State shall secure the payment of compensation in one or more of the following ways: • ▪ By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State. • ▪ By securing from the Director of Industrial Relations a certificate of consent to self-self- insure, which may be given upon furnishing proof satisfactory to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to its employees. I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the Services Work of this AgreementContract. Date: Proper 11/1/2024 Name of ContractorVendor or Company: Boys & Girls Clubs of Kern County Managed Facilities Solutions Signature: Print Name: Xxxx Xxxxx Name and Title: Executive Director Xxxxxx Xxxxxx CEO (In accordance with Article 5 – commencing at Section 1860, Chapter 1 1, part 7, Division 2 of the Labor Code, the above certificate must be signed and filed with the District prior to performing any Services Work under this AgreementContract.) FINGERPRINTING/CRIMINAL BACKGROUND INVESTIGATION CERTIFICATION Docusign Envelope ID: 25CC2E74-553C-4735-B85F-725D5364CA69 One of the three boxes below must be checked, with the corresponding certification provided, and this form attached to the Independent Contractor Vendor Agreement for Special Professional Services (“Agreement”): [To be completed by the authorized District employee onlyTO BE COMPLETED BY AUTHORIZED DISTRICT EMPLOYEE ONLY.] The Boys & Girls Clubs of Kern CountyVendor’s (“Contractor”) employees, agents and volunteers employees will (1) have only limited contact, if any, with District students pupils and the District will take appropriate steps to protect the safety of any students pupils that may come in contact with the ContractorVendor’s employees so that the fingerprinting and criminal background investigation requirements of Education Code Section section 45125.1 shall not apply to the Contractor Vendor for the Services under their Agreement; or (2) be under the immediate supervision and direction of certificated personnel of the District so that the fingerprinting and criminal background investigation requirements of Education Code Section 49024 shall not apply to the Contractor for the Services services under this Agreement. As an authorized District official, I am familiar with the facts herein certified, and am authorized to execute this certificate on behalf of the District. (Education Code Section § 45125.1 [(c])) Date: District Representative’s Name and Title: Signature: The fingerprinting and criminal background investigation requirements of Education Code Section 49024 section 45125.1 apply to the ContractorVendor’s Services services under this Agreement and Contractor Vendor certifies its compliance with these provisions as follows: The Contractor “Vendor certifies that the Contractor Vendor has complied with the fingerprinting and criminal background investigation requirements of Education Code Section 49024 section 45125.1 with respect to all the ContractorVendor’s volunteers, employees, subcontractors, agents, and subcontractors’ employees or agents (“Contractor PartiesEmployees”) regardless of whether those Contractor Parties Employees are paid or unpaid, concurrently employed by the District, or acting as independent contractor contractors of the ContractorVendor, who may have contact with District pupils in the course of providing Services services pursuant to the Agreement, and the California Department of Justice AND the Federal Bureau of Investigation have has determined that none of those Contractor Parties Employees has been convicted of a felony, as that term is defined in Education Code Section section 45122. 1. A complete and accurate list of all Contractor Parties Employees who may come in contact with District pupils during the course and scope of the Agreement is attached hereto. I am an authorized representative .” Vendor’s services under this Agreement shall be limited to the construction, reconstruction, rehabilitation, or repair of a school facility and although all Employees will have contact, other than limited contact, with District pupils, pursuant to Education Code section 45125.2 District shall ensure the safety of the Contractor entering into this Agreement with District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf pupils by at least one of the Contractorfollowing as marked: X The installation of a physical barrier at the worksite to limit contact with pupils. Continual supervision and monitoring of all Vendor’s on-site employees of Vendor by an employee of Vendor, , whom the Department of Justice has ascertained has not been convicted of a violent or serious felony. Surveillance of Employees by District personnel. [TO BE COMPLETED BY AUTHORIZED DISTRICT EMPLOYEE ONLY.] Date: Name of Contractor or Company: Boys & Girls Clubs of Kern County Signature: Print District Representative’s Name and Title: Xxxx Xxxxx, Executive Director The undersigned does hereby certify to the Governing Board of the District as followsSignature: I am a representative of the Boys & Girls Clubs of Kern County (“Contractor”) currently Vendor entering into this Agreement with the District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf of the ContractorVendor. The Contractor’s responsibility for tuberculosis clearance extends to all of its employees, subcontractors, and employees of subcontractors coming into contact with District students regardless of whether they are designated as employees or acting as independent contractors of the Contractor. The Contractor certifies that at least one of the following items applies to the Services that are the subject of the AgreementDate: The Contractor has complied with the tuberculosis requirements of Education Code Section 49406.1 with respect to all Contractor’s employees all of its subcontractor’s employees who may have contact with District students in the course of providing Services pursuant to the Agreement, and the California Department of Justice has determined that none of those employees has active tuberculosis, as that term is defined in Education Code Section 45122.1. A complete and accurate list of the Contractor’s employees and of all of its subcontractors’ employees who may come in contact with District students during the course and scope of the Agreement is attached hereto; and/or The Contractor’s Services under the Agreement are to be provided at an unoccupied school site only and/or will not be done on any District property and no employee and/or subcontractor or supplier of any tier of Agreement shall come in contact with District students. Name of Contractor Vendor or Company: Boys & Girls Clubs of Kern County Date: Managed Facilities Solutions Haynes Signature: Print Name and Title: Xxxx Xxxxx, Executive Director PARENT PERMISSION FROM FOR STUDENT TO PARTICIPATE IN FIELD TRIP, WAIVER OF LIABILITY AND CONSENT FOR MEDICAL TREATMENT I, (Parent/Guardian of Student), by signing below agree to the following with respect to my daughter/son’s, , (“Student”) participation in the voluntary activity described in this Consent and Release Form. Student has my consent to participate in the field trip described below and may participate in all activities associated with the field trip or schoolDallas CEO Docusign Envelope ID: 25CC2E74-related trip (hereinafter, “Field Trip”).553C-4735-B85F-725D5364CA69

COMPENSATION CERTIFICATION. Labor Code Section 3700 in relevant part provides: Every employer except the State shall secure the payment of compensation in one or more of the following ways: • By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State. • By securing from the Director of Industrial Relations a certificate of consent to self-insure, which may be given upon furnishing proof satisfactory to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to its employees. I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the Services of this Agreement. Date: Proper Name of Contractor: Boys & Girls Clubs of Kern County Signature: Print Name: Xxxx Xxxxx Title: Executive Director (In accordance with Article 5 – commencing at Section 1860, Chapter 1 part 7, Division 2 of the Labor Code, the above certificate must be signed and filed with the District prior to performing any Services under this Agreement.) FINGERPRINTING/CRIMINAL BACKGROUND INVESTIGATION CERTIFICATION One of the boxes below must be checked, with the corresponding certification provided, and this form attached to the Independent Contractor Agreement for Special Services (“Agreement”): [To be completed by the authorized District employee only.] The Boys & Girls Clubs of Kern County’s (“Contractor”) employees, agents and volunteers will (1) have only limited contact, if any, with District students and the District will take appropriate steps to protect the safety of any students that may come in contact with the Contractor’s employees so that the fingerprinting and criminal background investigation requirements of Education Code Section 45125.1 shall not apply to the Contractor for the Services under their Agreement; or (2) be under the immediate supervision and direction of certificated personnel of the District so that the fingerprinting and criminal background investigation requirements of Education Code Section 49024 shall not apply to the Contractor for the Services under this Agreement. As an authorized District official, I am familiar with the facts herein certified, and am authorized to execute this certificate on behalf of the District. (Education Code Section 45125.1 [c]) Date: _ District Representative’s Name and Title: Signature: The fingerprinting and criminal background investigation requirements of Education Code Section 49024 apply to the Contractor’s Services under this Agreement and Contractor certifies its compliance with these provisions as follows: The Contractor certifies that the Contractor has complied with the fingerprinting and criminal background investigation requirements of Education Code Section 49024 with respect to all the Contractor’s volunteers, employees, subcontractors, agents, and subcontractors’ employees or agents (“Contractor Parties”) regardless of whether those Contractor Parties are paid or unpaid, concurrently employed by the District, or acting as independent contractor of the Contractor, who may have contact with District pupils in the course of providing Services pursuant to the Agreement, and the California Department of Justice AND the Federal Bureau of Investigation have determined that none of those Contractor Parties has been convicted of a felony, as that term is defined in Education Code Section 45122. A complete and accurate list of all Contractor Parties who may come in contact with District pupils during the course and scope of the Agreement is attached hereto. I am an authorized representative of the Contractor entering into this Agreement with District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf of the Contractor. Date: Name of Contractor or Company: Boys & Girls Clubs of Kern County Signature: Print Name and Title: Xxxx Xxxxx, Executive Director The undersigned does hereby certify to the Governing Board of the District as follows: I am a representative of the Boys & Girls Clubs of Kern County (“Contractor”) currently entering into this Agreement with the District and I am familiar with the facts herein certified, and am authorized and qualified to execute this certificate on behalf of the Contractor. The Contractor’s responsibility for tuberculosis clearance extends to all of its employees, subcontractors, and employees of subcontractors coming into contact with District students regardless of whether they are designated as employees or acting as independent contractors of the Contractor. The Contractor certifies that at least one of the following items applies to the Services that are the subject of the Agreement: The Contractor has complied with the tuberculosis requirements of Education Code Section 49406.1 with respect to all Contractor’s employees all of its subcontractor’s employees who may have contact with District students in the course of providing Services pursuant to the Agreement, and the California Department of Justice has determined that none of those employees has active tuberculosis, as that term is defined in Education Code Section 45122.1. A complete and accurate list of the Contractor’s employees and of all of its subcontractors’ employees who may come in contact with District students during the course and scope of the Agreement is attached hereto; and/or The Contractor’s Services under the Agreement are to be provided at an unoccupied school site only and/or will not be done on any District property and no employee and/or subcontractor or supplier of any tier of Agreement shall come in contact with District students. Name of Contractor or Company: Boys & Girls Clubs of Kern County Date: Signature: Print Name and Title: Xxxx Xxxxx, Executive Director PARENT PERMISSION FROM FOR STUDENT TO PARTICIPATE IN FIELD TRIP, WAIVER OF LIABILITY AND CONSENT FOR MEDICAL TREATMENT I, (Parent/Guardian of Student), by signing below agree to the following with respect to my daughter/son’s, _, (“Student”) participation in the voluntary activity described in this Consent and Release Form. Student has my consent to participate in the field trip described below and may participate in all activities associated with the field trip or school-related trip (hereinafter, “Field Trip”).