LOS ANGELES UNIFIED SCHOOL DISTRICT

Division of Student Health and Human Services

AGENCY SERVICE DELIVERY APPLICATION

(Initial Application for Volunteer Services to LAUSD)

FOR VOLUNTEER* MENTAL AND HEALTH SERVICES ON SCHOOL SITE(S)

A. GENERAL INFORMATION
Name of Agency:
Agency Executive Director: / Title:
Business Address: / Business Telephone:
Fax: ______
Contact Person For Agency: / Telephone:
LEAD School in MOU:
Contact Person For Lead School: : / Telephone:
District and Complex:
Services Planning Area (SPA): Provider:
Grade Level(s): / Pre-School / E.S.
_____ / M.S. _____
_____ / H.S. / Adults ______
Proposed Dates of Services: / From: / To:
Language(s) spoken by agency personnel on site:

B. AGENCY PERSONNEL ON SCHOOL SITE TO DELIVER SERVICES

(Provide clear copies of licenses, credentials, and certifications appropriate to services)

(Check all that apply)
NAME / LIC. TYPE / LIC. NO. / EXP. DATE / TB DATE / INTERN / CLERICAL / SUPERVISOR / OTHER

C. THIRD PARTY PAYERS: Are you planning to bill Medi-Cal, CHDP, or other health insurance agencies?

Yes No Explain:

D. MEMORANDUM OF UNDERSTANDING (MOU) Use attached MOU Agreement for Volunteer Health Services on school sites. Provide a signed original. A copy signed by the LAUSD representative will be returned to you after it has been signed by the District’s Contracts Supervisor.

* The term “Volunteer Service” is defined by LAUSD as any service delivered at no cost to the District under the terms and conditions set forth in a Memorandum Of Understanding (MOU), and, use of this term does not imply that professional services rendered by an agency are uncompensated or unfunded by other non-District sources.

E. INSURANCE INFORMATION: Provide only original Certificates of Insurance.

Provider’s general liability, medical malpractice and vehicle coverage shall, at a minimum, provide for limits of $1,000,000/$3,000,000 per claim/occurrence. Los Angeles Unified School District shall be named as an additional insured. Provider shall maintain the aforementioned insurance in effect at all times during the life of this agreement. Los Angeles Unified School District shall be named as certificate holder.

(Ins. Co.) (Policy No.) (Exp. Date)

General Liability
Professional Malpractice
Workers’ Compensation
Vehicle*

*(If used to transport students/families and /or used to provide services.)

F.  TUBERCULOSIS CLEARANCE: Provide an individual Tuberculosis Clearance Form for each volunteer. The test must be administered within 6 months prior to application submission.

G.  CONVICTIONS: Provider certifies that all personnel providing services to students have been screened so as to prevent the assignment of personnel who have been convicted of a felony or have a pending criminal court case and/or may pose a threat to the safety and welfare of students.

Yes No
If no, please explain:

The following staff has reviewed the Service Delivery Application and accompanying School Site Delivery Plans, Memorandum of Understanding and approves this application:

4 SIGNATURE______DATE______

(District Nursing or Mental Health Coordinator)

4 SIGNATURE ______DATE______District Organization Facilitator

For Office Use Only

APPROVED

4 SIGNATURE ______DATE______

LAUSD Applicable Director

SUBMITTED

4 SIGNATURE ______DATE______

Director of Integrated Student Health Partnerships