SUPERIOR COURT OF CALIFORNIA County of Marin ANNUAL DECLARATION OF  PROFESSIONAL  THERAPEUTIC SUPERVISED VISITATION PROVIDER (pursuant to California Rules of Court, Standards of Judicial Administration, Standard 5.20) I declare that:  I am 21 years of age or older;  I have not been convicted of driving under the influence (DUI) within the last 5 years;  I have not been on probation or parole for the last 10 years;  I have no record of a conviction for child molestation, child abuse, or other crimes against a person;  I have proof of automobile insurance and use appropriate vehicle restraints if transporting the child;  I have no civil, criminal, or juvenile restraining orders within the last 10 years;  I have no current or past court order in which the provider is the person being supervised;  If I am unable to speak the language of the party being supervised and of the child, I will provide a neutral interpreter over the age of 18 who is able to do so; and  I agree to adhere to and enforce the court order regarding supervised visitation. I do not have a conflict of interest under subsection (g) in that:  I am not financially dependent on the person being supervised;  I am not an employee of the person being supervised;  I am not affiliated with any superior court in the county in which the supervision is ordered; and  I am not in an intimate relationship with the person being supervised. Please indicate your agreement by checking each box in front of each numbered paragraph.  1. I understand that my principal responsibility is to observe these visits in person and to take action immediately if a child needs protection, reassurance, or a break of any kind from the visit. I agree to perform my duties as a supervised visitation provider neutrally and without any bias or favoritism toward or against the supervised parent.  2. I agree that I will not, under any circumstances, leave the child with the supervised parent outside my presence.  3. I have received a copy of A Guide for the Supervised Visitation Provider (form FL039). I understand the Guide, and agree to comply with each provision in it.  4. I agree that I will report to the court if either parent violates any of the rules described in A Guide for the Supervised Visitation Provider (form FL039) and, if ordered by the court, on all the observations I make during the visits. FL038 (Rev. 6/11) ANNUAL DECLARATION OF PROFESSIONAL/THERAPEUTIC SUPERVISED VISITATION PROVIDER (Mandatory Form) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I declare that I have read the California Standards of Judicial Administration, Standard 5.20, and that I am in full compliance with the following subsections:  (d) Training for providers;  (e) Safety and security procedures;  (f) Ratio of children to provider;  (h) Maintenance and disclosure of records;  (i) Confidentiality;  (j) Delineation of terms and conditions;  (k) Safety considerations for sexual abuse cases;  (l) Legal responsibilities and obligations of a provider;  (m) Additional legal responsibilities of professional and therapeutic providers;  (n) Temporary suspension or termination of supervised visitation; and  (o) Additional requirements for professional and therapeutic providers. If any of the above boxes are not checked, please explain: DATE SIGNATURE OF SUPERVISED VISITATION PROVIDER PRINT NAME OF SUPERVISED VISITATION PROVIDER STREET ADDRESS CITY / ZIP CODE TELEPHONE NUMBER EMAIL ADDRESS FL038 (Rev. 6/11) ANNUAL DECLARATION OF PROFESSIONAL/THERAPEUTIC SUPERVISED VISITATION PROVIDER (Mandatory Form) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com