RETURN TO ATHLETIC DIRECTOR CMS AFTER SCHOOL SPORTS INSURANCE

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Columbia Middle School

Return to Athletic Director


CMS After School Sports

INSURANCE

We strongly recommend that parents carry health or accident insurance for their son/daughter.  The Sunnyvale School District neither carries accident insurance to cover sports related injuries, nor does it accept liability for such injuries.  Student accident insurance is offered through All American Life Insurance Company.


UNIFORM RESPONSIBILITY

It is the responsibility of the athlete and parent to care for and maintain the sports uniform.  If lost or damaged, the sports uniform must be paid for by the athlete and/or parent.  Athletes will be assigned one uniform per season.


FEES

Each season, students are responsible for a $35 participation fee. Checks need to be made out to the City of Sunnyvale, cash is accepted.  Refunds will be given through the second game of each season.


STATE/DISTRICT ELIGIBILITY REQUIREMENT

To encourage and promote academic excellence, students participating in extra co-curricular activities shall complete an eligibility card daily in order to participate in after school sports.  Students who do not complete this card or receive a failing grade will be ineligible for that day or multiple days. In order to participate, these card have to be turn in on time after school.


BEHAVIOR

The following behaviors are unacceptable at VJHSAL events. Violators will be asked to leave the premises. Repeated instances of unacceptable behavior will result in permanent exclusion of VJHSAL events.

  1. Verbally berating players, coaches, officials, or other spectators

  2. Obscene language or gestures directed at players, coaches, officials, or spectators

  3. Physical violence or threat of violence directed at players, coaches, officials, or other spectators


NOTIFICATION OF NON-DISCRIMINATION POLICY

The Sunnyvale School District is committed to providing equal opportunity for all individuals in education. District programs, activities, and practices shall be free from unlawful discrimination, harassment, intimidation, and bullying, including discrimination against an individual or group, on the basis of actual or perceived ancestry, color, national origin, sex, age, religion, gender, sexual orientation, gender expression, gender identity, actual or potential marital or parental status, pregnancy, actual or potential family status, physical or mental disability, nationality, race or ethnicity, ethnic group identification, medical condition, genetic information, homelessness or foster status; a perception of one or more of such characteristics; or association with a person or group with one or more of these actual or perceived characteristics.



CONSENT/TRANSPORTATION

I hereby give permission for my son/daughter to participate in the AFTER SCHOOL SPORTS PROGRAM at Columbia Middle School and to be transported to and from athletic events by the district personnel or parent’s automobile.  In case of an emergency and I cannot be reached, I authorize the school personnel to grant medical treatment for my son/daughter.  Also, attached is a practice and game schedule, area league map, and transportation by parent’s request.


I have been provided with and have read the following information and understand that this information must be followed.

*Student Insurance Liability *State/District Eligibility Requirement               * Fees

*Uniform Responsibility *Consent/Transportation            * Behavior


Student Name: ________________________________________________  Date: ______________

Parent/Guardian Signature: ________________________________   EmergencyPhoneNo. ____________________

PhoneNumber, work/phone: _______________________________       Doctor Name & Phone No. ________________


Available to drive students?       Please select one:   NO *YES


*If yes, please see Anthony Valdovinos at the CMS Office to complete the certification form and submit proof of insurance.


                     Return to Athletic Director


Columbia Middle School

739 Morse Avenue

Sunnyvale, CA 94085

408-522-8247


RETURN TO ATHLETIC DIRECTOR CMS AFTER SCHOOL SPORTS INSURANCE



Who: After School Sports Athletes

What: Away Games (see attached schedule)

When: As scheduled (see attached schedule)

Where: As scheduled (see attached schedule)

Why: Away Games

How: Private Automobile


My son/daughter, ___________________________________________ has my permission to go on to away games per the attached schedule.  

I understand transportation will be by private automobile leaving the school at approximately 3:10 p.m. and returning between 5:30 and 6:00 p.m.


California Education Code Section 35330 provides that all persons making the voluntary field trip are deemed to have waived all liability claims against the Sunnyvale School District.




____________________________________ ________________________
Parent/Guardian Signature Telephone Number


___________

Date


                                               










Sunnyvale School District

Columbia Middle School 739 Morse Ave. Sunnyvale, CA 94085

408.522.8247


Driver Certification Form



Driver’s Name: _____________________________________________________ Driver is a (circle one): Parent Volunteer Employee

Driver’s Address: ___________________________________________________________ Driver’s Phone/Cell No. __________________

Destination: __________________________________________ Estimated No. of Miles: ______________________

Purpose/Description of the trip: _____________________________________________ CA Driver’s License No. ______________________


Vehicle Information:

Registered Owner’s Name: ___________________________________________________________________

Vehicle Make: _______________________ Vehicle Model: ____________________________ Vehicle License Plate No. :______________

Number of Seatbelts: ____________ Registration Expires: ___________________________


Insurance Information:

Insurance Company: _____________________________________________________________ Policy Number: ______________________

Liability Limit: ________________________________


The minimum acceptable liability for privately owned vehicles is $100,000 per occurrence.

Your Insurance policy declarations page with coverage information MUST accompany this page.


Name of Insurance Agent: ________________________________________________ Agent’s Phone Number: ___________________


I certify that the information above is true and correct and I have read the attached board police BP 3541.1.

I understand that if an accident occurs, my insurance coverage shall bear primary responsibility for any losses of claims for damages.


Signature: _________________________________________________________________________ Date: ____________________



Note: A COPY OF YOUR INSURANCE POLICY & DRIVERS LICENCE MUST ACCOMPANY THIS CERTIFICATION FORM!

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Sunnyvale SD Board Policy BP 3541.1

Business and Non Instructional Operations

School-Related Trips-Transportation by School Vehicles

Besides taking students to and from school, school vehicles shall provide transportation for field trips and for special activities approved by the Governing Board. Such trips may be taken in buses or other school transportation vehicles owned, leased, or rented by the district. All vehicles shall meet federal and state standards.

The Superintendent or designee shall maintain procedures to regulate the use of the vehicles for approved school-related activities. Activity trips occurring outside of school hours shall be subject to the rules and policies regulating educational field trips. Student councils, parent-teacher associations, and any other organizations requesting transportation shall be fully responsible for the costs of the trip. To the extent that funding has been approved by the Board, such costs may be charged to the district. (cf. 6153 - Field Trips)

Transportation by Private Automobile

The Superintendent or designee may authorize the transportation of students by private automobile for approved field trips and activities when the vehicle is driven by an adult who has registered with the district for such purposes by filing a completed School Driver Certification Form (E(1)3541.1). When filing the School Driver Certification Form, all drivers shall be issued the Driver Instruction Form (E(2)3541.1) and asked to keep it in their car. All student passengers shall provide permission slips signed by their parents/guardians.

Drivers shall be required to possess a valid California driver's license and liability insurance of at least $100,000 per occurrence.

Owners, drivers and passengers shall be informed that the registered owner and his/her insurance company are responsible for any accidents which may occur. District personnel who frequently transport students in their private vehicles are urged to carry liability insurance of $300,000 or more per occurrence.

A seat belt must be provided for each passenger.

Trucks and pickups may not transport more persons than can safely sit in the passenger compartment.

The number of passengers, including the driver, shall not exceed the capacity for which the vehicle was designed and should not in any case exceed 10. (Education Code 39830)

Policy SUNNYVALE ELEMENTARY SCHOOL DISTRICT adopted: January 4, 1996 Sunnyvale, California

www.gamutonline.net














City of Sunnyvale Parks and Recreation Department

Emergency Card



Child’s Name______________________________________________________ Age ___________


Address______________________________________________________________ Birthdate ________________________


Mother’s/Guardian’s Name: _________________________________________ HM Phone (_______)_______________


Cell Phone (_______)______________ WK Phone (_______)_______________


Father’s/Guardian’s Name: __________________________________________ HM Phone (_______)_______________


Cell Phone (_______)_______________ WK Phone (_______)_______________


Emergency Contacts (Other than Parent/Guardians)


1.) __________________________________________________ HM Phone (_______)_______________

(Name/Relationship)

Cell Phone (_______)_______________ WK Phone (_______)_______________


2.) __________________________________________________ HM Phone (_______)_______________

(Name/Relationship)

Cell Phone (_______)_______________ WK Phone (_______)_______________


Additional Information (Allergies to Food, Bee Stings-Medications; Dietary Information; Developmental Disorders; Medications Etc…)



Please List Adults Permitted to Pick Up Your Child From The Program


1.) Name ______________________________________ HM Phone (____)____________


2.) Name ______________________________________ HM Phone (____)___________


________ My initials here indicate it is okay for my child to sign him/herself out of the program.

Liability Waiver

In consideration of participation in a class or activity offered by the Park and Recreation Department of the City of Sunnyvale, I, the undersigned for myself and/or as the  parent/guardian of the Minor named above, agree to indemnify and hold the City of Sunnyvale harmless and hereby waive, release and discharge any and all claims for damage, for death, personal injury, bodily injury or property damage which I and/or the Minor  may have or which hereinafter may accrue to me and/or the Minor against the City of Sunnyvale, its City Council, employees, agents, and volunteers from and against any liability arising out of or connected in any way with my and/or the Minor’s  participation in this class or activity, even though that liability may arise out of negligence or carelessness on the part of the person or entities mentioned above.


I understand that accidents and injuries can arise from participation in this class or activity; knowing the risks, nevertheless, I hereby agree to assume those risks on behalf of me and/or the above named Minor and to release and to hold harmless all of the persons or entities mentioned above whom (through negligence or carelessness) might otherwise be liable to me and/or the above named Minor (or my/our heirs or assignees) for damages. It is further understood and agreed that this waiver, release and assumption of risks has been freely entered into and is to be binding on my/our heirs and assigns.


I have read and agree to the registration and program policies. Further, I agree to allow use of my image and/or that of the above named Minor which may be captured through video, photo, digital camera or other media, for City of Sunnyvale promotional materials and publications. By my signature above, I acknowledge that I have read this document and understand its contents.


_____________________________________________             ________________________________________                         _____________________________

Print Parent/Guardian Name Parent/Guardian Signature Date



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