Napa County Office of Education
Sports Forms
Agreement for Team Participation
Before a student tries out for, participates in practices or training sessions, or is actually involved in team/group events, this form must be signed acknowledging the risks associated with such activities (including risks of injury during transportation to and from off-site events), the student’s and parent’s agreed compliance with districts safety rules, and the authorization to administer emergency care in the case of injury. The form also requires information regarding statutorily required insurance the student must provide, absent financial circumstances requiring that such insurance/coverage be obtained through other sources.
Concussion Head Injury Information Sheet
Sheet must be provided each year to students participating in any District-sponsored sports programs or activities (interscholastic, intramural, recreational); the only exception to the statutory requirement is for P.E. classes.
Concussion Head Injury Report Form and Medical Release
Used by District to track students removed from sports participation who cannot resume participation until they obtain medical clearance. Form also contains required medical clearance form to be executed only by MD/DO (required by law), except for non- concussion situations, where NP/PA can also sign.
COVID-19 Health & Information Form
To be completed by the student's parent or legal guardian, the COVID-19 Health & Information Form addresses students' current and future health conditions, informational issues regarding sports in the time of COVID-19, and compliance with special safety standards.
Sports Physical
Before a student tries out for, or participates in, any of the listed extra-curricular activities, the student must have (a) a parent or legal guardian complete the medical history, and (b) a medical doctor, doctor of osteopathy, or doctor- supervised nurse practitioner or physician’s assistant conduct the examination and execute the form.
Student Related Forms
Adult Student Activity Participation
Before an adult education student participates in a class or program involving potentially “risky”/”dangerous” activities, this form should be executed acknowledging the risks associated with such activities (including risks of injury during transportation to and from off-site events), the adult student’s agreed compliance with districts safety rules, and the authorization to administer emergency care in the case of injury.
All Purpose Agreement for Participation
Alumni events (students and alumni), “fun runs” involving both students and adults, etc.
Emergency Medical Assistance Opt-out
Can be used for both religious and non-religious decisions to direct withholding of emergency medical care.
Medication Assistance Authorization
Self-contained form includes all information/waivers/authorizations necessary for all medications.
Student Activity Participation
Before a K-12 student participates in extra-curricular or “risky”/”dangerous” curricular classes, this form should be executed acknowledging the risks associated with such activities (including risks of injury during transportation to and from off-site events), the student’s and parent’s agreed compliance with districts safety rules, and the authorization to administer emergency care in the case of injury.
Student Field Trip Authorization
While the Education Code provides immunity for field trip activities, the form requires parents to acknowledge the immunity laws, and the risks associated with the activity, as well as providing authorization to administer emergency care in the case of injury. This form is not subject to HIPPA, and is not subject to a prohibition of such disclosure.
Student Out-of-State Field Trip
In addition to the issues covered by the standard field trip form, this form also notes the limitations on payment for travel- related costs and expenses and the risks of financial loss to the student/parent if the trip is cancelled for some reason.
Work Experience Education (WEE) - Student Training Agreement
Use this form when student enters the Work Experience program. The Agreement will be signed by the student, his/her parent or guardian, the site manager/employer and the work experience coordinator.
Transportation Forms
Employee Personal Auto Use
Similar to the Volunteer Personal Automobile Form, this form addresses employee use of their personal automobiles on District business.
Student Alternate Transportation
This is the second form to be completed when a student is allowed to drive himself/herself to a District-sponsored curricular or extra-curricular activity. The Student Personal Automobile Use Form is used as a general screening form, making sure the student will be able to safely transport himself/herself to an event. This form must be signed by the supervising coach/teacher, and serves the separate purpose of gaining their approval for the student to transport himself/herself to the event. Some coaches/students do not want students to engage in such activities, so this form ensures that all involved parties agree to the self-transportation and the accountability of the student for such self-transportation
Student Personal Automobile Use
This is the first form that must be completed before a student can drive himself/herself to a District-sponsored curricular or extra-curricular activity. This form contains basic information regarding the student’s license, insurance and vehicle information. The form also acknowledges that the driver’s insurance coverage will be primary to any insurance coverage available to the District. The form also notes the student’s obligation to maintain a safe vehicle and to operate that vehicle in a safe manner at all times. It does not require the District to conduct “pull-notice” or other background checks, but it does authorize the District to conduct such reviews if it deems it appropriate to do so.
Volunteer Personal Auto
Before an adult is allowed to operate a private passenger vehicle (or a District-owned vehicle, should that ever be allowed), this form should be completed identifying their insurance and vehicle information, further confirming that the driver’s insurance coverage will be primary to any insurance coverage available to the District. The form also notes the driver’s obligation to maintain a safe vehicle and to operate that vehicle in a safe manner at all times. The form does not require the District to conduct “pull-notice” or other background checks, but it does authorize the District to conduct such reviews if it deems it appropriate to do so.
Use of Facility Forms
Facilities Use Agreement Cover Letter - Special COVID-19 Requirements for Use
Use this cover letter when approving or renewing Facility Use Agreements with specific COVID-19 requirements for use.
Master Agreement for Indemnity, Coverage, and Joint Defense Cost Obligations (Pool-to-Pool)
This Agreement is made by and between NBSIA and another risk management pool for shared defense/indemnity when NBSIA Members want to enter into a Joint Use/Mutual Aid Agreement with another public entity. Members can then execute their Joint Use/Mutual Aid Agreements with the named Member Agency
NBSIA Master Agreement for Indemnity, Coverage, and Joint Defense Cost Obligations
This Agreement is made by and between NBSIA Members allowing them to jointly enter into their Joint Use/Mutual Aid Agreements
Use of Facilities Agreement between Public Agencies
Applies to any public agency (Parks and Recreation Districts, the State of California, etc.) and its sponsored activities. A facility use fee is not required, but may be charged. Determination of an appropriate fee level will be based on the activity and imposition on the District’s resources. Indemnity and insurance requirements are fully negotiable and should be as broad/protective as the “All Other Private Entities Form.” Indemnity and insurance provisions will in each instance need to be carefully reviewed, particularly in circumstances in which the government agency is self-insured or covered by another Joint Powers Agency.
Use of Facilities, Indemnity, and Insurance Agreement (Ed. Code 38134(a) - Private Entities)
Applies to non-profit organizations, clubs, or associations organized to promote youth or school activities if they confirm that no other alternate location is reasonably available for their meeting or activity. Contemplated groups include Boy Scouts, Girl Scouts, PTAs, PTOs, and school-advisory groups. Liability insurance requirements should be in accordance with approved District requirements. If no requirements exist, suggested liability limits are at least $1 million per occurrence/$2 million in the aggregate. Insurance is required because, under Section 38134, each party must defend, indemnify and insure itself against risks of loss arising from its separate activities/obligations. The District cannot compel the group to name it as an additional insured under its liability policy. This form does not apply to any otherwise qualified group which intends to use school grounds for fundraising activities not directly beneficial to youth or public school activities of the District. (i.e., a girl scout bake sale for UNICEF)
Use of Facilities, Indemnity, and Insurance Agreement (Non-Ed. Code 38134(a) - Private Entities)
Applies to all non-public agency groups who may use the facilities for entertainment or meetings. Groups contemplated by this provision include churches, religious organizations, charitable fundraisers not falling within the 38134(a) provisions, sports leagues (except for public entity-sponsored sports leagues), and political groups or organizations. The District can charge both direct costs and a “fair market rental” fee. Insurance requirements for liability arising from the group’s activities should be in accordance with approved district requirements. If no requirements exist, it is suggested that the liability limits be at least $1 million per occurrence/$2 million in the aggregate. District should obtain an “additional insured endorsement” from the group before the group actually begins use of the facility.