Resources block - Sports forms for Davis Joint Unified.

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

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.

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.

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Frequently Asked Questions

Put simply, a public risk pool is a group of public agencies that form a partnership to manage their shared risk management goals and responsibilities. Of course, there are variations in how pools are formed, structured, and operated, but the essence of public pooling is self-governed partnership.

In California, the Government Code allows public agencies to form risk pools under the Joint Exercise of Powers Act. This is why pools are also known as Joint Powers Authorities (JPA), although risk pools are a unique type of JPA.

Public entities created risk pools beginning in the early 1970s after most commercial insurers abandoned the public entity market. At that time, and again in the mid-1980s, commercial insurers responded to changing risks facing local governments by limiting coverage or withdrawing from the market entirely. Pools emerged as the stabilizing force the public sector needed.

Today, risk pools are a source of both stability and innovation, helping public entities to address continuing challenges in risk management, even as the insurance crisis has calmed. The collaborative and self-governing nature of pooling is embodied in the Swedish proverb: The best place to find a helping hand is often at the end of your own arm.

There are an estimated 450 risk pools serving municipalities, school districts, special districts and other public agencies in the United States and Canada. Around one-third of these pools are in California. The vast majority of California public agencies participate in one or more risk pools.

Thank you for your interest. Please visit our Members page for more information.

If you have a work-related injury or illness, your employer is required by law to pay for workers' compensation benefits. You could get hurt by:

One event at work, such as hurting your back in a fall, getting burned by a chemical that splashes on your skin or getting hurt in a car accident while making deliveries.

--or--

Repeated exposures at work, such as hurting your wrist from doing the same motion over and over or losing your hearing because of constant loud noise.

Report the injury to your employer by telling your supervisor and Company Nurse right away. If your injury or illness developed over time, report it as soon as you learn or believe it was caused by your job.

Reporting promptly helps prevent problems and delays in receiving benefits, including medical care you may need.

Get emergency treatment if you need it. Company Nurse will refer you to a facility for medical treatment (Clinic Map). Tell the health care provider who treats you that your injury or illness is job-related.

If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to workers’ compensation benefits. Use the attached form to file a workers’ compensation claim with your employer. NBSIA is responsible for handling your claim and will notify you as to whether your claim is accepted or whether additional information is needed. (DWC-1 Form)

A medical provider network (MPN) is an entity or group of health care providers set up by an insurer or self-insured employer and approved by DWC's administrative director to treat workers injured on the job. Under state regulations, each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. MPNs are required to meet access to care standards for common occupational injuries and work-related illnesses. The regulations also require MPNs to follow all medical treatment guidelines established by the DWC and allow employees a choice of provider(s) in the network after their first visit. Additionally, MPNs must offer an opportunity for second and third opinions if the injured worker disagrees with the diagnosis or treatment offered by the treating physician. If a disagreement still exists after the second and third opinion, an injured worker in the MPN may request an independent medical review (IMR). The MPN program became effective Jan. 1, 2005 and employees can be covered by an MPN once a plan has been approved by the DWC administrative director. Please read the following Employee Notification regarding Medical Provider Network. You may visit our Medical Provider Network at www.nbsiampn.com.

The following School Districts and County Offices have adopted a Medical Provider Network which is administered by Networks By Design, Inc. on behalf of North Bay Schools Insurance Authority. Click the link below and enter your zip code to find a Designated Medical Clinic near your home or work place.

Designated Provider Map

Please read Info Regarding MPN for additional information Medical Provider Networks.

NBSIA has a medical provider network (MPN) with physicians in every specialty for which you must seek treatment with. However, if you have pre-designated your own physician PRIOR to your injury, you may treat with your own doctor; otherwise, you must treat with a physician in our network.

Pre-designation of a personal physician is a one-time process by which an employee provides the employer with the name of a personal physician, in writing, who is then designated as the treating physician if you are injured on the job. Without pre-designation, you would go to a provider in the medical provider network (MPN). For a pre-designation form please contact your HR department.

Yes. Medical treatment that does not fall within the American College of Occupational and Environmental Medical guidelines will be reviewed to determine medical necessity as set forth by the State Division of Workers’ Compensation. Your Claims Examiner does not have the authority to modify or deny medical treatment.

Workers' Compensation insurance provides five basic benefits:

Your local I&A officers listed on https://www.dir.ca.gov/dwc/I&A.html are a great resource and their services are free. They are not there to act on your behalf as an attorney would, but they'll help you understand how to act on your own behalf. Attend a free seminar for injured workers at a local DWC district office for a full explanation of workers' comp benefits, your rights and responsibilities. You can also make an appointment with an I&A officer and speak to them privately at your convenience.

If you are eligible for Industrial Accident Leave, you will receive your full salary in your regular paycheck up to 60 days. If you are not eligible Industrial Accident Leave, NBSIA will issue payment to you directly every 14 days.

For medical appointments, you will be required to use your sick leave. Lost time from work due to a workers’ compensation injury is only compensated when your treating physician declares you “temporarily disabled” and therefore unable to work.

No, workers' comp benefits aren't considered "earned income," so you don't pay taxes on those benefits.

Health insurance claim number refers to the number assigned by the Social Security Administration and an individual for the purpose of identifying him/her as a Medicare beneficiary. Liability insurers are required by law to report specific information about Medicare beneficiaries who have other insurance coverage. Claimants will be requested to complete the (Health Insurance Claim Number (HICN)/Social Security Number (SSN) verification form).

After you make a claim for workers’ compensation benefits, your medical records will not have the same level of privacy that you usually expect. If you don’t agree to voluntarily release medical records, a workers’ compensation judge may decide what records will be released. HIPAA compliant Authorization to Use or Disclose Protected Information Medical Release form

If you have to travel to get treatment for your work injury, you are entitled to re-payment of your travel costs. The current mileage rate (effective January 1, 2022) is 58.5 cents ($0.585) per mile. Mileage for reasonable travel to the pharmacy, parking, bridge tolls, public transportation and other travel-related costs are also included. Complete the Medical Mileage Expense Form and attach receipts, then send the original to NBSIA and keep a copy for your records.

Yes, here is a Glossary of Workers’ Compensation terms for injured workers (Fact Sheet B)

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