Forms and Checklists

Waivers and Authorization Forms

SIA recommends that districts use the following forms available in English, Spanish, Russian, Ukrainian, Hmong, Hindi, Punjabi, Tagalog and Vietnamese.  These forms have been formatted with space at the top to allow for printing on district letterhead. The purpose and use guideline is provided for each of the available forms.
 
Use of Facilities Forms  

• Use of Facilities, Indemnity and Insurance Agreement (Education Code)
• Use of Facilities, Indemnity and Insurance Agreement (Non-Education Code)
• Use of Facilities Agreement Between Public Agencies

Participation Forms  

•   Sports-Related Form "Cheat Sheet"
• Agreement for Activity Participation
• Contract for Adult Activity Participation
• Agreement for Team Participation
• Sports Physical Examination Form
•   Concussion & Head Injury (& Serious Injury) Report Form
•   Concussion & Head Injury Information Sheet
• Student Field Trip Authorization
• Student Field Trip (Outside California) Authorization

Transportation Forms  

• Volunteer Personal Automobile Use Form
• Student Personal Automobile Use Form
• Student Alternate Transportation Form

Purpose and use guidelines for Waivers and Authorization Forms - descriptions
   Download Waivers and Authorization Forms "Cheat Sheet" 

Americans with Disabilities Act (ADA)

• ADA Public Notice for District Website (Updated 5-9-13)
    Download Template 
  
  
• ADA Public Notice for Parent/Student Handbook
    Download Template  

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Compliance

Injury and lllness Prevention Program

• Appendix C – Sample Safety and Health Policy Statement
   Download Sample Statement 
  
  
• Appendix D – Monthly Property Checklist
   Download Checklist 
  
  
• Appendix E – Hazard Alert Form
   Download Form 
  
  
• Appendix H – Safety Meetings
   Download Form 
  
  
• Appendix J – Accident Investigation Report
   Download Form  

Stormwater

• Quarterly Non-Storm Water Discharge Inspection Report Form
   Download Form 
  
  
• Monthly Storm Water Inspection Report Form
   Download Form 
  
  
• Individual Annual Comprehensive Site Compliance Evaluation Form
   Download Form  

Driving Safety

SPAB Checklist
 Download Form  

Fire Safety and Arson Prevention

Arson Prevention Tips Checklist
 Download Checklist  

Health and Wellness

Golden Carrot Fund

• Golden Carrot Fund Request Form
   Download Form 
  
  
• Golden Carrot Fund Prevention Project/ Activity Evaluation
   Download Form 

CPR Posters

• Steps for Choking Emergencies
    Download Form  
  Request Poster  

Playground Safety

Playground Initial Inspection Checklist
 Download Checklist 

Low Frequency Inspection Form 
 Download Form 

High Frequency Inspection Form
 Download Form 

 Playground Signage - School playgrounds are often available for use by the public during non-school hours. These labels were designed to help the public use your equipment safely. The labels indicate the appropriate age range of the user, suggestions for safe play and direction for adult supervision and concerns. Each label is 5x7 inches and can be affixed directly onto the equipment. There are three age range options 2 to 5 years, 5 to 12 years and 2 to 12 years. Select the label that is most appropriate for the design of your equipment. 
 Download Order Form  

School, Employee and Workplace Safety

Swimming Pool Safety & Compliance Checklist

  Download checklist 

Appendix C – Sample Safety and Health Policy Statement
 Download Sample Statement 

Appendix D – Monthly Property Checklist
 Download Checklist 

Appendix E – Hazard Alert Form
 Download Form 

Appendix H – Safety Meetings
 Download Form 

Appendix J – Accident Investigation Report
 Download Form 

Warning Labels
The following Warning Labels are available upon request to Prevention Services. Be sure to indicate the specific label you are interested in.

• "Do Not Remove Paperguard from this Papercutter"
• "AV Cart Tipover Hazard"
• "Folding Table Tipover Hazard" (1 1/2" x 10")
• "Folding Table Tipover Hazard" (8 1/2" x 11")
• "Warning! Alarm System Electronically Protected" 4" x 4" (specify front adhesive or back adhesive)

  Download Form  

Request Warning Label  

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