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19-045.00 WVSD: Facility Use for Knox Ave Sidewalk Project Meeting 0'-045 Upon approval,these documents must be submitted before you can begin using the facilities: West Va l o Compliance Statement Form(if applicable)o Hold Harmless Agreement Yo Sudden Cardiac Arrest Certificate(if applicable) SCHOOL DISTRICT#363 o Certificate of Liability Insurance Application for Community Use of School Facilities (All applications must be submitted at least 14 days prior to event) APPLICATION FOR(SCHOOL): S r\t V c'�.\\'t4♦ r T l r)h 5c\r‘cbl ` NAME OF ORGANIZATION/TEAM NAME/GRADE: ‘ t_3T" SJ` CA.r1P_ vo1�\ Please provide a complete Team Roster.Roster must include hame of partici cants,school attending,and hc�ne address. NAME OF HEAD COACH/ASSISTANT COACH: FACILITIES REQUESTED: LiVirar-y Cri YVA'eeiflc-` 1))11.1 (Main Gym,Auxiliary Gym,Field House llym,Community Room,Commons-Athletic Field,Theater,Career� Center,Library,Classroom,Kitchen) Purpor and Natureeooff Facilities Req� ) 4G V� 'y r— r+; ( GI, SPECIALUENT Requested: E (?1:ea.,pr;wi not•e ava7aWiraurreTaigj One Time Use: EVENT DATE(S): 'FrfloMa l 4B cD Oet Begin/End Time: c5%U.) — ' . ‘nn Recurring Use:(same time each day) DAY(s)OF WEEK-1st Choice: 2nd Choice: START/END DATE: START/END DATE: TIME-Begin/End: TIME-Begin/End: Number of People Expected: Participants Spectators Will there be admission,collection or funds solicited? Yes:❑No: If Yes,admission fee$ Contact Person: Ct CIL • IkC'�YA Please submit forms to: Address: Patp E. _ 1 A1se. ' West Valley High School All other schools City,State,Zip: , • - Lindsey Kingsley:340-7103 Shanda Gorder: 340-7184 Email:lJCO — C�Cell: lindsey.kingsley@wvsd.org shanda.Rorder@wvsd.org Email: Qr Sola. Fick(Are•\)Q1 ND I AGREE THAT THE ABOVE INFORMATION IS CORRECT AVE READ AND AGREE TO ABIDE BY THE RULES AND REGULATIONS AS APPROVED BY THE BOARD OF DIRECTORS AND THE ASSIGNING SCHOOL.I FURTHER AGREE TO REIMBURSE THE SCHOOL DISTRICT FOR ACTUAL USER COSTS AS DESCRIBED IN THE FINAL BILLING. VSignature of Applicant orAuthorized Representative: W 1 D5112,1 Date: 2/20/N 6 District Use Only:Class I,Class II,Class III(Please Circle One) ROOM(S)/CUSTODIAL RATE ESTIMATED CHARGES ACTUAL CHARGES *PAYMENT OF RENTAL FEES:Please provide name and email address of responsible person if different than contact person. Rental fees shall be determined by the latest established rental rates and are payable upon receipt of invoice to WEST VALLEY SCHOOL DISTRICT NO.363,2805 N.Argonne Rd.,Spokane,WA 99212 or by Credit Card by calling(509)340-7184 APPROVED BY: Building Principal Date Facilities Manager Date Upon approval,you will receive an email with your approved dates and times,please keep a copy on you at all times. HOLD HARMLESS AGREEMENT The undersigned hereby makes application for the use of school facilities described on the facility use agreement to West Valley School District No. 363 and agrees and acknowledges that use of school facilities is without representation or warranties by the school district, its employees and agents as to the condition of the property. The undersigned further states that he has the authority to make this application for the applicant and agrees that the applicant will observe all rules and regulations of the Board of Education and the school in which the facilities are required. The applicant agrees to exercise the utmost care in the use of the school premises and property and further agrees to use only those facilities indicated under Facilities required listed. The applicant further agrees to take full responsibility for any and all damage to the property and/or injury to persons allowed or reasonably anticipated to be on the premises by the undersigned.The applicant specifically waives any and all rights, remedies and causes of actions against West Valley School District, its employees and agents and further agrees to hold the school district harmless from any and all claims arising out the use of premises. The applicant agrees to reimburse the school district for any and all judgment costs and expenses, including attorney's fees, incurred by the school district in the defense of any such action. Applicant has read and agrees to abide by the Rules & Regulations as approved by the Board of Directors and assigning school. Signature: ( j1L,&aA._ Date: 2120 1� � Self-Insured Coverage Document # c T- 20 1 9 cities Insurance Authority WCIA Coverage Document#CT-2019 Page 2 WASHINGTON CITIES INSURANCE AUTHORITY Self-Insured Coverage Document CT-2019 January 1, 2019 to January 1, 2020 12:01 am Pacific Standard Time LIMITS/ULTIMATE NET LOSS: SELF-INSURED LAYER LIMIT: $4,000,000 PER OCCURRENCE REINSURED LAYER GEM: $3,000,000 PER OCCURRENCE REINSURED LAYER Argonaut Insurance Company: $8,000,000 PER OCCURRENCE AND $8,000,000 AGGREGATE PER MEMBER REINSURED LAYER Allied World Assurance Company, Inc.: $5,000,000 PER OCCURRENCE AND $5,000,000 AGGREGATE PER MEMBER TOTAL LIMIT: $20,000,000 PER OCCURRENCE, subject to aggregates and sub-limits below and in Section I.D, and Section I.E in the WCIA Joint Protection Program. SPECIFIC AGGREGATE LIMITS/SUB-LIMITS: $4,000,000 per occurrence limit and$4,000,000 annual aggregate per Member applying to Terrorism. $5,000,000 per occurrence limit and$5,000,000 annual aggregate limit per member for Errors or Omissions Coverage arising out of the operations, ownership, maintenance or use of any airport. $5,000,000 per occurrence limit and $5,000,000 annual aggregate limit per member for any liability arising out of Land-Use Planning and Land-Use Regulation,zoning,and any other land use and permitting process. DESCRIPTION OF COVERAGE: General Liability,Automobile Liability, Stop-Gap Coverage, Errors or Omissions Liability, Employee Benefits Liability and Employment Practices Liability Coverage. LIMITS OF LIABILITY FOR ALL COVERAGE: The Limits/Ultimate Net Loss stated herein and the rules below set the maximum the Authority will pay regardless of the number of: a. members, b. claims made or lawsuits brought,or c. persons or organizations making claims or bringing lawsuits. TERRITORY:This coverage applies to General Liability,Automobile Liability, Stop-Gap Coverage, Errors or Omissions Liability, Employee Benefit Liability and Employment Practices Liability occurring anywhere in the United States of America, its territories and possessions or Canada. Members covered by this agreement include the following and new members approved by the Executive Committee during the Coverage Year; members of the Large Deductible Program have their deductible levels listed by their names: A Regional Coalition for Housing (ARCH) LOU Clean Water Alliance Aberdeen Mabton Anacortes Mason County Emergency Communications Arlington (MACECOM) Auburn Maple Valley Bainbridge Island Marysville Fire District Battle Ground McCleary Benton City Medical Lake Benton County Emergency Services(BCES) Medina Bonney Lake Mercer Island Bothell Metropolitan Park District of Tacoma($25,000) Brewster Mill Creek Brier Millwood Burien Milton Burlington Monroe Camas Monroe Transportation Benefit District Cashmere Moses Lake($25,000) Centralia Mount Vernon Chehalis Mountlake Terrace Chelan Mukilteo Cheney Multi Agency Communications Center(MACC 911) Clark Regional Emergency Services Agency(CRESA) Newcastle Clarkston Normandy Park Cle Elum Normandy Park Metropolitan Park District Clyde Hill North Bonneville Coupeville Northshore Utility District Covington NW Incident Management Team Cowlitz 911 Oak Harbor Cowlitz-Wahkiakum Council of Governments Ocean Shores Des Moines Olympia Des Moines Pool Metropolitan Park District Olympia Metropolitan Park District Duvall Olympia Transportation Benefit District Eastside Public Safety Communications Agency Olympic View Water and Sewer District (EPSCA) Othello eCity Gov Alliance Pasco Edgewood PENCOM Edmonds Port Angeles($50,000) Ellensburg Port Townsend Elma Poulsbo Enumclaw Pullman Everson Pullman Metropolitan Park District Ferndale Pullman-Moscow Regional Airport Board Fife Puyallup($100,000) George Richland Goldendale Ridgefield Grandview Sammamish Grays Harbor Communications Center, E9-1-1 Seattle Southside Regional Tourism Authority Hoquiam Sequim Issaquah Shelton Jefferson County 911 Shelton Metropolitan Park District Kelso Shoreline Kenmore Silver Lake Water&Sewer District Kennewick Skagit 911 Kirkland Skagit Council of Governments Kitsap 911 Public Authority Snohomish Kitsap Regional Coordinating Council (KRCC) Snohomish County 911 La Conner Snoqualmie Lacey Soap Lake Lake Forest Park South Correctional Entity(SCORE) Lake Stevens South Sound 911 Lakewood Spokane Regional Emergency Communications Leavenworth Spokane Valley Long Beach Stanwood Longview Steilacoom WCIA Coverage Document#CT-2019 Pane 4 Sumner Warden Sunnyside Washougal Three Rivers Regional Wastewater Authority Washington Cities Insurance Authority Thurston 9-1-1 Communications Washington Multi-City Business License and Tax Thurston Public Utility District Portal Agency Thurston Regional Planning Council(TRPC) Water Operating Board Toppenish West Richland Tukwila ($25,000) Westport Tukwila Pool Metropolitan Park District WHITCOM 911 Tumwater William Shore Memorial Pool District Union Gap Woodinville University Place Woodway Valley Communications Center Yakima Valley Conference of Governments Valley Regional Fire Authority Yarrow Point Walla Walla Zillah Walla Walla Valley Metropolitan Planning Organization This document is not an insurance policy. The Washington Cities Insurance Authority(Authority) is not an insurance company. This document is an agreement by and between the Authority and its members to pay all covered losses subject to the limits and other terms, exclusions and conditions of this Agreement and any addenda attached. This document is to be construed and enforced under the law of the State of Washington. In consideration of the assessments paid by the members,this Agreement provides the following coverages: I. COVERAGE AGREEMENTS A. GENERAL&AUTOMOBILE LIABILITY COVERAGE 1. Coverage In consideration of the assessment herein provided,the Authority hereby agrees, subject to the limitations,terms, exclusions and conditions hereinafter mentioned, to pay on behalf of the member all sums which the member shall be obligated to pay by reason of liability: a. imposed upon the member by law; or b. assumed under contract or agreement by the member and/or any officer, director, official,or employee of the member,while acting in his or her capacity as such; c. for damages, direct or consequential and expenses, all as more fully defined by the term"ultimate net loss"on account of: i. personal injury, ii. property damage, iii. advertising liability, caused by or arising out of an occurrence during the coverage period.The coverage for the liability assumed under contract in I.A.1.b.above shall be limited to the terms, conditions, limitations and exclusions in the Coverage Document and the Liability Joint Protection Program document. "Damages"as used in this section and this Agreement, do not include punitive or exemplary damages or fines or penalties or any similar relief awarded against the member. 2. Defense and Settlement of Covered Claims Subject to the limits and other terms, exclusions and conditions of this Agreement,for any claim covered by this Agreement and properly tendered to the Authority,the Authority shall have the absolute and unrestricted right and duty to select legal counsel to defend the member against the claim and pay the costs of the selected defense counsel and;further,shall have the absolute and unrestricted right to settle any covered claim within the limits of the provided coverage. The Authority shall have no obligation or duty to pay for the defense costs of a member for any uncovered or excluded claim.