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.