Summer Program Risk Management
SCHOOLS INSURANCE ASSOCIATION OF WASHINGTON
SUMMER PROGRAMS RISK MANAGEMENT ANALYSIS
Please use the backside of this application form if insufficient space is provided for your response.
Feel free to photocopy this form if additional forms are needed.
School District:______Olympia #111_____ Building:_____Capital High School_____
Contact Person:_____________________ Phone Number:__________________
Name of Activity:______________________ Describe the activity’s schedule/routine:______________________
Facilities/grounds to be used:________________________________
Identify the students to be served:_______________________________
Identify the supervisor(s) and appropriate background information: __________________________________________________________________________________
__________________________________________________________________________________
___________________________
Supervision Plan: __________________________________________________________________________________
__________________________________________________________________________________
___________________________
List safety concerns, equipment and precautions to be taken: __________________________________________________________________________________
__________________________________________________________________________________
___________________________
Fee Requirement:__________________
Student Medical Insurance:__________________ Parent Permission:_________________
Emergency Medical Release:__________________ Medical Exam:________________
Warning of Inherent Dangers:________________
WIAA out-of-season standards: ______Satisfied ______Not Satisfied
School Board action for approval: _____Yes _____No
Supervisor’s Signature:___________________________
District Superintendent’s Signature:________________________