1. education
2. school

NAME________________
DATE _________________
PERIOD
-----------------
Congratulations,
Your son/daughter has been selected to participate in one of Earl Warren's newest courses, the SURF
P.E. course. We are excited about offering this opportunity to our students and we appreciate the Del
Mar Lifeguard's partnership as we offer this course.
Surf P.E. is one of three courses offered in the Physical Education department. The course will be held
at 17'h Street in Del Mar from 12:15- 2:15, during your child's scheduled PE class. The class may also
meet at the Earl Warren campus.
Requirements:
•
•
•
•
•
•
•
•
Provide own transportation. Carpooling must be arranged by parents. Pleas.e understand that,
due to privacy concerns, we are unable to provide a class list to each parent.
Field Trip Permission Form- Please note when you sign this form you are agreeing to allow
your student to attend class at the designated meeting areas, which includes the Boys &
Girls Club and Surf location;
Complete Release of Liability for Off Campus PE Program Participation Form
Use of Private Automobile for School Activity Form
Complete emergency form
Be on time every day, participate, and leave the site promptly after being released.
Demonstrate competency of swimming skills by having successfully completed Surf PE during
their ?'h grade school year.
Pass a swim test held at the Solana Beach Boys and Girls Club. The test will be administered
during the second week of school. The test will include:
100 yard swim I 2 minutes, 30 seconds
3 minutes treading water
20 second underwater breath hold
Students who are not able to pass this test will be scheduled into general Physical Education.
Daily Supplies"
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•
•
•
•
Surfboard/Boogie Board - LEASH REQUIRED
Towel
Wetsuit (Optional)
PE Uniform (including athletic shoes)
Swim fins for all Body Boarders
Earl Warren Surf P.E. Mandatory Rules
Students are required to abide by the following rules:
1.
2.
3.
4.
I will arrive to class on time every day and be prepared to fully participate in the class.
My uniform in this P.E. class is appropriate swimming attire.
I promise to be courteous to all others, both in and out of the water.
I know and accept that only participating Surf P.E. students are allowed in the water.
Non-suits and others are required to stay in the designated area.
5. I understand that my grade in Surf PE will be based on participation and my adherence
to all safety rules.
6. I understand that I may not participate in this class until all attached forms are
completed and returned with parent/guardian signature.
In the event that students cannot enter the water (ie, pollution, run off, dangerous surf, etc.), a Dry
Land Beach Workout will be held at 151h St. Occasionally, it may be necessary to keep students on
campus. I either event you will be notified via E-blast and/or All Call. Please make sure all of your
contact information is current.
Surf P.E. is released at 2:15. All students are expected to sign in on time every day. They are also
required to promptly leave the site after they have signed out and have been released by their
teacher. There will be no supervision after 2:15.
Grading Policy:
Please remember that Surf PE is a voluntary choice in lieu of Earl Warren's on-campus general
Physical Education class. Due to the participatory nature of Surf PE, absences weigh heavily on a
student's grade. We ask that absences and school off-grounds passes be avoided unless
absolutely necessary. Please attempt to schedule appointments and other commitments after the
end of the school day at 2:15p.m.
Students with excused PE absences may attend make up sessions held during school in order to
earn missed class credit. Make-ups will be announced the prior week. As in any Earl Warren class,
students with excused absences (illness, injury, medical appointments, family emergencies, etc.all governed by District Board Poiicy and California State Education Code) are not penalized, but
are required to complete a make-up assignment to earn class credit lost due to any absence(s).
Students with unexcused absences (family trips, truancies, suspensions, non-suits, etc.) may not be
allowed do make up PE credit lost.
We do appreciate all you do to get your student to Surf PE on time on a daily basis. Thank you for
your attention to this matter. Feel free to contact us if you have any questions.
By signing below, I agree to all requirements of the Surf PE Class:
Student Name (Printed)
Student Signature
Parent/Guardian Name (Printed)
Parent/Guardian Signature
San Dieguito Union High School District
Field Trip Permission Form
Name of Student:
----------------------Activity Date(s) :
2014-2015 School Year
0
Departs/Returns:
Transportation~
D
AM
DAM
PM
PM
0
------~~~--------~~~
0
0
~Private Car
School BusJV an
Charter Service
Activity:
354I.l i AR-:2 Attachment
6153.1 ! AR-2 Attachment
Off Campus Physical Education
-----------------------------------------
Location: SO Boys & Girls Club/18th St Del Mar
Teacher:
Driver:
[&I Walk
Period: _ __
0
0
School District Employee
Charter Service Employee
0
0
Parent/Adult
Student
1 understand and agree that my participation in the activity or trip is not to be used as an excuse for absence other than for the period indicated
above. I know that 1 am responsible for all class work missed. I understand and agree that I remain under the jurisdiction of the school district
while participating in this off-campus activity and I will abide by all rules set forth by the faculty, principal, superintendent, or Board of Trustees.
To Be Complclcd !l\ l'arcntiGu.ll dian:
I, the undersigned, hereby grant permission for my child to participate in the above named activity.
In accordance with Education Code §35330, I, the undersigned, hereby RELEASE, DISCHARGE and HOLD HARMLESS the San Dieguito Union
High School District, the Board of Trustees, its officers, employees and agents from all liability, including injury, death, or other damages,
occurring in the course of or while traveling to or from the above named activity which my child may suffer or cause another person to suffer
arising out of, or in connection with, or resulting from my child's participation in the above named activity.
EMERGENCY: In an emergency, I give my consent: For family pbysician, EMT and/or hospital to provide
D No D Yes
emergency treatment to my son/daughter:
Student has medical insurance?
0
No
D Yes
Medical insurance in: Father's name
0
Mother's name
0
Medical Insurance Carrier: --------------------Policy/Group#: _______________________
Insurance Contact Number(s): - - - - - - - - - - - - - - - - - - - - - -
Parent/Guardian Signature
Revised 5112
Date
Telephone Number
San Dieguito Union High School District
2014-15 School Year
RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT FOR
OFF-CAMPUS PHYSICAL EDUCATION PROGRAM PARTICIPATION
This is a release of liability and assumption of risk agreement. Read it carefully and sign below. Completion of this release is a
prerequisite to participation in off-campus physical education program. This release essentially says the student named below is going
to participate in an off-campus physical education program which involves inherent risks to participants. If he/she is hurt, injured, or
~ven dies, you (i.e., the student, parents and heirs) will not make a claim against or sue the San Dieguito Union High School District,
tts Board of Trustees, officers, employees, volunteers, and agents, or expect them to be responsible or pay for any damages.
NOW, THEREFORE LET IT BE KNOWN:
We, the undersigned, understand and acknowledge that
(NAME OF STUDENT)
has voluntarily chosen to participate in an off-campus physical education program. We know and fully understand that any physical
education activity, including, but not limited to, beach activities, bowling, golf, racquetball, skateboarding, surfing, swimming &
aquatic games, and weight conditioning, involves numerous risks, dangers, and hazards, both known and unknown, where serious
accidents can occur, participants can sustain physical injuries, damage to their property, and even die. Regardless of whether the
athletic activity involves physical contact or not, all athletic activities and sports have inherent risks of injury which are inseparable
from the activity and cannot be entirely eliminated regardless of the care taken by players, instructors, coaches, trainers, or other staff.
Furthermore, we understand that the off-campus physical education program may involve physical activities which are off of school
district premises and unsupervised by the school district We acknowledge and willingly assume all risks and hazards of potential
injury and death in this off-campus physical education program, including any transportation to or from any such program.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 's (NAME OF STUDENT) participation in this off-campus physical education
program is purely voluntary and it is being done at his/her own risk
In consideration for San Dieguito Union High School District allowing the above-named student to participate in this off-campus
physical education program, we voluntarily agree to release, waive, discharge, and hold harmless San Dieguito Union High School
District, its Board of Trustees, officers, employees, volunteers, and agents from any and all claims of liability arising out of their
negligence, or any other act or omission which causes the student illness, injury, death and damages of any nature in any way
connected with the student's participation in this program. We also expressly agree to release and discharge San Dieguito Union High
School District, its Board of Trustees, officers, employees, volunteers, and agents from any act or omission of negligence in rendering
or failing to render any type of emergency or medical services.
As parent or legal guardian of the student/participant under 18 years of age, I have read and voluntarily agree that my son/daughter
may participate in this off-campus physical education program, and I sign this release on hiS/her behalf. In signing this document, I
fully recognize and understand that if my son/daughter is hurt, dies, or his/her property is damaged, I am giving up the student's right
and the rights of the parents and heirs to make a claim or file a lawsuit against San Dieguito Union High School District, its Board of
Trustees, officers, employees, volunteers, and agents.
California Law provides as follows: "All persons making the field trip or excursion shall be deemed to have waived all claims against
the district or the State of California for injury, accident, illness, or death, occurring during or by reason of the field trip or excursion.
All adults taking out-of-state field trips or excursions and all parents or guardians of pupils taking out-of-state field trips or excursions,
shall sign a statement waiving such claims." (Education Code Section 35330)
WE, THE UNDERSIGNED, HAVE READ THIS DOCUMENT. WE UNDERSTAND THAT IT IS A RELEASE OF ALL CLAIMS.
WE FURTHER UNDERSTAND THAT WE ARE ASSUMING ALL RISKS INHERENT IN THIS OFF-CAMPUS PHYSICAL
EDUCATION PROGRAM. WE VOLUNTARILY SIGN OUR NAME AS EVDENCE OF OUR ACCEPTANCE OF THE ABOVE
PROVISIONS, PARTICIPATION IN THE PROGRAM AND ANY FIELD TRIP OR EXCURSION ASSOCIATED WITH IT.
Student/Participant Signature
Date
Parent/Guardian Signature (if Student/Participant is under 18)
Date
Rev 03/04
San Dieguito Union High School District
Use of Private Automobile for School Activity Form
0
Dnver Information
Parent/AdultNolunteer
0
Student/Under 18
Driver Name:
Student/Over 18
Birth Date:
Driver License #:
Provisional License?
O
Expiration Date:
0
0
Yes
No
State: - - - - -
Driver will transport other students?
DYes
0No
Teacher must verify provisional license status of any driver under 18
Vehtcle lnformatton
Vehicle Make:
Vehicle M o d e l : - - - - - - - - - - - - - - - - - -
Vehicle license#:
Model Year:
Registered Owner:
Number of Seatbelts:
Insurance lnfot mallon
Insurance Company:
Policy Number:
Expiration Date:
Polley Limits:
Bodily Injury-Per Person/Accident:
$
$ ~ 00,000 I $?.00,000
Property Damage:
$
$100,000
Medical Payments -Per Person:
$
$2,000
Minimum Limits
r·~
Date(s):
ActtV1ty:
Driver Agreemet1t
l, the undersigned, certify that all infonnation provided herein is correct. 1 understand that I must have a valid driver's license and automobile liability insurance
coverage in force at all times while using my vehicle on District business or transporting students and agree to advise the District, in writing, of any changes in the
above information. I further certifY that my vehicle is mechanically safe. I understand that if I drive my personal automobile while on school business and I am
involved in an accident, by law my own insurance coverage will be primary and not contributory to any insurance the District may carry. In accordance with Education
Code §35130, l hereby RELEASE, DISCHARGE and HOLD HARMLESS the San Dieguito Union High School District, the Board of Trustees, its officers, employees
and agents from all liability, including injury, death, or other damages, occurring during or while traveling to or from the above named activity which I may suffer or
cause another person to suffer arising out of, or in connection with, or resulting from my participation in the above named activity.
Driver Signature
Date
Parent/Guardtan PermiSSion
I, the undersigned, hereby grant my pemussion for my child,
, a minor, to drive the above stated vehicle and to transport other
students, if so indicated, to and from the above stated activity. I have xead understand, and agree to the foregoing Driver Agreement and certifY that all informati
provided herein is correct. In accordance with Education Code §35330, I hereby RELEASE, DISCHARGE and HOLD HARMLESS the San Dieguito Union Hig
School District, the Board of Trustees, its officers, employees and agents from all liability, including injury, death, or other damages, occurring during or while travelin
to or from the above named activity which my child may suffer or cause another person to suffer arising out of, or in connection with, or resulting from my child's
participation in the above named activity.
Parent/Guardian Signature
Date
SAN DIEGUITO UNION HIGH SCHOOL DISTRICT
EMERGENCY FORM
The following Information is necessary for the Student Healtll Record.
Please complete this form,
and ~to your school annually. This is not a "change of residency" form,
!!.9!!.
*If you have changed your residence, please complete and submit a nverlfication of Residency Form"
available at your student's school registrar's office.
0
STUDENT: Last Name
Male
0
Initial
FlrstNam10
Address Where the Student Resides currently Apartment #
Qty
Zip
Student Cell Phone
Female _ _ _ _ _ _ _ IDn - - - - - - Student Jdentincatlor>
Date ol Birth Month/Day/ v.. r
Cod~
Grade
SChool
Student Email
Guardian should be contacted
first:
MOTHER_D
Father's Name
Mother's Name
(Please Indicate: Father/Guardian/Tutor)
(PII!IIse lndiCi!lte: Mother/Guardian/Tutor)
Home Phone II
Cell II
Home Phone#
Ceil II
Place of Employment /Department
Work Phone#
Place of Employment /Department
Worl< Phone II
Father's E-mail Address
Mother's E-mail Address
Father's Current Address Is This New Address? No
0
*Yes
0
Mother's Current Address l11 Thia 11 New Addressl' No
Mailing Address (If different than above)
Father's Years of Education: None
0
*Yes
Mailing Address (If different than above)
Language
#of years
Mother's Years of Education: None
-----
Father needs interpreter for phone calls and meetings: NO
ADDmONAL CONTACTS:
0
0
ru
Language - - - - -
#of year.
0
Mother needs interpreter for phone calls and meebngs: NO
0
YES
0
CONTACTS MUST Bf LOCAL- List contacts for two adults other than parent/guardian.
If parent/guardian cannot be reached, we authortze the school staff to release the student to:
1) Local Contact:......,..-:-::,....,~~-------=-~,.-:-:-:-::::-:-......,..--:-:--~""7":-:--::-----:c:-:-:--:---Adult'5 Full Name
Relationship to Student
Home 1 Work Number
Cell Number
2) Local Contact: ....-,:-=:c:-=~,--------=-.,...,.,---:--:-:--:::--:--:-- -:-:--7:7:-:--:-:---:--- ..,..,::-:-:---,----Adult'.. Full Name
Relationship to Student
Home I Work Number
Cell Number
MEDICAL INFORMATION: EC §49423
Name of Student's Physician/Clinic: ..,.,.....----------:-:-:------:::--7."":~~:7:;;:;::---Name
Address
Phone II Physician/Clinic
I give my consent for school personnel to communicate with my son/daughter's physician
Does the student take continuing medication:
NO
Will it be necessary to take medication at school? NO
0
0
YES
YES
NO
0
YES
D
0
0
If student requires administration of medication during school hours, parent must complete and deliver to the
school's Health Office the
"Authorization for Administration of Medication " form signed by parent and
p_hysician. The form is available at: http:tfwww.sduhsd.net/downloads/
EMERGENCY: In an emergency, I give my consent: For family physician, EMT and/or hospital to provide
emergency treabnent to my son/daughter: NO 0 YES
Student has medical insurance? NO 0 YES 0
Medical insurance in:
Father's name 0
Mother's name
Policy Number I Group
Medical Insurance carrier
Signature
ll.evislon 3·12
of Father/Guardian
Date
Insurance Contact Number/s
Signature of Mother/Guardian
Date
O
0