PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT

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1 PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT High School Independent Study Physical Education (ISPE) Checklist The following documents must be completed and submitted to your student s counselor for ISPE consideration. After the documents have been reviewed, the student and parent/guardian will be notified regarding the approval or denial of the ISPE application. Required from student and parent/guardian: Written request/cover sheet to site administrator requesting consideration for Independent Study Physical Education (ISPE Form 1) A copy of the student s transcript or previous semester report card Completed Independent Study Physical Education application (ISPE Form 2) Evidence and documentation of individual proficiency and elite status (May include certificates for competitions and/or published state/national rankings) Waiver, Release, and Indemnity Agreement - Assumption of Risk Form (ISPE Form 3) Required from off-campus athletic instructor, coach or agency: Completed Hold Harmless and Insurance Agreement (ISPE Form 4) Evidence of Certificate of Insurance, must also include: Evidence of additional insured Palos Verdes Peninsula Unified School District First Aid Certification CPR Certification Proof of coach/instructor s age (over 21 years) Coach qualifications/credentials Signature and completed information on Independent Study Physical Education application Please return the completed application packet to the Counselor of your child s high school one week before the beginning of the Quarter for which ISPE is requested

2 Student Name: Date: School: Grade: Address: Phone Number: Name of program or sport: PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT Request for Independent Study Physical Education (ISPE) Cover Sheet Please describe the sport, activity or competition, and the reasons you are applying for the Independent Study Physical Education program: Principal/Designee Name: Principal/Designee Signature: Date: Approved: Not approved: ISPE FORM 1 Revised: 05/2018

3 PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT Application for High School Independent Study Physical Education (ISPE) DUE 1 WEEK PRIOR TO THE START OF THE APPLICABLE QUARTER Directions: This form must be completed and returned to the student s counselor at least 1 week before the start of the quarter for which the Independent Study Physical Education is being requested. Independent Study Physical Education (ISPE) is an optional alternative instructional strategy, not an alternative curriculum. Students work independently adhering to a written agreement under the general supervision of a credentialed physical education teacher. While ISPE Students follow the Districtadopted curriculum and meet the District graduation requirements, ISPE offers flexibility to meet individual needs and interests. The out-of-school activity being proposed must: 1) Be instructed under the direct supervision of a credentialed or otherwise qualified coach who is at least twenty-one years of age; 2) Consist of instruction that includes a minimum of ten hours a week in the student s competitive sport; 3) Incorporate research and learning in the District health standards; 4) Incorporate the eight P.E. model content standards mandated by the state and District; 1 5) Include a student journal (activity logs and time logs) documenting progress in the requirements for each content area as explained by the general supervising P.E. teacher. Student Name: Date: School: Grade: First Quarter Second Quarter Third Quarter Fourth Quarter Address: Home Phone Number: Cell Phone Number: Parent/Guardian 1 District Board Policy and Administrative Regulation No ISPE FORM # 2 Application for High School ISPE Revised: 05/2018

4 DUE 1 WEEK PRIOR TO THE START OF THE APPLICABLE QUARTER I. General information (to be completed by student and parent/guardian): Description of proposed activity(ies) for the year: Location where activity(ies) will take place: Total number of minutes per week of out-of-school activity(ies): How long has the student participated in this activity? What are the student s accomplishments in this activity to date? What are the student s specific goals in this activity for this year? Scheduled dates and times of activity(ies): Must include a month by month calendar printout indicating weekly practice schedule and goal setting in preparation for competitions for the quarter. Include dates of invitational, regional, sectional, national & international competitions. Fall Winter Spring Summer Attach additional pages if needed to answer the questions in Sections I and II. ISPE FORM # 2 Application for High School ISPE

5 DUE 1 WEEK PRIOR TO THE START OF THE APPLICABLE QUARTER II. Name and statement of out-of-school coach (to be completed by coach): Full name of coach: Qualifications/Credentials of coach (describe and/or attach documentation): Attach a copy of CPR/First Aid Certificate of coach: Mailing address of coach: Telephone of coach: address of coach: Are there any special conditions the student must meet to participate in this activity? Yes NO If yes, specify the conditions: I hereby certify that the above-named student has discussed the proposed activity(ies) with me and that the time commitment and information outlined in the preceding portion of the application are correct. I accept responsibility for the instruction and direct supervision of the above-named student for the independent study physical education program. I further certify that I will immediately advise the school if any of the specifications above change or are not satisfied. Signature of Coach Date Coach Name (Please Print) ISPE FORM # 2 Application for High School ISPE

6 DUE 1 WEEK PRIOR TO THE START OF THE APPLICABLE QUARTER III. Statement of understanding for student and parent/guardian: I certify that the specifications of the out-of-school instruction as outlined above are correct and that the school will be immediately notified of any changes in this proposal. I further understand that the general supervising P.E. teacher will not supervise my child during his/her participation in the abovelisted activity(ies). The general supervising P.E. teacher only oversees the student s progress and determines the time values for ISPE. (5 CCR ) I further understand that the student must: Attend the mandatory meetings held on the first and last week of each quarter along with the periodic individual progress meetings. Per PVPUSD Administrative Regulation 6158, students are required to meet for ISPE. During these meetings, students will turn in their logs and receive their assignment for the month. The assignments are part of your child s Pass/Fail grade and must be completed in order to pass the course. These meetings are required and if a student is absent more than one time, they will be dropped from ISPE and placed in a regular P.E. class. Missing assignments or appointments with the general supervising P.E. teacher without valid reasons will result an evaluation to determine whether the student should remain in ISPE. Students must also complete all lessons assigned by the general Supervising P.E. teacher. The Time Logs of activities are required as part ISPE. Submit a journal of progress (Time Logs and Activity Logs) toward fulfilling the requirements for each of the eight content areas with the time logs prior to the last day of each quarter as detailed by the supervising teacher. Students are to turn their Time and Activity logs in at each meeting (not before or after) and students who are remiss in turning in a log will not pass the course and will be removed and placed in regular PE. Students who are injured must provide the school/teacher a physician s note indicating the injury and length of time that the student will not be able to participate in physical activity. The logs still need to be kept while a student is injured. Physicians may sign the logs excusing the student from activity during that time or if the student participates in physical therapy that may be logged on the time sheet as well. Regardless of injury, the logs must still be completed and signed. All students must maintain a 2.5 on a 4.0 grade point average while in ISPE each grading period. If a student does not meet the grade point average requirement, they will be removed from the course the following trimester. Students who are removed from ISPE will remain out for the rest of the school year and can reapply the following year. 9 th Grade Students are required to take the California Physical Fitness Test, in the Spring. Your child will be notified by the school/ispe teacher of when he/she will be tested. Please visit this link for more information on Physical Fitness Testing. Your child must also exit the school and may not be on campus during their ISPE period. When students are without a class on campus, it is disruptive to the learning environment for others and they must be picked up or find an alternate way home. ISPE FORM # 2 Application for High School ISPE

7 DUE 1 WEEK PRIOR TO THE START OF THE APPLICABLE QUARTER Student s failure to satisfy any requirements in Section III will result in removal from ISPE and a grade of FAIL earning zero credits. Student s Signature Date Parent/Guardian Signature (if Student under 18) Parent/Guardian Name (Please Print) Date IV. Principal/Designee Determination: Approved Denied V. Recommendation of counselor (to be completed by student s counselor) I believe the instruction specified above satisfies the criteria for granting outof-school instruction ISPE. Signature of Counselor: Date: Office Use Only VI. VII. Approval of principal (to be completed by principal or designee) Approved Denied Signature of Principal or Designee: General Supervising PE teacher (to be completed by PVPUSD PE teacher): Signature of Teacher: Date: Date: ISPE FORM # 2 Application for High School ISPE

8 PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT WAIVER, RELEASE OF LIABILITY, INDEMNITY AGREEMENT, ASSUMPTION OF RISK, HOLD HARMLESS AGREEMENT AND MEDICAL TREATMENT AUTHORIZATION Student Name: Description of Activity: Date(s) of Activity/Program: I request that my son/daughter be approved to participate in the above mentioned activity as part of the independent study physical education program. I understand that the Palos Verdes Peninsula Unified School District (PVPUSD) does not require that my son/daughter participate in this activity, but I choose to allow my son/daughter to do so, despite the possible dangers and risks. I understand that these risks may include personal injury, illness, permanent disability, dismemberment, or even death. To the best of my knowledge, my son/daughter is in good health, and has no medical, physical, or health condition that would prevent his/her participation in the above mentioned activity or pose a risk to the safety of others by participating. Should my son/daughter have a medical, physical, or health condition that may affect his/her participation in the above mentioned activity, it shall be incumbent upon me to provide PVPUSD with a medical release signed by his/her treating physician, allowing my son/daughter to participate in the above mentioned activity. I further agree to hold harmless and indemnify PVPUSD for any injury, illness, permanent disability dismemberment, or death my son/daughter sustains as a result of his/her existing medical, physical, or health condition. In the event that my son/daughter is injured or becomes ill due to his/her participation in the above mentioned activity, I hereby authorize and consent to x-ray, examination, anesthetic, medical, dental, or surgical diagnosis or treatment, emergency medical treatment, and hospital care from a licensed physician and/or surgeon, as well as emergency transportation as deemed necessary for my son/daughter s safety and welfare. I understand that all resulting expenses will be my responsibility as the parent/guardian of my minor son/daughter. I voluntarily release, discharge, waive, and relinquish any and all actions or causes of action for personal injury, property damage or death occurring to my son/daughter arising as a result of not adhering to the instructions received in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities or instruction may continue. I fully understand that I and my son/daughter are to abide by all rules and regulations, including and not limited to District policies and procedures governing conduct during participation in the above mentioned activity. Any violation of these rules and regulations may result in my ISPE Waiver, Release and Indemnity Agreement - Assumption of Risk - ISPE FORM #3 Revised: 05/2018

9 son/daughter being dismissed from independent study physical education program with any expenses incurred being my responsibility as the parent/guardian of my minor son/daughter. By signing this Agreement, I understand that I will personally provide for the transportation of my son/daughter to and from the above mentioned activity, at my sole expense and in adherence to all California vehicle code regulations. I understand and agree that PVPUSD is no way responsible, nor does PVPUSD assume liability for any injuries, losses, death, or any other adverse results that may occur to my son/daughter or any other individual(s) who accompany my son/daughter as a result of me providing for my son/daughter s transportation. For and in consideration of permitting the above named-child to participate in the activity described above, the undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury, bodily injury, property damage or wrongful death occurring to him/herself arising in any way whatsoever as a result of engaging in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue. The undersigned does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive discharge and relinquish any action or causes of action, aforesaid, which may hereafter arise for him/herself and for his/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, bodily injury, property damage or wrongful death against PVPUSD, its Board of Education, or any of its officers, agents, servants, employees and volunteers for any of said causes of action. The foregoing waiver does not apply in the event of the sole negligence or willful misconduct of PVPUSD. I, my heirs, executors, administrators or assigns agree that in the event any claim for personal injury, property damage or wrongful death shall be prosecuted against PVPUSD, I shall hold harmless and indemnify PVPUSD, its officers, agents, employees, and volunteers from any and all claims or causes of action by whomever or wherever made or presented for personal injuries, property damage or wrongful death, whether the same shall arise by my negligence or that of any of said persons, or otherwise. IT IS MY INTENTION BY THIS AGREEMENT, TO EXEMPT AND RELIEVE THE PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH CAUSED BY THE NEGLIGENCE AND CONDUCT OF MY SON/DAUGHTER OR THE OFF-CAMPUS PHYSICAL EDUCATION INDEPENDENT STUDY INSTRUCTOR. ISPE Waiver, Release and Indemnity Agreement - Assumption of Risk - ISPE FORM #3 Revised: 05/2018

10 I ACKNOWLEDGE THAT I HAVE READ THIS WAIVER, RELEASE OF LIABILITY, INDEMNITY AGREEMENT, ASSUMPTION OF RISK, HOLD HARMLESS AGREEMENT AND MEDICAL TREATMENT AUTHORIZATION, AND WILL ABIDE BY ALL RULES AND REGULATIONS INCLUDING AND NOT LIMITED TO DISTRICT POLICIES AND PROCEDURES GOVERNING CONDUCT AND INDEPENDENT STUDY. I FULLY UNDERSTAND THESE TERMS AND THE LEGAL CONSEQUENCES OF SIGNING THIS AGREEMENT, AND SIGN THIS AGREEMENT FREELY AND VOLUNTARILY. Student Signature Date Parent/Guardian Signature (if Student is under 18) Date Parent/Guardian Name (Please Print) Date ISPE Waiver, Release and Indemnity Agreement - Assumption of Risk - ISPE FORM #3 Revised: 05/2018

11 PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT HOLD HARMLESS, INDEMNITY & INSURANCE AGREEMENT Agency Name: Description of Activity: (Agency) acknowledges that Palos Verdes Peninsula Unified School District (PVPUSD) independent study physical education students participate in the abovementioned activity(ies) through the Agency. The Agency agrees to defend, indemnify, and hold harmless the PVPUSD, its Board of Education, or any of its officers, agents, servants, employees and volunteers from any and all loss, costs, and expense, including legal fees, or other obligations or claims, arising out of any liability or claim of liability for personal injury, bodily injury to persons, contractual liability or damage to property or any other loss, sustained or claimed to have been sustained arising of activities of the Agency or those of any of its officers, agents, employees, or volunteers whether such act it authorized by this Agreement or not. Agency further agrees to waive all rights of subrogation against the PVPUSD. The provisions of the Agreement do not apply to any damage or losses caused solely by the active negligence of the PVPUSD or its Board of Education, or any of its officers, agents, servants, employees and volunteers. The Agency also agrees to furnish the PVPUSD with certificates of insurance evidencing the Agency s general liability coverage with limits not less than $1,000,000 per occurrence to be enclosed with this Agreement. The PVPUSD, its Board of Education, or any of its officers, agents, servants, employees and volunteers must also be named as an additional insured by separate endorsement to Agency s general liability coverage. Evidence of workers compensation coverage evidencing statutory limits and employer s liability limits of $1,000,000 per accident must also be provided by Agency. Agency agrees to maintain sexual abuse or molestation insurance at a minimum limit of $1,000,000 per occurrence. Agency shall ensure that such policies are primary non-contributory, provide a waiver of subrogation, and provide for notification to PVPUSD at least thirty (30) days in advance of any material modification or cancellation of such coverage. The undersigned acknowledges that they have read the Hold Harmless, Indemnity & Insurance Agreement and are fully aware of the legal consequences of signing this Agreement. The undersigned acknowledges that they are in fact an authorized agent for the Agency, and maintain the capacity to sign such an agreement on its behalf. Authorized Agent s Signature Date Print Name and Title Hold Harmless, Indemnity & Insurance Agreement ISPE FORM #4 Revised 05/2018

12 Palos Verdes Peninsula Unified School District Time Log for High School Physical Education Independent Study Student s Name: Grade: Sport: The time log below must be maintained for the above named student each quarter, along with an activity log that documents progress toward the eight required PE components. Days when the student is absent from school will not count toward the total minutes needed each week. According to the contract, you, as the approved out-of-school coach/instructor, must notify the school immediately: 1. If there are any changes in time and/or days of instruction. 2. If there are any changes in addresses or telephone number. 3. If the student does not exceed 400 minutes of instruction every two weeks. Students will receive an INCOMPLETE grade if this form is not returned by the end of the quarter. Students will have five (5) days after the quarter ends to turn in the Time Log. Students submitting a late Time Log will receive an F grade on their transcript and the student will be placed in a regular PE class for the second quarter. This is a sample time log for one week: Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday 10/01/18 Illness Practiced 2 hrs Rained out Competition 2 hrs Holiday Practiced 2 hrs Make-up Practice 2 hrs Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday PE Independent Study Time Log High School

13 Aerobic Capacity Body Composition Abdominal Strength Trunk Extensor Strength Upper Body Strength Flexibility Please verify the Time Log and check off which of the eight PE components the student has successfully met. Please initial the student s Time Log and then sign your name below. Coach s name: Date: Coach s signature: Parent s Signature: Date: Parent s Name: PE Independent Study Time Log High School

14 Palos Verdes Peninsula Unified School District High School Physical Education Independent Study Activity Log 9, Activity Log for Quarter Student s Name Grade School The activity log format must be maintained for this student each quarter, along with a record that documents progress toward the eight required PE components. Days when the student is absent from school will not count toward the total minutes needed each week. Log must be presented to the school prior to the conclusion of each grading period. According to the contract, you, as the approved out-of-school coach/instructor, must notify the school immediately: 1. If there are any changes in time and/or days of instruction 2. If there are any changes in addresses or telephone number 3. If the student does not exceed 400 minutes of instruction every two weeks. 4. If the student becomes injured or is otherwise unable to complete the approved contract. This is a sample activity log for one week: Week/ Monday Tuesday Wednesday Thursday Friday Standard 3 # Hours / Standards Addressed Cardio Training 2. / 3, 4, 5. Off Skills Practice 3. / 1, 2, 5. Off Individual Event 2.5. / 2, 4, 5. Please verify the Activity Log, sign your name below and return it to school by / / Students will receive a Fail grade if this form is not returned prior to the day indicated above. Student Signature Parent Signature Instructor Signature SCHOOL USE ONLY Grade: Pass Fail Comments: General Supervising PE Teacher Signature: Date: / / Activity Log Grades 9, 10, 11 &12 Page 1 of 2

15 Palos Verdes Peninsula Unified School District High School Physical Education Independent Study Activity Log 9, Week MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Activity Log Grades 9, 10, 11 &12 Page 2 of 2

OVERNIGHT PERMISSION FORMS

INSTRUCTIONS: OVERNIGHT PERMISSION FORMS (TRANSPORTATION BY BUS, LEASED VEHICLES, OR PRIVATE VEHICLES) (revised 9/1/11) NOTE: All forms are interactive, so you can type in the information needed. Items