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For official copies of board policies and procedures please contact the superintendent's office at (253) 583-5190 or email

Form 3422-F1

Student Sports-
Concussion, Head Injury and Sudden Cardiac Arrest:

Use of District Facilities Agreement

Compliance Statement for HB 1824, Youth Sports-Head Injury Polices and SB 5083, Sudden Cardiac Arrest Awareness.

(attach to any building/facility use request form)

requests the use of Clover Park School District facilities for the following dates: a private non-profit youth sports group, verifies all coaches, athletes and their parent/guardian have complied with mandated policies for the Management of Concussions and Head Injuries as prescribed by HB 1824, section 2 and Sudden Cardiac Arrest Awareness as prescribed by SB 5083, section 3.

Attached is a proof of insurance under an accident and liability policy issued by an insurance company authorized to do business in Washington state covering any injury or damage with at least $50,000 due to bodily injury or death or one person and at least $100,000 due to bodily injury or death to two or more persons.




*Note: Access to school facilities may not be granted until all requirements of this application are complete and approved by the school district and/or designee.