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HomeMy WebLinkAboutPK13-179 - Original - Kent East Hill Kids Boxing Club - Amateur Boxing Classes - 06/20/2013 ecords NV-,,,r-.'agem6AN KENO W ASHINGTON Document CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed. If you have questions, please contact City Clerk's Office. Vendor Name: Kent East hill Kids Boxing Club Vendor Number: JD Edwards Number Contract Number: 12KI 3-171 This is assigned by City Clerk's Office Project Name: Kent East Hill Kids Boxing Club Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ® Contract ❑ Other: Contract Effective Date: Termination Date: 12/31/2014 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: Lori Hogan Department: Parks and Recreation Detail: (i.e. address, location, parcel number, tax id, etc.): Facilities Use Agreement If agreed, anAddendum will be executed to extend contract termination date at the end of one year s•Public\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08 FACILITIES USE AGREEMENT between the City of Kent and Kent East Hill Kids Boxing Club THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and Kent East Hill Kids Boxing Club located and doing business at 28026 189tn Avenue S.E., Covington, WA 98042 (hereinafter"Kent Boxing Club"). I. RECITALS The City strives to offer recreation and cultural programs and services to meet the diverse needs of the Kent community. The City currently operates a Teen Community Center at the Phoenix Academy under the terms of a reciprocal use agreement with the Kent School District The City's goal is to offer a wide breadth of programs to youth and teens at that location. The City has found that collaborative partnerships allow it to expand program offerings and participant access within budget constraints. The City has been approached by the Kent Boxing Club to teach amateur boxing and individual conditioning to kids aged 8 - 20 at that location. A boxing program would be of value and interest to youth in the Kent community, but the City does not have sufficient staff or resources to make that program available. Entering into an agreement that allows Kent Boxing Club to use the Teen Community Center will enable that program to move forward. II. DESCRIPTION OF WORK. Kent Boxing Club shall perform the following services for the City: The Kent Boxing Club will teach amateur boxing and individual conditioning. Through their work with young people and their families, Kent Boxing Club hopes to create in their participants a sense of community involvement and engagement in their neighborhood while strengthening individual skills including leadership, communication, fitness, and positive conflict resolution. Schedule of operations: Monday through Thursday, 5:30pm - 7:30pm, following the Teen Community Center's scheduled days of operation. Boxing staff will be on site at least 5 minutes prior to the start of the program and at least 5 minutes after the conclusion of the program. Changes in scheduling must be approved by the City. Location: Kent Parks Teen Community Center (operating within the weight room of the Kent School District's Phoenix Academy, 11000 SE 264", Kent, WA 98030). This Agreement only governs activity of the Kent Boxing Club that occurs at the Kent Parks Teen Community Center; specifically, any offsite activity by members of the Kent Boxing Club is not governed by this Agreement. Sanctioning:The program will be sanctioned by USA Boxing. Individual participants will become members of USA Boxing through payment of fees established by that entity. Kent Boxing Club will provide appropriate certification signifying their affiliation with this sanctioning body. Program: Standards for curriculum, safety and health, personal safety equipment, attire, equipment use, and equipment maintenance shall be consistent with those established through USA Boxing Guidelines. The program shall not include competitions with other boxing clubs that occur at the Kent Parks Teen Community Center. Participation: All girls and boys, ages 8 - 20 will be eligible for participation. Prior to participation, they will receive clearance established by USA Boxing Guidelines. Only members of the Kent Boxing Club may use the facilities; specifically, this Agreement does not sanction use of the Kent Parks Teen Community Center for competitions with other boxing clubs. Facilities Use Agreement - Kent East Hill Kids Boxing Club Page 1 J Concussion Awareness: Kent Boxing Club will sign and adhere to the requirements of the Youth Sports Organization Concussion Awareness Statement (attached). Staffing and volunteers: One professionally trained coach (training consistent with USA Boxing standards and curriculum) will be on site at all times. Additional adult staff or volunteers will be on-site as available. Program participants will be under adult supervision at all times. Kent Boxing Club's Executive Director will be responsible to ensure that all staff and volunteers have passed a Washington State Patrol background check, have received concussion awareness training as outlined in RCW 28A.600.190, and have received adequate training prior to participation in the program. Kent Boxing Club's Executive Director will be responsible for the behavior and conduct of all staff while they are on site. Facility Use: All persons associated with the Kent Boxing Club including program staff, volunteers, participants, and parents will adhere to Kent School District and Kent Parks, Recreation, and Community Services Department rules for use of and access to the facility. Evaluation: City staff will meet quarterly with Kent Boxing Club's Executive Director (more often if deemed necessary by either party) to evaluate performance. Fees and Charges: Kent Boxing Club will be responsible for any damages, additional fees, or charges incurred through their use of the Phoenix Academy Community Center. Kent Boxing Club further represents that the services furnished under this Agreement will be performed in accordance with generally accepted professional practices within the Puget Sound region in effect at the time those services are performed. III. TERM OF PROGRAM The parties agree that the program will begin as described in Section II above immediately upon the effective date of this Agreement and shall continue through December 31, 2014, unless the Agreement is terminated prior to that date pursuant to Section V herein. Upon expiration of this Agreement, if it is the desire of both parties to extend this Agreement, the parties may execute an addendum extending the term of this Agreement for an additional year on an annual basis. IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor relationship will be created by this Agreement. By their execution of this Agreement, and in accordance with Ch. 51.08 RCW, the parties make the following representations: A. Kent Boxing Club has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. B. Kent Boxing Club has an established and independent business that is eligible for a business deduction for federal income tax purposes that existed before the City retained Kent Boxing Club's services, or Kent Boxing Club is engaged in an independently established trade, occupation, profession, or business of the same nature as that involved under this Agreement. C. Kent Boxing Club is responsible for filing as they become due all necessary tax documents with appropriate federal and state agencies, including the Internal Revenue Service and the state Department of Revenue. D. Kent Boxing Club has registered its business and established an account with the state Department of Revenue and other state agencies as may be required by Kent Boxing Club's business, and has obtained a Unified Business Identifier (UBI) number from the State of Washington. E. Kent Boxing Club maintains a set of books dedicated to the expenses and earnings of its business. Facilities Use Agreement - Kent East Hill Kids Boxing Club Page 2 + L V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party seven (7) calendar days written notice at its address set forth on the signature block of this Agreement. VI. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any subcontract, Kent Boxing Club, its subcontractors, or any person acting on behalf of Kent Boxing Club or subcontractor shall not discriminate against any person who is qualified and available to perform the work to which the employment relates as provided for by the City of Kent's Equal Employment Opportunity Policy. Kent Boxing Club shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with the attached City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement. VII. INDEMNIFICATION. Kent Boxing Club shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or in connection with Kent Boxing Club's performance of this Agreement, except for that portion of the injuries and damages caused solely by the City's negligence. The City's inspection or acceptance of any of Kent Boxing Club's work when completed shall not be grounds to avoid any of these covenants of indemnification. The provisions of this section shall survive the expiration or termination of this Agreement. VIII. INSURANCE. Kent Boxing Club shall procure and maintain for the duration of the Agreement, insurance of the types and in the amounts described in Exhibit A attached and incorporated by this reference. IX. KENT BOXING CLUB'S WORK AND RISK. Kent Boxing Club agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable to Kent Boxing Club's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those services. All work shall be done at Kent Boxing Club's own risk, and Kent Boxing Club shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. X. MISCELLANEOUS PROVISIONS. A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its contractors and consultants to use recycled and recyclable products whenever practicable. A price preference may be available for any designated recycled product. B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute, difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or award provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section VII of this Agreement. D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. Facilities Use Agreement - Kent East Hill Kids Boxing Club Page 3 E. Assignment. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding unless in writing and signed by a duly authorized representative of the City and Kent Boxing Club. G. Entire Agreement. The written provisions and terms of this Agreement, together with any Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the City, and such statements shall not be effective or be construed as entering into or forming a part of or altering in any manner this Agreement. Should any language in any of the exhibits to this Agreement conflict with any language contained in this Agreement, the terms of this Agreement shall prevail. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. KENT EAST HILL KIDS (PAL) BOXING CLUB: CITY OF KENT: By. By: (s�gna (signature) Print ame: eS l C _A _ A Pr a e: Jeff Watling Its: e - e to ���/� Its: Director, Parks, Recreate janCommunity DATE:— Services ` C DATE: NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: KENT EAST HILL KIDS (PAL) BOXING CLUB: CITY OF KENT: Leslie Kae Hamada, Executive Director Lon Hogan, Supt, Recreation and Cultural Services Kent East Hill Kids (PAL) Boxing Club City of Kent 28026 189t' Avenue S.E. 220 Fourth Avenue South Covington, WA 98042 Kent, WA 98032 Leslie.hamada@yahoo.com Ihogan@ci.kent.wa.us 253-631-3895 / 206-892-8197 (cell) (253) 856-5050 (telephone) Facsimile: 253 856-6050 facsimile C:\Users\Home\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\7S3YBTJ3\BOXING ProfessionalServicesAgreement Revised2 2013.docx Facilities Use Agreement - Kent E. Hill Kids (PAL) Boxing Club Page 4 EXHIBIT A INSURANCE REQUIREMENTS FOR THE FACILITIES USE AGREEMENT Between the City of Kent and Kent East Hill Kids Boxing Club Insurance Kent Boxing Club shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Kent Boxing Club, their agents, representatives, employees or subcontractors. Minimum Scope of Insurance Kent Boxing Club shall obtain insurance of the types described below: Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01 and shall cover liability arising from premises, operations, independent contractors, P P roducts-com leted operations, personal injury and advertising injury, and liability assumed under an insured contract. The City shall be named as an insured under Kent Boxing Club's Commercial General Liability insurance policy with respect to the work performed for the City using ISO additional insured endorsement CG 20 10 11 85 or a substitute endorsement providing equivalent coverage. Minimum Amounts of Insurance Kent Boxing Club shall maintain the following insurance limits: Commercial General Liability insurance shall be written with limits no less than $2,000,000 each occurrence and $3,000,000 general aggregate limit. This coverage may include both a primary layer and an Excess layer in order to achieve the liability limit required under this agreement. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions for Commercial General Liability insurance: 1. Kent Boxing Club's insurance coverage shall be primary insurance as respect the City. Any Insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of Kent Boxing Club's insurance and shall not contribute with it. 2. Kent Boxing Club's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. 3. The City of Kent shall be named as an additional insured on all policies (except Professional Liability) as respects work performed by or on behalf of Kent Boxing Club and a copy of the endorsement naming the City as additional insured shall be attached to the Certificate of Insurance. The City reserves the right to receive a certified copy of all required insurance policies. Kent Boxing Club's Commercial General Liability insurance shall also contain a I EXHIBIT A (Continued) clause stating that coverage shall apply separately to each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer's liability. D. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best rating of not less than ANII. E. Verification of Coverage Kent Boxing Club shall furnish the City with original certificates and a copy of the amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of Kent Boxing Club before commencement of the work. F. Subcontractors Kent Boxing Club shall include all subcontractors as insureds under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the same insurance requirements as stated herein for Kent Boxing Club. 157533 �► CERTIFICATE OF LIABILITY INSURANCE °Al2`120,0112Y' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s) PRODUCER NAMEACT Andrea Wright Commercial Lines-(719)592-1177 PHONE g00-332-9256 FAXAICfAiC Not 877 405-9032 Wells Fargo Insurance Services USA,Inc E-MAIL DRESS andrea wright@wellsfargo com 5755 Mark Dablmg Blvd,Suite 300 INSURER($)AFFORDING COVERAGE NAIL# Colorado Springs,CO 80919-2228 INSURERA Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B United States Amateur Boxing,Inc dba USA Boxing INSURER C One Olympic Plaza INSURER D INSURER E Colorado Springs CO 80909 INSURER F COVERAGES CERTIFICATE NUMBER 5319769 REVISION NUMBER See below THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN SR ADOL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DDlYVYY MMIDD/YYYY A GENERAL LIABILITY PHPK956964 01/01/2013 01/01/2014 EACHOCCURRENCE $ 1000000 X DAMAGE TO RENTED 300000 COMMERCIAL GENERAL LIABILITY PREMISES Ea wcurrence $ CLAIMS-MADE 1 7X OCCUR MED EXP(Any one person) $ Excluded PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $ 5000000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 1000000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 5 ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED SCHEDULED BODILY INJURY(Per accident) 5 AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIREDAUTOS AUTOS Per accident 5 A UMBRELLA LIAB X OCCUR PHUB405395 01/01/2013 01/01/2014 EACH OCCURRENCE $ 1000000 EXCESS LIAB CLAIMS-MADE AGGREGATE IS 1000000 DED RETENTION$ 1 $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY YIN FIR ANYCER/MEMBER EXCLUDE EXECUTIVE❑ NIA EL EACH ACCIDENT $ (Mandatory inN OFFICER/MEMBER (Mandatory in NH) E L DISEASE-EA EMPLOYE $ If yes,descri En be under RIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ D DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES lAttach ACORD 101,Additional Remarks Schedule,if more space is required) Named Insured Includes Kent East Hill Boxing Club The certificate holder is an Additional Insured with respect to liability arising out of the negligence of the Named Insured as per endorsement Additional Insured-Certificate Holders(Form PI-AM-002) Coverage applies to sanctioned activities and for supervised club approved practice and training of USA Boxing member athletes for USA Boxing sanctioned events Coverage is excluded for ANY martial arts or kick-boxing activities,regardless of whether they are part of a USA Boxing sanctioned activity or club activity CERTIFICATE HOLDER CANCELLATION City of Kent Parks Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 220 Fourth Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Kent Slate,WA 98032 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION All rights reserved ACORD 25(2010105) (This cemfcaie raga.es cururwtew az94ria1 ewee on lLlTROtz1 PHPK956964 PI-AM-002(12/08) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - CERTIFICATE HOLDERS This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION II —WHO IS AN INSURED is amended to include any Certificate Holder, identified as an additional insured, on a Certificate of Insurance issued by Philadelphia Indemnity Insurance Company or our authorized representative, but only for liability arising out of the negligence of the named insured The limits of insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreement These limits are inclusive of and not in addition to the limits of insurance shown in the declarations Page 1 of 1 DECLARATION CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically identify the requirements the City deems necessary for any contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the Agreement; The questions are as follows: 1. I have read the attached City of Kent administrative policy number 1.2. 2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability. 3. During the time of this Agreement the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 4. During the time of the Agreement I, the prime contractor, will actively consider hiring and promotion of women and minorities. 5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above. By signing below,II agree to fulfill the five requirements referenced above. Dated this / day of 20,_,_,. By: For: Title: �/� 4, CAC Date: CITY OF KENT ADMINISTRATIVE POLICY NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998 SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996 CONTRACTORS APPROVED BY Jim White, Mayor POLICY: Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding Agreements with the City amounting to $10,000 or more within any given year, must take the following affirmative steps: 1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 2. Actively consider for promotion and advancement available minorities and women. Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and equal opportunity requirements shall be considered in breach of contract and subject to suspension or termination for all or part of the Agreement. Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments. 1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City's equal employment opportunity policy. 2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines. CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. L / I, the undersigned, a duly represented agent of ; l �� s� l � & Company, hereby acknowledge and declare that the before-mentioned company was the pr me contractor for t e Agreement known as that was entered into on the (date), between the firm I represent and the City of Kent. I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. Dated this day of UA) , 20By: For: Title: A) Date: U,�� a 6/3 `•� �*T w. PARKS RECREATION S COMMUNITY SERVICES City of Kent Parks, Recreation and Community Services YOUTH SPORTS ORGANIZATION CONCUSSION AWARENESS STATEMENT RCW 28A.600.190 Na em of Orga zati ( Street Address ��� �� ��Phone Con t Name o Representative Street Address one'Contact What is the nature and purpose for facility use? ton alm Z& i Kent Boxing Club, a youth sports organization/team, hereby verifies all coaches, athletes and their parent/guardian have complied with mandated policies for the management of concussions and head injuries as prescribed by RCW 28A.600.190. A copy of the text of this statute is provided on the back of this form. All community organizations/teams requesting use of City of Kent Park facilities must also submit a Certificate of Insurance and Endorsement naming the City of Kent as an additional insured for the amount of $2,000,000. The undersigned representative certifies that the information above is true and correct and hereby certifies this statement on behalf of the identified organization including all teams, players, coaches and parents/guardians affiliated with such organization. Signe / Representative of Organization Date Note: Access to City of Kent facilities may not be granted until all requirements of this application are complete and approved by the Kent Parks Department and/or designee. RCW 28A.600.190 Youth sports — Concussion and head injury guidelines — Injured athlete restrictions — Short title. (1)(a) Concussions are one of the most commonly reported injuries in children and adolescents who participate in sports and recreational activities. The centers for disease control and prevention estimates that as many as three million nine hundred thousand sports-related and recreation-related concussions occur in the United States each year. A concussion is caused by a blow or motion to the head or body that causes the brain to move rapidly inside the skull. The risk of catastrophic injuries or death are significant when a concussion or head injury is not properly evaluated and managed. (b) Concussions are a type of brain injury that can range from mild to severe and can disrupt the way the brain normally works. Concussions can occur in any organized or unorganized sport or recreational activity and can result from a fall or from players colliding with each other, the ground, or with obstacles. Concussions occur with or without loss of consciousness, but the vast majority occurs without loss of consciousness. (c) Continuing to play with a concussion or symptoms of head injury leaves the young athlete especially vulnerable to greater injury and even death. The legislature recognizes that, despite having generally recognized return to play standards for concussion and head injury, some affected youth athletes are prematurely returned to play resulting in actual or potential physical injury or death to youth athletes in the state of Washington. (2) Each school district's board of directors shall work in concert with the Washington interscholastic activities association to develop the guidelines and other pertinent information and forms to inform and educate coaches, youth athletes, and their parents and/or guardians of the nature and risk of concussion and head injury including continuing to play after concussion or head injury. On a yearly basis, a concussion and head injury information sheet shall be signed and returned by the youth athlete and the athlete's parent and/or guardian prior to the youth athlete's initiating practice or competition. (3) A youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time. (4) A youth athlete who has been removed from play may not return to play until the athlete is evaluated by a licensed health care provider trained in the evaluation and management of concussion and receives written clearance to return to play from that health care provider. The health care provider may be a volunteer. A volunteer who authorizes a youth athlete to return to play is not liable for civil damages resulting from any act or omission in the rendering of such care, other than acts or omissions constituting gross negligence or willful or wanton misconduct. (5) This section may be known and cited as the Zackery Lystedt law. 157533 �"R CERTIFICATE OF LIABILITY INSURANCE °nTa(MMmow ) 118/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Andrea Wright NAME: 9 Commercial Lines-(719)592-1177 PHONE 800-332-9250 FAX 877-405-9032 AIC No: Wells Fargo Insurance Services USA,Inc. EMAIL andrea.wri ht@wellsfar o.com ADDRESS: 9 C� 9 5755 Mark Dabling Blvd.,Suite 300 INSURER(S)AFFORDING COVERAGE NAIL V Colorado Springs,CO 80919-2228 INSURERA: Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B: USA Boxing, Inc. INSURER C: One Olympic Plaza INSURER D INSURER E Colorado Springs CO 80909 INSURER F: COVERAGES CERTIFICATE NUMBER: 7158693 REVISION NUMBER: See below THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR WE POLICY PERIOD -- INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS - CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY eFF POLICY EXP TYPE OF INSURANCE AINSIR DDLS D POLICY NUMBER MMIDOIYYYY MMIDDIYYVY LIMITS R GENERAL LIABILITY EACH OCCURRENGE $ 1000vOC A PHPK1109202 01/0112014 01/0112015 DAMAGE To RENTED - X COMMERCIAL GENERAL LIABILITY PRENIS S(Ea occullerce)_ $ t000000 CLAMS-MADE OCCUR MED EXP(Any ona pee,nm $ ✓.,IUdad PERSONAL&ADV INJURY $ loci GENERAL AGGREGATE $ 501C0000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ tori POLICY PRO- $ _ ... JECT HOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCiEDULED BODILY INJURY Per accident) $ AUTOS L AUTOS NON-OWNED I PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Peracc'dent) A UMBRELLA LIAB X OCCUR PHUB443077 01/01/2014 011OV2015 EACi OCCURRENCE $ 1000000 EXCESS LIAB CLAIh1S-MADE AGGREGATE $ tari I DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTI I- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROP RIETOR/PARTN ER/EXECUTIVE YD NIA EL EACH ACCIDENT $ OPFICERIMEMBER EXCLUDED' (Mandatory in NH) EL OIS EASE-EA EMPLOYEE $ b yes,describe under DESCRIPTIO N OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ADDED 101,Additional Remarks Schedule,if more space is required) Named Insured Includes THE KENT EAST HILL KIDS BOXING CLUB PAL The certificate holder is an Additional Insured with respect to liability arising out of the negligence of the Named Insured as per endorsement:Additional Insured-Certificate Holders(Form PI-AM-002).Coverage applies to sanctioned activities and for supervised club approved practice and training of USA Boxing member athletes for USA Boxing sanctioned events. Coverage is excluded for ANY martial arts or kick-boxing activities,regardless of whether they are part of a USA Boxing sanctioned activity or club activity. CERTIFICATE HOLDER CANCELLATION City of Kent Parks and Recreation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 220 Fourth Ave South THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ken[,WA 98032 AUTHORIZED REPRESENTATIVE fyfy�T / 7 The ACORD name and logo are registered marks of ACORD ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) , rvpla®.a rn� a 7s1ely—d-lfeQU141 POLICY NUMBER: PHPKII09202 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): PERSONS OR ORGANIZATIONS AS REQUIRED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS LIMITED TO THE NEGLIGENCE OF THE INSURED Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III —Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. law; and 2. If coverage provided to the additional insured is -- required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 04 13 C Insurance Services Office, Inc., 2012 Pagelo of 10