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CAIS School Program Supplemental Application
       2005 Policy Term

Please fill out the information below. Fields marked with * are mandatory.

Contact Information
   
* First Name:
* Last Name:
* Position:
* Phone:
* Email:
   
Name of School:
Address:
City:
State:
Zip:
List Any Additional Location(s):
 

Coverage Information
Please provide the following information for EACH school covered by the application by completing additional applications as needed.
 
Is school a current member of the
California Association of
Independent Schools?
Yes No
   
Total Number of Students:
Grades Range: (example: K-12)
School Year: Late August through May/June or Other:
If Other, please specify the number of students by time periods (quarters, other):
   
Number of Years in Business:
Annual Revenue:
Has the school experienced any significant revenue increases or decreases >15% in the past year? Yes   No
If yes, please explain:
   
Is the school affiliated with a
religious organization?
If Yes, answer A) through F).
If No, skip A) through F).
Yes No
A) Is there a facility that provides religious services to the public covered by this application?
Yes No
B) Is there a facility on a campus that is especially for religious activities for students?
Yes No
C) If services are open to the public, please describe hours of service, facility and address or location:
Yes No
D) Number of clergy in Class 8840 (if any):
Full-Time Part-Time
E) Number of employee parking attendants for religious services:
All-Volunteer Full-Time Part-Time
F) Number of employee security guards that work at religious services:
None Full-Time Part-Time
   
Are any Security Guards on the premises armed? Contracted: Employees:
If so, please give details of locations and hours of armed guards:
   
Day Care/After Care: Does the school operate a day care / aftercare facility?
Yes No
Please give details such as ages of children in day care and the numbers of full-time and part-time staff:
Please provide accurate numbers of employees at the school, by job category.
 
School Term
Summer Session
 
Full-Time
Part-Time
Full-Time
Part-Time
Total Number Of Employees At This Location:
   
School Term
Summer Session
Please Supply the Number of Employees in Each Classification:
Class Code
Full-Time
Part-Time
Full-Time
Part-Time
Teachers:
8868
Administrative:
8810
Security Guard Employees:
9101
Building Operations/Maintenance:
9101
Greens Maintenance/Gardening:
9101
Custodial/Trash Removal:
9101
Bus Operators:
9101
Camp Counselors:
9048 / 8868
   

Vehicles

  
Number of vehicles which the organization owns/leases:
Buses Vans Trucks
Approximate number of times per year that vans are rented for athletic or other outings:
Are DMV records checked at least annually for staff that has some driving responsibilities?
Yes No
If yes, records are checked by the:
School Insurance Broker
   
School sponsored extracurricular activities
(on and off campus)?
Yes No
If Yes, please describe:
   

Food Service:

 
Is hot lunch offered to students?
Yes No
Is hot food prepared on campus?
Yes No
Served by:
# of Employees # of Contractors
Prepared by:
# of Employees # of Contractors
   

Boarding:

  
Do students live on campus?
Yes No
Do faculty live on campus?
Yes No
Number of students that reside during term?
If any staff or employee lives on
campus, please provide details.
(Include caretakers, farm workers, etc.)
Does the school own, operate or lease aircraft or watercraft?
Yes No

During the school term, does the school sponsor students on overnight trips such as camping.

Provide details.
   
Volunteers?
Yes No
If Yes, please describe duties:
   

Sponsored Events:

Does the school sponsor out-of-country excursions for students or exchange programs with students in other countries?
Yes No
Provide detailed information: Number of times per year, Number of students involved, Number of staff involved, Period of time overseas. Please list all countries visited in the last 3 years and those planned to visit in the coming year.
   

Benefits:
A) Benefits available to full-time workers:
Yes No
B) Number of hours worked per week to be considered a full-time employee:
C) What percentage of the employee's Medical coverage is paid by the organization?
D) What is the waiting period from first day of full-time employment?
E) Are part-time workers eligible for any Health Plan benefits?
Yes No
If Yes, please specify:
   

Safety:
Who is the Safety Coordinator for the Organization?
Safety Coordinator's telephone number:
Is there a system for
training new employees/ staff?
Yes No
If yes, please give some examples
for different job categories:
Is there a scheduled safety
communication system with staff?
Yes No
Please give frequency and examples; Is there a record of communication?
Are safety inspections of the premises scheduled and completed?
Yes No
Please give frequency and examples. Are there written records of the inspections? Who conducts the inspections?
If an employee is injured, is an accident/ incident investigation performed and recorded?
Yes No
   

Volunteers
Is there any volunteer or donated labor?
If Yes, please answer A) through C).
If No, skip to "Summer Activities"
Yes No
A) If there is volunteer or donated labor, is coverage requested for the volunteers?
Yes No
B) Does the school have any mandatory volunteer hours for parents of students?
Yes No
If there are mandatory requirements, how many hours per family per year?
If there are no mandatory requirements, please give the average number of donated hours per family:

C) What types of activities or events do volunteers support? Please describe the activity, the frequency of the activity per year and the approximate numbers of volunteers per event.

For example: Fund-raising Family Fair -- Annual with 30 volunteers.

Summer Activities

Please state the types of programs that are offered during the summer months, such as day care/ after care; summer classes, (provide dates of summer session and enrollment); athletic camps or programs, summer camp activities. For any off-campus activities, give specifics and number of times each summer that off-premises events take place.
 
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