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Lemoore Union HSD |  E  3515.21  Business and Noninstructional Operations

Unmanned Aircraft Systems (Drones)   

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REQUEST TO OPERATE UNMANNED AIRCRAFT SYSTEM FORM

This Request to Operate Unmanned Aircraft System (UAS) Form must be completed and submitted to the Superintendent for review and approval prior to any UAS operation on District property. Anyone who intends to operate an UAS on District property must submit this document not less than ten (10) days in advance of flight operations. The requestor will receive a response within five (5) days of receipt of the request. If the Department requires more time to process the request or requires more information, the Department will notify the requester as soon as reasonably possible. Prior to submission of this form, the requestor must review the District's Board Policy 3515.21. Any omission of information requested in this form may result in the delay of processing.

SECTION 1: REQUESTOR CONTACT INFORMATION

(Contact information must be included for all UAS operations. Please attach additional sheet, if needed.)

Applicant Full Name: First M.I._____ Last:________________

Age:_________ Affiliation:

(Current employee, vendor, etc.)

District Department or Organization:

Mailing Address

Contact Phone:___________________ Email Address:

SECTION 2: PURPOSE OF UAS REQUEST-PROPOSED ACTIVITY

Provide full details of flight purpose (education, research, promotional, etc.), including identity of UAS operator(s) and/or flight team. Provide all forms of data to be collected, such as imagery, and the intended use of such data. Depending on your intended use and activities associated with the use of your UAS, there may be other District approvals required before you can operate your UAS on District property. (Please provide information on an additional sheet of paper if more room is needed.)

Specific Location of Flight:

Date(s) of UAS Flight:

Start Time: End Time:__________________________

Photos/Videos will be taken? ______yes ______no

SECTION 3: EXPERIENCE OF OPERATORS

Provide full details on each UAS operator's flight experience. Provide information regarding all UAS operators' remote pilot airman certificates. All operators must present proof of a Remote Pilot Certificate.

SECTION 4: UAS DESCRIPTION

Type/Model of UAS:

Weight/Dimensions:

Power Source/Serial #:

Equipment Attached (e.g. cameras, Geo-fencing, etc.):

Previous request approved? ______yes ______no

If yes, date of previous approval:

FAA Registration No. (not applicable to model aircraft):

FAA Authorization and Expiration Date (not applicable to model aircraft):

I have attached an FAA Certificate of Waiver or Authorization, Remote Pilot Certificate, and/or other relevant documentation for this request.

Signature Date_____________________

Printed Name

By signing above, the individual/entity submitting this request attests to prior review of the District's Board Policy 3515.21, and agrees to and will abide by all District policies governing the use of UAS on or over District property. A copy of the approved Request to Operate Unmanned Aircraft System (UAS) Form must be in the possession of the operator(s) at all times during the activity, and must be presented to any District official or representative with control or jurisdiction over the activity, upon request. The District reserves the right to request additional documentation as a condition of approval and operation. In addition, any operator violating any portion of the District UAS Policy will be held accountable for their actions.

SECTION 5: INSURANCE

All third parties (any individuals other than District employees operating UAS in their capacities as employees) must submit a Certificate of Insurance with insurance providing primary coverage and naming the District as an additional insured. Unless otherwise amended by written agreement executed by the Superintendent, the third party shall procure and maintain the following coverage for the duration of this UAS authorization: Comprehensive General Liability insurance providing coverage for injuries and death in an amount not less than $1,000,000 per occurrence and Property Damage insurance in an amount not less than $1,000,000 per occurrence.

SECTION 6: HOLD HARMLESS, AGREEMENT, AND UNDERSTANDING

I agree to indemnify, hold harmless, and defend in accordance with Civil Code Section 2778, the District, its Board of Trustees, officers, agents, employees and representatives from all claims, lawsuits, or actions of every name, kind and description, brought for, or on account of injuries to or death of any person, including user or any employee, agent or invitee of user, or damage to or damages occurred in, upon, or due to user's use of the District's premises or property, provided that this indemnity obligation shall not apply to injuries for which the District has been found in a competent jurisdiction to be solely liable by reason of its own negligence.

Signature Date_____________________

Printed Name

____ (Initial) I agree to hold Lemoore Union High School District harmless from any claims of harm to individuals or property resulting from the operation of an Unmanned Aircraft System (UAS) or drone.

____ (Initial) I understand and agree to comply with the terms and conditions of the district's policy, federal law and regulations, state law, and any local ordinances related to the use of a UAS or drone, including, but not limited to, requirements that the UAS or drone not be flown at night, above 400 feet in altitude, or over any people unless they are in a covered structure or stationary vehicle.

____ (Initial) I understand that I shall maintain the visual line of sight with the UAS or drone at all times.

____ (Initial) I understand that the UAS or drone shall be kept away from any area reasonably considered private, including, but not limited to, restrooms, locker rooms, and individual homes.

____ (Initial) I understand that the District reserves the right to rescind my authorization for the use of a UAS or drone at any time.

Signature Date_____________________

____ Attached copy of Certificate of Waiver/Authorization or Exemption from the Federal Aviation Administration

____ Attached copy of Certificate of Liability Insurance

SECTION 8: SUPERINTENDENT'S OFFICE

Request approved? ______yes ______no

Superintendent's comments or requirements for operation are listed below and must be observed. If not approved, a summary of the decision is outlined.

Exhibit LEMOORE UNION HIGH SCHOOL DISTRICT

version: March 26, 2020 Lemoore, California