PCS Student Protection Plan Acknowledgment Form
STUDENT PROTECTION PLAN

MANDATED REPORTING
Portland Community Squash requires all staff and volunteers to immediately report any suspicion of child abuse or neglect to the Executive Director. In any case of suspected child abuse or neglect, all employees and volunteers of Portland Community Squash must be respectful of the rights of privacy of the family concerned. You must keep the matter confidential and discuss it with no one except the Executive Director. Involvement of additional parties is at the discretion of the Executive Director only.

Immediately upon receiving a report, the executive director will:
● Complete an incident report
● Notify lawyers at Bernstein Shur
● Call DHHS (Dept. Child + Family Services) immediately or at minimum within 24 hours:
DHHS 1-800-452-1999
● Follow instructions from DHHS You can suspect child abuse or neglect if:
● You or another staff member or volunteer witness abuse.
● You or another staff member or volunteer sees physical signs of abuse or neglect.
● A child reports abuse or neglect to you.

Child abuse and neglect can take the following forms:
Abuse: the non-accidental commission of any act by a caretaker upon a child under age 18 which causes, or creates a substantial risk of, physical or emotional injury; or constitutes a sexual offense under the laws of the Commonwealth; or any sexual contact between a caretaker and a child under the care of that individual.

Neglect: Failure by a caretaker, either deliberately or through negligence or inability to take those actions necessary to provide a child with minimally adequate food, clothing, shelter, medical care, supervision, emotional stability and growth, or other essential care; provided, however, that such inability is not due solely to inadequate economic resources or solely to the existence of a handicapping condition.

Physical Injury: Death; or fracture of a bone, subdural hematoma, burns, impairment of any organ, and any other such nontrivial injury; or soft tissue swelling or skin bruising, depending upon such factors as the child's age, circumstances under which the injury occurred and the number and location of bruises; or addiction to a drug or drugs at birth; or failure to thrive.

Emotional Injury: an impairment to or disorder of the intellectual or psychological capacity of a child as evidenced by observable and substantial reduction in the child's ability to function within a normal range of performance and behavior.

If a staff member or volunteer is accused of suspected abuse or neglect:
Upon receiving any report of suspected abuse or neglect or any accusation of abuse or neglect against an employee, Portland Community Squash will investigate the situation in consultations with the counselor and other persons as appropriate. Accused staff members may not work directly with children during this investigation.

APPROPRIATE CONDUCT AND DRESS WHILE INTERACTING WITH YOUTH

Abuse: Portland Community Squash expects exemplary behavior by all its participants and it will hold a strict line on conduct as laid out in these policies.
● Abusive statements such as those that deal with race, ethnicity, religion, nationality, gender, age, sex, or sexual orientation are not permitted.
● Physical, emotional, sexual, and ethical abuses are prohibited, as is neglect or endangerment of a child.
● All PCS staff and volunteers are strictly prohibited from engaging in any romantic or sexual conduct with all current program participants including all students receiving services through their college graduation. This includes any romantic or sexual encounters or relationships that the staff or volunteer perceives to be consensual. Engaging in any such conduct will result in the immediate termination of the volunteer or staff member and could result in criminal prosecution.

Clothing:
The following kinds of clothing or accessories are not acceptable:
● Items that advertise drugs, alcohol, tobacco, sex, or otherwise inappropriate things
● Items that do not appropriately cover the wearer’s body (ex: cropped shirts, low cut shirts, muscle shirts, short shirts, etc.)
● Items with messages that are offensive or inappropriate

Behavior: Examples of Appropriate and Inappropriate Behaviors
Although not a comprehensive list of appropriate, inappropriate and harmful behaviors, examples of other acceptable and unacceptable behaviors include:

Verbal Communication:
Appropriate:
● Praise
● Positive reinforcement for good work/behavior
Inappropriate/harmful:
● Sexually provocative or degrading comments
● Risqué jokes

Physical Behavior:
Appropriate:
● Pats on the back or shoulder
● Side Hugs when initiated by a student

Inappropriate/harmful:
● Patting the buttocks
● Piggy Back Rides
● Intimate/romantic/sexual conduct
● Corporal punishment

Some forms of touching are acceptable as long as they are respectful and appropriate:
1. Touching should be with the child’s permission.
2. Resistance to touching must be respected.
3. Touching must never include the breast, buttocks, or groin.
4. Touching should be done in the open, NOT IN PRIVATE.
5. Touching should have a brief, limited duration.

Other Prohibited Conduct:
1. Providing minors with alcohol or drugs (including prescription pills)
2. Encouraging violence, physical altercations, sexual activity, or use of alcohol or illegal drugs.
3. Threatening, bribing, or extorting minors for any purpose
4. Facilitating a minor’s possession of any contraband, including weapons, firearms, or stolen property
5. Wrestling or sparring with students, even in jest
6. Sharing anytime of sexually explicit visuals

A child’s comfort level with touching is influenced by factors such as age, developmental stages, social and emotional well-being, life experiences, gender, etc. all of which change over time. At all times, if it is unclear whether the minor is comfortable with touching, PCS staff and volunteers should err on the side of caution and refrain from having physical contact with the student.


ALCOHOL AND DRUG POLICY

Portland Community Squash is committed to protecting the safety, health, and well-being of its employees, students, families, and all people who come into contact with the Portland Community Squash facility and programs. Recognizing that drug and alcohol abuse pose a direct and significant threat to this goal, Portland Community Squash is committed to ensuring a substance-free work environment for all of its employees and volunteers.

Therefore, Portland Community Squash explicitly prohibits:

• The use, possession, solicitation for, or sale of narcotics or other illegal drugs, alcohol or
prescription medication without a prescription on Portland Community Squash premises, while
supervising children, or while acting on behalf of Portland Community Squash in any capacity.
• The presence of any detectable amount of prohibited substances in the employee’s system while at work, while on Portland Community Squash premises or while acting on behalf of Portland Community Squash in any capacity.

“Prohibited substances” include illegal drugs, alcohol, or prescription drugs not taken in accordance with a prescription given to the employee or volunteer.

Any violation of this policy will result in adverse action up to and including dismissal.

See Facility policy for member and event alcohol policies.

If a participant admits illegal use of drugs or alcohol to a staff member or volunteer, the staff member or volunteer should immediately notify the Executive Director. The ED will determine whether the student is in danger, at which point parents will be contacted.


STAFF/VOLUNTEER BOUNDARIES WITH STUDENTS

Staff members and volunteers must maintain professional relationships and boundaries with program participants at all times. A program participant is defined as a current member of the afterschool or college support program who is currently receiving services from Portland Community Squash. Past participants who have completed college and are no longer receiving services from Portland Community Squash are not included in this definition.

Consensual sexual relationships between any employee/volunteer and any participant, including participants who have reached the age of consent and those who are employed by Portland Community Squash, are prohibited.

Employees/volunteers shall refrain from socializing with participants, except as part of Portland Community Squash-sponsored or Portland Community Squash-sanctioned activities. Employees/volunteers may not consume alcohol in the presence of participants.

There may be situations in which employees/volunteers have prior relationships with Portland Community Squash participants, but employees/volunteers are still expected to set and maintain appropriate boundaries, reflecting the difference in power and authority between staff members and participants.

Employees/volunteers are encouraged to seek supervision when they encounter ambiguous situations regarding socializing or relationships with participants.

Portland Community Squash reserves the right to investigate concerns of volunteer misconduct involving participants even if no written complaint has been filed. Employees/volunteers are required to report known misconduct and questionable behavior on the part of fellow employees/volunteers involving participants.


PRIVACY POLICY

Portland Community Squash (PCS) occasionally collects personal information from students, volunteers, and other individuals associated with the program. This information is only collected when you voluntarily provide it to PCS, either through the PCS website or from forms completed in hard copy.

Any personal information may be used by PCS to transmit PCS communications to you; to perform criminal background checks on you; to process PCS transactions; or to aggregate data about PCS participants. PCS protects your personal information by restricting the individuals that have access to it to PCS staff and criminal background check vendors.

PCS is committed to maintaining the confidentiality of your personal information and will not otherwise sell, trade, or transfer to outside parties, your personally identifiable information. However, PCS may release your personal information when we believe release is appropriate to comply with the law, enforce PCS policies, or protect our or others’ rights, property, or safety.


ELECTRONIC COMMUNICATION & SOCIAL MEDIA POLICY

Portland Community Squash (PCS) is committed to protecting children from abuse. This includes protecting a child’s privacy rights from being compromised or violated. PCS is also committed to protecting its students, staff and volunteers from dangers inherent in maintaining an online presence. PCS therefore recommends the following guidelines for electronic communications and the use of social media sites, such as Facebook, Twitter, Instagram, Snapchat, and Google+.

Consistent with PCS’s Student Protection Program policies, PCS asks all volunteers, regardless of whether they have a current volunteer application form on file, to maintain transparency in their communications with children while protecting children’s identity and privacy. Volunteers older than 18 years old should refrain from private, personal, ongoing electronic conversations with children (with the exception of Mentors who work one-on-one with individual students). Volunteers are discouraged from ‘friending’ or connecting with PCS participants on social media. Emails regarding PCS sanctioned activities are permitted.

All PCS websites and pages on social media sites such as Facebook, Twitter, Google+ and others must be monitored by PCS staff to prevent inappropriate postings, blogs or tweets which either divulge the identity of minors or include any disparaging comments or pictures. Neither PCS websites nor social media sites may be conduits for social bullying, airing grievances, or gateways for predators. All PCS or social media sites/pages should conform to the rules and regulations for use and safety as outlined by the site owner.

The Portland Community Squash Participation Agreement includes a general photo release for non-commercial purposes. Pictures posted on public sites should only include the first names of individual players to avoid identifying children to the wrong individuals. Team rosters with names or other identifying information, such as phone numbers and contact information, must not be posted on any public website or social media page. Photos of students may not be posted to any non-PCS maintained websites or social media pages.

The advantages and convenience of electronic communications and social media pages make them valuable and necessary tools for communicating with PCS participants. As long as the same Student Protection Program guidelines for interactions between volunteers and children are used in electronic media, the risk of abuse and misunderstandings can be minimized.


BACKGROUND CHECKS

● TIER ONE: Paid staff members, anyone who will be alone with students (i.e. mentors and chaperones).
○ Before working with students, tier one participants will undergo a national and county background check
with Intellicorp. Participants must submit the Intellicorp paper disclosure form. Tier one participants must
sign the PCS Student Protection plan.
○ If the tier one participant will be driving PCS vehicles or students, they will undergo an Intellicorp motor
vehicle background check.
○ Every two years, tier one participants will renew their national background check (through Protect Youth Sports for mentors) and re-sign the PCS student protection plan

● TIER TWO: Volunteers over 18, who will not be alone with students.
○ Tier two participants will be required to follow steps for the Protect Youth Sports national background check. They are also required to sign the PCS Student Protection Plan.
○ Tier two participants are recommended, but not required, to take the Protect Youth Sports student safety training.
○ Every two years, tier two participants will be required to renew their national background check with Protect Youth Sports and re-sign the PCS Student Protection Plan.

● TIER THREE: One-time volunteers or volunteer groups.
○ Individuals who are invited by Portland Community Squash to volunteer in a one-time capacity or with a
group (i.e. college sports team) will sign the electronic guest form, which includes the Portland Community Squash Code of Conduct.

See Background Check Policy for more information...


CONCUSSION PROTOCOL

PCS uses the guidelines provided by Heads Up: Concussion Guide for Coaches

Recognize - To help recognize a concussion, you should watch for and ask others to report the following two things among your athletes:
1. A forceful bump, blow, or jolt to the head or body that results in rapid movement of the head.
2. Any concussion symptoms or change in the athlete’s behavior, thinking, or physical functioning.
Athletes who experience one or more of the signs and symptoms listed below after a bump, blow, or jolt to the head or body should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says they are symptom-free and it’s OK to return to play.

SIGNS OBSERVED BY COACHING STAFF
● Appears dazed or stunned
● Is confused about assignment or position
● Forgets an instruction
● Is unsure of game, score, or opponent
● Moves clumsily
● Answers questions slowly
● Loses consciousness (even briefly)
● Shows mood, behavior, or personality changes
● Can’t recall events prior to hit or fall
● Can’t recall events after hit or fall

SYMPTOMS REPORTED BY ATHLETE
● Headache or “pressure” in head
● Nausea or vomiting
● Balance problems or dizziness
● Double or blurry vision
● Sensitivity to light
● Sensitivity to noise
● Feeling sluggish, hazy, foggy, or groggy
● Concentration or memory problems
● Confusion
● Just not “feeling right” or is “feeling down”

Action Plan: If you suspect that an athlete has a concussion, implement your four-step “Heads Up” action plan:
1. Remove the athlete from play. Look for signs and symptoms of a concussion if your athlete has
experienced a bump or blow to the head or body. When in doubt, sit them out.
2. Ensure that the athlete is evaluated by a health care professional experienced in evaluating for concussion.
Do not try to judge the severity of the injury yourself. Health care professionals have a number of methods that they can use to assess the severity of concussions. As a coach, recording the following information can help health care professionals in assessing the athlete after the injury:
a. Cause of the injury and force of the hit or blow to the head or body
b. Any loss of consciousness (passed out/knocked out) and if so, for how long
c. Any memory loss immediately following the injury
d. Any seizures immediately following the injury
e. Number of previous concussions (if any)
3. Inform the athlete’s parents or guardians about the possible concussion. Make sure they know that the athlete should be seen by a health care professional experienced in evaluating for concussion.
4. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play. A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death.


STUDENT SUPERVISION POLICY

One-on-One Interactions: One-on-one interactions between students and staff or volunteers are to be an extremely rare occurrence. PCS staff or volunteers working with students individually/one-on-one as part of an individual tutoring program, mentoring program or as part of an overnight PCS-sponsored trip will occur only after notification and approval by the PCS Executive Director or Program Director.

Responsibility for Students: Once the PCS staff or volunteer has assumed charge of the students/youth under his or her direction, she or he remains responsible until a duly designated adult has taken charge of each child after practice or a match or the child leaves the immediate vicinity of the practice or game as prearranged by the parent or guardian. Volunteers and staff who are below the age of 18 may not be responsible for sole supervision of students/youth at any time.

Student-to-Staff Ratio: For the protection of both the children and the volunteer, no volunteer should generally permit herself or himself to be alone with any child or group of children during PCS-sponsored activities. The recommended supervision ratio should be 1:12 – One (1) adult staff for every twelve (12) students, or less.

FIELD TRIP PROTOCOLS

Information to Parents: Prior to a field trip (college visit, squash match, overnight tournament, team trip, etc...) staff should prepare an informational flyer with the following information: staff and contact information, destination and all pertinent address, how students will be transported, when students will be traveling, pickup and drop off information, and a packing list. The flyer should also include a passive or required permission slip. Passive permission slips are only permissible for day-trips and parents should only return a passive permission slip if they do not want their child to participate. Overnights warrant a required permission slip, which requires parents to return the permission slip prior to the trip.

Overnight Trips: Overnight trips require background checks when staying in private home. There should be a staff student ratio of 1:8, and there should be a staff member of each gender, unless it is a single gender trip.

Swimming Trips: Swimming trips are only permitted where lifeguards are present. Prior to any swimming, staff members should identify who knows how to swim. If a student wants to swim, they must swim with a buddy. Buddies are responsible for checking on each other, making sure they are ok, and if one buddy leaves the water, so does the other. Any time students are in the water, a staff member must have two feet in the water or be sitting in a chair at the water line.


STUDENT MENTAL HEALTH POLICY

If a student makes comments about hurting themselves, hurting others, or suicide, the ED should be notified immediately. Portland Community Squash will notify the parents and the school counselor.


TRANSPORTATION

Vehicle Safety: The executive director is responsible for ensuring that all vehicles have current inspections, current registrations, and no dangerous driving hazards.

Pre-Drive Checklist: A pre driving inspection should be reviewed before every trip to ensure the vehicle is safe to drive.

Driver Agreements: Before driving a vehicle all employees must have a Motor Vehicle Background Check. If the executive driver sees more than two infractions, the driver will be denied driving privileges. Before driving, all drivers must sign a no distracted driving agreement - copies are kept in the vehicles.

Driving PCS Vehicles: Cell phones should be placed in the cell phone holder while driving and only used for directions. Pull over when making phone calls. PCS picks up students from school and drop students off at home. There are times that one student and one staff member will be alone in the vehicle. To protect students and staff members, all van rides are video taped - inside and outside of the cabin. Footage is saved for 30 days.

Employee Vehicle Policy: If a staff member decides to drive students in a personal vehicle, the employee does so at their own risk.

Mentor Mentee Trips: Mentors can drive mentees in their personal cars, as long they have undergone the driving agreements, appropriate background checks, and have prior written consent from the student’s legal parent/guardians and PCS staff.

Accident Protocol:
1. STOP. Never drive away from the scene of an accident, even a minor one.
2. PROTECT THE SCENE. You can prevent further accidents by setting up flares, or keeping your flashers on. If it is dark and your lights don't work, you should have a flashlight to keep you safe while you wait in your disabled car or by the side of the road.
3. CALL THE POLICE. Even if there are no serious injuries, it is a good idea to call the police. You may need a police report to file a claim with your insurance company, even if it is just to make a claim for damage to your vehicle. The vehicles involved in the accident should remain where they are, unless they interfere with traffic.
4. MAKE AN ACCURATE RECORD. When the police arrive, make sure you tell the investigating officer(s) exactly what happened, to the best of your ability. If you do not know certain facts, tell that to the officer. Do not speculate, guess or misstate any of the facts. If you are asked if you are injured and you are not sure, say you are not sure, rather than no. Often, the pain and injuries from motor vehicle accidents become apparent hours after the actual collision. You should also make sure statements made by other persons involved in the accident are accurate as well.
5. TAKE PICTURES. If you happen to have a camera in your vehicle, or a cell phone equipped with a camera, you should take pictures of the vehicles if there is visible damage. If you have visible injuries, you should photograph them as well. However, you should in no way interfere with the on-going police investigation. If you cannot take pictures at the scene of the accident, take them as soon as possible after the accident.
6. EXCHANGE INFORMATION. Typically, the investigating police officer obtains this information. However, if the police do not respond to the accident, you should obtain the name, address and telephone number of all persons involved in the accident, drivers and passengers alike. You should also obtain information about insurance by asking to see the insurance card for all vehicles involved in the accident. If there are witnesses, you should get information from them as well so that you or your attorney can contact them in the future. If police respond to the accident, the investigating officer usually will provide all drivers with a police report number. You can use that number later to obtain the police report. If the accident occurs on a state highway, you must request the report from the state police.
7. REPORT THE ACCIDENT. Notify your insurance company as soon as possible. Many policies require immediate reporting and full cooperation. Find out if you have medical benefits as part of your insurance coverage. You pay extra for that type of coverage - known as "medpay" - so you should use it. In fact, if you have medpay coverage, you are required to submit your accident-related medical bills to your insurance company. Medpay coverage is primary for accident-related medical bills. Once medpay benefits are exhausted, private health insurance becomes your primary insurer. Medpay benefits are available to all the occupants of the vehicle. Your insurance rates should not increase as a result of submitting claims for medpay coverage.
8. SEEK MEDICAL ATTENTION. Often, injuries caused by motor vehicle accidents are not immediately apparent. Most of our clients report feeling the most pain a day or two following an automobile accident. Unless you are absolutely certain you were not injured, you should seek medical attention at your local emergency room or by seeing your family physician. Even in accidents involving minor impact, you can sustain a serious and permanent injury to your spinal cord. If you lost consciousness or were dazed for even a short period of time following the collision, you may have suffered a concussion or closed head injury. This can cause cognitive and behavioral changes if left untreated.
9. KEEP A FILE. Keep all your accident-related documents and information together. This information should include a claim number, the claim's adjuster who is handling the claim, names and phone numbers of all contacts, receipts for a rental car and other expenses incurred as a result of the accident.
10. PROTECT YOUR RIGHTS. Perhaps the most important thing you should do after an accident is to consult your attorney. Your attorney can protect your rights and make sure valuable evidence is not destroyed. Often, insurance companies want to take statements immediately after an accident. It is important that you have received legal advice before providing such a statement. Your attorney can advise you on issues ranging from how to make sure you are fully compensated for your vehicle to how to make sure you are getting the best medical treatment available. Personal injury attorneys work on a contingency fee basis, which means there is no legal fee unless the attorney recovers compensation for your injuries.


BACKGROUND CHECK POLICY

PORTLAND COMMUNITY SQUASH BACKGROUND CHECK POLICY:

Portland Community Squash uses Intellicorp and Protect Youth Sports for online trainings, background checks, and legal compliance.

BACKGROUND CHECK TIERS

● TIER ONE: Paid staff members, anyone who will be alone with students (ie mentors and chaperones).
○ Before working with students, tier one participants will undergo a national and county background
check with Intellicorp. Participants must submit the Intellicorp paper disclosure form.
○ If the tier one participant will be driving PCS vehicles or students, they will undergo an Intellicorp
motor vehicle background check.
○ Tier one participants will also be required to sign the PCS Student Protection Plan
○ Every two years, tier one participants will renew their national background check with Protect
Youth Sports and re-sign the PCS Student Protection Plan.

● TIER TWO: Volunteers over 18, who will not be alone with students.
○ Tier two participants will be required to follow steps for the Protect Youth Sports national background check and sign the PCS Student Protection Plan.
○ Tier two participants are recommended, but not required, to take the Protect Youth Sports student safety training.
○ Every two years, tier two participants will be required to renew their national background check with Protect Youth Sports and re-sign the PCS Student Protection plan.

● TIER THREE: One-time volunteers or volunteer groups.
○ Individuals who are invited by Portland Community Squash to volunteer in a one-time capacity or
with a group (ie college sports team) will sign the electronic guest form, which includes the Portland Community Squash Code of Conduct.

BACKGROUND CHECK PROCEDURES
I - Portland Community Squash reserves the right to determine eligibility on a case-by-case basis.
II - ED or the Safety Coordinator will run all background checks.
III - When the ED determines that an applicant cannot be associated with PCS based on the results of their criminal background check, a copy of the criminal conviction report received by the PCS Executive Director must be sent to that applicant in an envelope marked “Confidential – to be opened by addressee only” along with a cover letter documenting PCS’ decision.
IV - If a conviction is disclosed or discovered, the PCS Executive Director must make a decision on
whether or not the applicant may be used based on the following guidelines and partial Table of Convictions (i) and
must advise the volunteer of the decision. As used in this policy, the term conviction refers to a conviction entered after a trial, after a guilty plea, or after a plea of no contest/nolo contendere.
a. Any application that does not contain honest answers or that misrepresents the
number, type or gravity of any conviction(s) may result in immediate withdrawal of the offer of employment with
PCS, irrespective of the nature of the offense or the time that has transpired since the conviction.
b.Any person convicted of a crime against or otherwise involving a minor at any time in the past will not be approved to be a volunteer or staff member.
c.. Persons convicted of driving while under the influence within the preceding 3 years will be disqualified from holding the position of team coach or assistant coach or any related position. Persons convicted of driving under the influence within the preceding 3 years may be
d. All other criminal convictions and arrests will be evaluated considering the following factors:
● The duties and responsibilities that are necessarily related to the job;
● Whether the conviction or arrest has a bearing on the applicant’s ability to perform those duties
and responsibilities;
● How much time has passed since the conviction(s);
● How old the applicant was at the time of the offense;
● The seriousness of the offense;
● Any information the applicant provides about his or her rehabilitation; and
● The employer’s legitimate interest in protecting property and the safety and welfare of its
employees and the public.
V - The PCS Executive Director will be immediately notified when a negative determination is made, or if there are issues related to an application. The specific results leading to a negative determination must remain confidential and will only be available on an as needed basis.
VI - Should an applicant seek to challenge the results of the background check, PCS may require the applicant to submit any relevant documentation.
STUDENT PROTECTION PLAN ACKNOWLEDGMENT:
By signing below, I acknowledge that I have received and read the Portland Community Squash Student Protection Plan and/or have had it explained to me. I understand that Portland Community Squash will not tolerate any employee, volunteer, board member or third party who violates this policy. Disciplinary actions will be taken against those who are found to have violated this policy, including potential termination from the program.I understand that it is my responsibility to abide by all rules contained in the policy. I also understand how to report incidents of child abuse or neglect as set forth in this policy, and am aware that retaliation against any employee/volunteer carrying out his or her duties as outlined in this policy is prohibited.
First Name & Last Name *
Today's Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Portland Community Squash. Report Abuse