This packet must be filled out completely and returned to the

This packet must be filled out completely and returned to the

San Luis High School
YUMA UNION HIGH SCHOOL DISTRICT
ATHLETIC CLEARANCE PACKET
2012-2013
This packet must be filled out completely and returned to the Athletics Office
In order to be cleared for an athletic competition.
… Parent Permission / 520 Process / Emergency Contact
… AIA Eligibility Requirements for Athletics
… Student Code of Conduct
… Athletic Equipment Contract
… AIA MTBI / Concussion Form
… Concussion Fact Sheet For Parents
… Brain Book Concussion Quiz
… Concussion Fact Sheet For Students
… AIA Physical Examination
… HIPPA Disclosure / Emergency Contact Form
… Athletics Clearance & Emergency Card
In addition to the attached forms you must provide the following:
… Birth Certificate or Passport (unless already currently on file in the Athletics Office)
… $35.00 Athletic Fee Receipt (to be paid in the bookstore)
Parent Permission y Emergency Healthcare y Contact
Student’s Name:___________________________________________ Birthdate: ______________________________ Grade: __________
Address: _________________________________________________________________________________________________________
Home Phone: __________________________________________ Parent’s Work/Cell Phone: _____________________________________
Emergency Contact:_____________________________________________________ Phone: _____________________________________
(Person who can answer in your behalf for your son/daughter in case of an emergency)
School Attended Last Year: _________________________________________________________________________
Sports Played Last Year:____________________________________________________________________________
If you attended a different high school within the last year, you must complete the 520 Process. The 520 form can be
found at www.aiaonline.org. Please go online to complete the form and submit it. If you have questions regarding the
520 Process, please contact your Athletic Director.
PARENT OR GUARDIAN PERMISSION: I/We give my/our permission for the above named student to participate in interscholastic
athletics, realizing that such activity involves the potential for injury and/or transmittable diseases, which is inherent in all sports. I/We
acknowledge that even with the best of coaching, use of approved equipment, and strict observance of the rules, injuring and/or transmittable
diseases are still a possibility. On rare occasions these injuries and/or transmittable diseases can be so severe as to result in total disability,
paralysis, quadriplegia, or even death.
CONSENT FOR EMERGENCY CARE: BE IT KNOWN that I, the undersigned parent or guardian of the above named student, do hereby
give and grant unto any medical doctor and/or certified athletic trainer/hospital my consent and authorization to render such aid, treatment or
care to said student as in the judgment of said doctor and/or certified athletic trainer/hospital, may be rendered, on an emergency basis, in the
event said student should be injured or stricken ill while participating in an interscholastic activity sponsored or sanctioned by the Arizona
Interscholastic Association, Inc., of which the above named high school is a manner.
IT IS HEREBY understood that the consent and authorization hereby given and granted are continuing and intended by me to extend
throughout the current school year.
IT IS FURTHER understood that any expenses incurred will be paid for by the insurance of the parent of the student;
payment of any medical expenses is NOT a school responsibility.
I / We have Read, Understand and Agree to all of the above statements and their conditions.
________________________________________________________________
Parent / Guardian’s Signture
______________________
Date
________________________________________________________________
Student’s Signature
______________________
Date
Permiso de Padres y Atención Medica y Contacto
Nombre del estudiante: _____________________________________ Fecha de Nacimiento: ____________________ Grado: __________
Domicilio: ________________________________________________________________________________________________________
Teléfono de Casa:_______________________________________ Teléfono de Celular: __________________________________________
Contacto de Emergencia: _________________________________________________ Teléfono:___________________________________
(Persona que pueda tomar decisiones sobre su hijo/a en caso de emergencia solamente)
Escuela ala que asistió el año pasado: ________________________________________________________________
Ultimo Deporte en que participo el año pasado:__________________________________________________________
Si asistió a una high school diferente al año pasado, tiene que completar el proceso 520. La forma 520 la encuentra en
www.aiaonline.org. Porfavor de completar y someter la forma en Internet. Si tiene alguna pregunta referente al
proceso 520, por favor de contactar al Director de Deportes.
PERMISO DEL PADRE/GUARDIAN: Yo/Nosotros damos mi/nuestro permiso al estudiante mencionado arriba para que
participe en deportes escolásticos, con el entendimiento que tal actividad envuelve el potencial de lastimaduras y/o
enfermedades transmisibles, las cuales son un aspecto inevitable en todos los deportes. Yo/Nosotros reconocemos que aun con
los mejores entrenadores, y con el uso del equipo apropiado, y observación de estricto reglamentos, lesiones y/o enfermedades
transmisibles pueden ocurrir. En raras ocasiones, estas lesiones y/o enfermedades transmisibles pueden ser muy severas hasta
tener un resultado de total discapacidad, parálisis, quadriplejo y hasta la muerte.
CONCENTIMIENTO PARA TRATAMIENTO DE EMERGENCIA. RECONOSCO QUE YO, como legal padre o tutor del
estudiante, doy por este medio y concedo a cualquier doctor medico y/o a un entrenador de atletismo certificado de hospital el
permiso y autorización de rendir tal ayuda, tratamiento, y cuidado al estudiante con el criterio del susodicho doctor, entrenador
certificado de hospital, pueden rendir en caso de emergencia, en el evento que el estudiante sea lesionado o aquejado por una
enfermedad durante su participación en un actividad escolar patrocinado o sanción por la Asociación Arizona Interscholastic
Asociación, Inc., la cual la escuela mencionada en esta forma participa como un miembro.
POR ESTE MEDIO las condiciones son entendidas que el consentimiento y autorización son otorgados continuamente y con la
intención por mi ser prolongados durante el actual año escolar.
ADDICIONAL es entendido que los costos médicos obtenidos, co-pagos, y el porcentaje serán pagados por la
aseguransa, y/o el padre del estudiante. ● COSTOS MEDICOS NO SON LA RESPONSABILIDAD DE LA ESCUELA.
YO/Nosotros hemos leído, entendido, y estamos de acuerdo con todas las declaraciones y sus condiciones mencionadas.
________________________________________________________________
Firma del Padre / Guardián
______________________
Fecha
________________________________________________________________
Firma del Estudiante
______________________
Fecha
ARIZONA INTERSCHOLASTIC ASSOCIATION
ELIGIBILTY REQUIRMENTS FOR ATHLETICS
Students are responsible for meeting the following eligibility requirements before practicing in any sport. Failure to
meet eligibility requirements may result in student, team, or school forfeiture, disqualification, or disciplinary action as
determined by the High School and/or the A.I.A.
1. PARENTS’ PERMISSION FOR ATHLETIC PARTICIPATION: Parent consent is required before a student can be
eligible to practice or compete in interscholastic competition.
2. PHYSICAL EXAMINATION FORM: Parents are to complete and sign the Student Health History and annual Health
Questionnaire portions of the physical exam forms. The examining medical provider is to complete and sign the
physical examination summary form. NO STUDENT WILL BE PERMITTED TO PRACTICE OR PARTICIPATE IN AN
INTERSCHOLASTIC ATHLETIC CONTEST WITHOUT HAVING A PHYSICAL EXAMINATION AND APPROVAL BY
A DOCTOR OF MEDICINE OR OESTEOPATHY.
3. HEALTH INSURANCE: Before being permitted to practice or participate in an interscholastic athletic contest, a
student must be covered by their parents’ insurance, or by student activity insurance. A copy of the student’s most
current insurance card must accompany the clearance packet. It is the parents’ responsibility to keep the Athletic
Office notified of any changes in the student’s insurance coverage, and to purchase student insurance if necessary.
4. EMERGENCY CONSENT: A parental signature on an emergency consent form is required. NO STUDENT WILL
BE ISSUED A PRACTICE PERMIT UNTIL HE/SHE HAS PRESENTED AN EMERGENCY CONSENT FORM, WHICH
IS SIGNED BY A PARENT.
5. BIRTH CERTIFICATE OR PASSPORT: Students who have not previously presented a birth certificate to the
Athletic Office for recording must do so. A birth certificate must be on file in the Athletic Office before a student is
eligible for participation in an athletic contest. If a student becomes 19 years old after September 1, he/she is not
eligible for any part of that school year.
6. ACADEMIC ELIGIBILITY: A student must be passing all subjects at grade check time in order to be academically
eligible to compete in athletic contests. The day after grades are submitted, a grade report will be run for all studentathletes. Students who are ineligible must not compete for a minimum of 5 consecutive school days. Students will
have those 5 days to become eligible for the following week. Students who are still ineligible at the end of the 5 days,
will then be ineligible for another 5 days. This cycle is repeated until the student has become eligible in the class they
were failing.
7. ATHLETIC CLEARNCE CARD: The Athletic Department Secretary shall issue an Athletic Clearance Card to the
student when ALL CLEARANCE requirements have been verified and recorded. Until the ATHLETIC CLEARANCE
CARD is completed and signed by the secretary and is presented to the coach, NO EQUIPMENT OF ANY KIND
SHALL BE ISSUED TO THE STUDENT NOR SHALL HE/SHE BE PERMITTED TO PRACTICE OR PARTICIPATE IN
INTERSCHOLASTIC ATHLETICS.
8. COMPETITION ON A SCHOOL TEAM: A student who is a member of a school team cannot practice or compete
for or with another club, group, organization, association, etc., in that same sport during the interscholastic season of
competition of that sport as defined in the A.I.A. bylaws. Any student violating the above rule shall forfeit his/her
eligibility for a minimum of the balance of the season. (Contact the Athletic director for exceptions to this rule).
I/We affirm that I/We have read the above A.I.A. eligibility requirement for athletic participation.
Parent/Guardian’s Signature
Date
Student’s Signature
Date
STUDENT CODE OF CONDUCT
(Athletic Responsibility Acknowledgement)
As a Yuma Union High School District student-athlete, who is participating voluntarily in inter-scholastic athletics, I
understand that my participation is a privilege and dependent on my acceptance of the following rules and
expectations:
BULLEYING / HARRASSMENT / HAZING:
1. I will not use abusive and/or offensive language, insults, teasing, or unreasonable criticism.
2. I will not use or participate in physical abuse or intimidation of another student.
3. I will not use technology, my peers or other means to bully, harass, or haze another student.
SUBSTANCE ABUSE:
4. I will not use or be in possession of alcohol, tobacco, or any illegal substances. Failure to comply with this rule will
result in my immediate dismissal or suspension from the sport in which I am participating.
ELIGIBILITY:
5. I will at all times maintain a satisfactory academic eligibility standing by passing all classes in which I am enrolled
with the highest grades possible in each subject area. Failure to do so will result in my suspension from game
competition on a week-to-week basis.
ATTENDANCE:
6. I will attend all my classes and practices each and every day. I will NEVER have an unexcused absence from
class or practice. Failure to comply with this rule may result in a loss of playing time for a first offense, a one game
suspension for the second offense, and dismissal from the team on the third offense.
CITIZENSHIP:
7. I will be a good citizen and conduct myself in an exemplary manner at all times so as not to bring discredit or
embarrassment to me personally, my parents, my team, and my school. Failure to comply with this expectation
may result in my suspension or dismissal from the team depending on the severity of my actions.
RESPONSIBILITY:
8. I will be responsible for all athletic equipment issued to me, will return such equipment in good condition and will
pay the current replacement cost for any equipment not returned by me at the end of the season.
My parents and I acknowledge that I have read, understand, and agree to abide by these rules and expectations along
with established consequences, as a condition for my participation in the Yuma Union High School District sports
program.
Parent/Guardian’s Signature
Date
Student’s Signature
Date
ATHLETIC EQUIPMENT CONTRACT
ISSUING EQUIPMENT: I/We understand that all athletic equipment will be checked out through the Equipment
Manager and/or the coach of sport. I/We understand that once the equipment has been issued to the student, it is then
the responsibility of the student to care for, maintain and return the issued equipment in good working condition.
RETURNING EQUIPMENT: I/We agree to be responsible for the safe return of all athletic and/or activity
equipment issued by the school to the below named student, and in the case of lost, stolen, or damaged equipment be
responsible for paying for the replacement of such equipment at a cost determined by the Athletic Department.
I/We understand all assigned equipment will be returned only to the Equipment Manager no later than 5 days after the
last competition. I/We understand that if the equipment issued is not returned within the time frame the following will
occur:
• Fees will be accessed to the students account (see back of form for fees)
• Student-athletes will not be allowed to participate in another YUHD sport until the fees have been paid and/or
the equipment returned.
• Student-athletes will not be allowed to purchase tickets for school events or any other activity requiring
students to have their fees paid.
• Academic transcripts will not be released.
My signature affirms that I have read and understand the expectation set forth in this contract and I agree to assume all
the responsibilities it entails.
__________________________
PRINT Student Name
__________________________
Student Signature
______________
Date
__________________________
PRINT Parent/Guardian Name
__________________________
Parent/Guardian Signature
______________
Date
__________________________
Home Phone Number
__________________________
Cell Phone Number
______________
Date
CONTRATO DE EQUIPO DEPORTIVO
Distribución de Equipo Deportivo: Yo/Nosotros estamos concientes que todo equipo deportivo será alquilado por
medio del Manager de Atletismo o el entrenado del deporte que participa. Yo/Nosotros entendemos que el momento
que el equipo deportivo se aya otorgado al estudiante, es responsabilidad del estudiante de cuidarlo, mantenerlo y
regresarlo en la misma condición en que se otorgo.
Regresar el Equipo Deportivo: Yo/Nosotros nos hacemos responsables del el regreso de TODO el equipo deportivo
o actividad prestada por la escuela a nombre del estudiante mencionado abajo. En caso que se pierda, robe o se dañe el
equipo deportivo es responsabilidad de ustedes de pagar el replazo de tal equipo deportivo a costo determinado por el
Departamento de Atletismo.
Yo/Nosotros estamos concientes que todo equipo deportivo asignado será regresado al Manager de Atletismo no mas
tardar de 5 días de el ultimo juego. Yo/Nosotros entendemos que si el equipo deportivo no es regresado en el tiempo
dado lo siguiente ocurrirá:
• Cuotas serán agregadas a la cuenta del estudiante (vea siguiente pagina)
• Estudiantes – Atletas no serán permitidos participar en otro YUHSD deporte hasta que las cuotas aya sido
pagadas y/o el equipo deportivo aya sido regresado.
• Estudiantes – Atletas no serán permitidos comprar boletos para eventos escolares o cualquier otra actividad
requiriendo estudiantes que paguen cuotas.
• Historial Académico oficial no serán otorgados.
Mi firma afirma que eh leído y entendido la expectación puesta por este contrato y estoy de acuerdo en asumir todas
las responsabilidades escritas.
__________________________
Escribir en letra molde
Estudiante
__________________________
Firma del Estudiante
______________
Fecha
__________________________
Escribir en letra molde
Padre/Guardián
__________________________
Firma de Padre/Guardián
______________
Fecha
__________________________
Numero de teléfono CASA
__________________________
Número de CELULUAR
______________
Fecha
FOOTBALL
Helmet w/ chin strap
Shoulder Pads
Game Jersey
Travel Bag
Game Pants
Cowboy Collar
Practice Jersey
Practice Pants
Thigh Guards
Hip Pads
Rib Protector Pad
Knee Pads
Tailbone Pads
Lineman Gloves
Neck Roll Pad
Back Pad
Mesh Bag
Practice Belt
Elbow Pad Set
Forearm Pad Set
Arm Pad Set
Hand Pad Set
$200.00
$125.00
$100.00
$75.00
$50.00
$40.00
$25.00
$25.00
$25.00
$25.00
$25.00
$20.00
$20.00
$20.00
$20.00
$18.00
$10.00
$10.00
$6.00
$8.00
$8.00
$6.00
CROSS COUNTRY
Top
Shorts
$40.00
$35.00
VOLLEYBALL
Travel Bag
Varsity Jersey
JV Jersey
Frosh Jersey
Shorts
Knee Pad Set
$45.00
$40.00
$35.00
$35.00
$30.00
$15.00
BASKETBALL
Varsity Jersey
Varsity Short
Travel Bag
Warm-Up Top
Warm-Up Bottom
JV Jersey
JV Short
Frosh Jersey
Frosh Short
Practice Jersey
Practice Short
$65.00
$60.00
$60.00
$50.00
$45.00
$50.00
$45.00
$45.00
$40.00
$25.00
$22.00
LOCK
$7.00
TRACK
Warm-Up Jacket
Warm-Up Pant
Top
Short
$45.00
$45.00
$35.00
$30.00
WRESTLING
Singlets
Travel Bag
Tights
Warm-Up Tops
Warm-Up Bottoms
Head Gear
Knee Pad Set
$60.00
$50.00
$45.00
$35.00
$35.00
$30.00
$15.00
SOCCER
Travel Bag
Jersey
Warm-Up Jacket
Warm-Up Pant
Practice Top
Shorts
Practice Ball
Socks
Goal Keeper Pant
Goal Keeper Gloves
Goal Keeper Jersey
Goal Keeper Short
Shin Guards
$60.00
$55.00
$45.00
$40.00
$40.00
$35.00
$15.00
$10.00
$38.00
$22.00
$40.00
$30.00
$8.00
BASEBALL
Varsity Jackets
Varsity Travel Bag
Varsity Jersey
Varsity Pants
Varsity Shirts
Warm-Up Jersey
JV & Frosh Pants
JV Jersey
Frosh Jersey
Windbreaker
Belt
$75.00
$65.00
$65.00
$55.00
$40.00
$45.00
$35.00
$45.00
$40.00
$38.00
$6.00
TENNIS
Travel Bag
Varsity Shirts
Tennis Racquets
JV & Frosh Shirts
Shorts/Skirts
$40.00
$35.00
$35.00
$25.00
$20.00
SOFTBALL
Varsity Travel Bag
Varsity Jersey
Varsity Shirts
Varsity Travel Shirts
Varsity Pants
JV & Frosh Jersey
JV & Frosh Pant
Sliding Short
Belt
$60.00
$50.00
$40.00
$40.00
$40.00
$40.00
$35.00
$15.00
$6.00
CHESS
Varsity Bag
JV Bag Set
$65.00
$40.00
CHEERLEADER
Top
Skirt
Pom Poms
$78.00
$75.00
$18.00
Late Fees Per Sport
$5.00
I have read the Concussion Fact Sheet:
Parent Signature
AIA / NFHS BRAIN BOOK
All student-athletes must complete the Brain Book concussion quiz. Students must pass with at least an 80% or must
retake the quiz. Students should print off their certificate indicating they have passed and submit it with their
clearance packet.
To complete the Concussion Brain Book Quiz:
1. Go to www.aiaacademy.org
2. Click on the “Brainbook” link at the top of the page.
3. Click register as a student on the sign in page.
4. Fill out the account creation information and click the appropriate school.
5. Select the sport you are taking the test for and also click any additional sports you may participate in. Then
click register.
6. Once registration is complete – log in.
7. Complete the pre-quiz.
8. Athletes must answer all of the questions as your going from page to page through the course.
9. Print out your certificate and submit it to the Athletics Office.
(Athletes must pass with at least an 80% or must retake the quiz.)
I have read the Concussion Fact Sheet:
Student Signature
HIPPA DISCLOSURE AUTHORIZATION FORM
Student Name:
Student ID #:
Parent/Guardian Name:
I hereby authorize
The School Athletic Trainer
to use or disclose my protected health information related
to Sports Related Injuries and Head Injuries to Doctors, Teachers, Counselors, and the School Nurse for the following
purpose: Provide the highest quality care for your athlete in and out of the classroom while they attend any school in
the Yuma Union High School District.
• I understand that I may inspect or copy the protected health information described by the authorization.
• I understand that, at any time, this authorization may be revoked, when the office that receives this authorization
receives a written revocation, although that revocation will not be effective as to the disclosure of records whose
release I have previously authorized, or where other actions have been taken in reliance on an authorization I
have signed. I understand that my health care and the payment for my health care will not be affected if I refuse
to sign this form.
• I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure
by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.
Parent or Guardian Signature
Date
Relationship to Student
Phone Number
EXPERATION DATE: This authorization will expire on
be six years from the date of this authorization.
.
. If no date or event is stated, the expiration date will
YUMA UNION HIGH SCHOOL DISTRICT
EMERGENCY CONTACT FORM
Student Name:
Nickname:
ID #:
Grade:
Age:
Birth date:
Parent/Guardian Name:
City:
Home Address:
Home #:
Cell #:
Zip:
Work:
Family Doctor:
Insurance Company:
Policy/Group#:
Allergies:
Medications:
Other medical concerns:
Emergency Contact:
Phone #:
Siblings in High School:
If emergency service involving medical action or treatment is required and neither the parent nor guardians can be
contacted, I hereby consent for the student named above to be given medical care by the doctor selected by the
school.
Parent/Guardian Signature
Date