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Name ____________________________ ID# ____________ Grade ____ Sport____________

Student Educational History (Parent & Student Signatures Required)

Parent Permission/Emergency Health/Contact (Parent & Student Signatures Required)

Student Code of Conduct (Parent & Student Signatures Required)

AIA Eligibility Requirements for Athletics (Parent & Student Signatures Required)

Athletic Equipment Contract (Parent & Student Signatures Required)

AIA MTBI / Concussion Form (Parent & Student Signatures Required)

Concussion Fact Sheet For Parents (Parent Signature Required)

Brain Book Concussion Quiz (Parent & Student Signatures Required)

Concussion Fact Sheet For Students (Student Signature Required)

AIA Physical Examination (Parent & Student Signatures Required)

HIPAA Disclosure Authorization Form (Parent & Student Signatures Required)

Emergency Contact Form (Parent & Student Signatures Required)

Original Birth Certificate or Passport (unless currently on file in the Athletics Office)

$35.00 Athletic Fee Receipt (to be paid in the bookstore)

YUMA UNION HIGH SCHOOL DISTRICT

ATHLETIC CLEARANCE PACKET

2015-2016

This packet must be filled out completely and returned to the Athletics Office

in order to be cleared for an athletic competition.

In addition to the attached forms you must provide the following:

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STUDENT EDUCATIONAL HISTORY

NAME: _______________________ STUDENT # _____________ GRADE: _____

Please complete this information prior to eligibility clearance:

List all school(s) attended while in high school (include school address,

Athletics/Activities, dates of attendance)

Grade Name of School Address City/State Dates Attended School Sports

9th

10th

11th

12th

If you attended a different high school within the last academic 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. Are you now or have you ever been home-schooled? ____________________________________________

Did you attend Summer School? Yes _____ No _____

If yes, what classes did you take: ______________________________________________________________

Student Athlete Signature: ___________________________________________ Date: ___________________

Parent/Guardian Name (please print): __________________________________________________________

Parent/Guardian Signature: __________________________________________ Date: ___________________

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PARENT PERMISSION / EMERGENCY HEALTHCARE / CONTACT

STUDENT’S NAME: BIRTHDATE: / / GRADE:

ADDRESS:

Number and Street Apt. # City/State Zip Code

HOME PHONE: PARENT’S WORK/CELL PHONE:

EMERGENCY CONTACT: PHONE:

(Person who can answer on your behalf for your son/daughter in case of an emergency)

School attended last year: Sports played last year (at other schools): 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 Signature Date

Student’s Signature Date

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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:

BULLYING / HARASSMENT / 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 we 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

athletic program.

Parent/Guardian’s Signature Date

Student’s Signature Date

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ARIZONA INTERSCHOLASTIC ASSOCIATION ELIGIBILTY REQUIREMENTS 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. PARENT/GUARDIAN PERMISSION FOR ATHLETIC PARTICIPATION: Parent/Guardian 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 Osteopathy.

3. BIRTH CERTIFICATE OR PASSPORT: Students who have not previously presented a birth

certificate or Passport to the Athletic Office for recording must do so. A birth certificate/passport 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 before September 1, he/she is not eligible for any part of that school year.

4. ACADEMIC ELIGIBILITY: Students who receive an "F" at the end of the six (6) week, (12) week, or

semester grading period shall remain ineligible until the requirements of eligibility are met. Students who are ineligible will not be able to compete for a minimum of one (1) full calendar week, Monday through Sunday. Following the mandatory week of ineligibility, a student would immediately become eligible when a grade check is turned in showing that a previous failing grade is now a passing grade for the semester. It will be the student's responsibility to have the teacher sign the grade check form when he/she becomes eligible and to turn it in.

5. ATHLETIC CLEARANCE 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.

6. 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

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ATHLETIC EQUIPMENT CONTRACT

(Replacement Cost for Equipment is listed on the back page of this packet)

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 assessed to the students account (see back page for replacement costs)

Student-athletes will not be allowed to participate in another YUHSD 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.

Official 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 Work Phone Number

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I have read the Concussion Fact Sheet:

Parent Signature

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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. Athletes are only required to complete the Brain Book training once during their four year high school career. ** IF YOU HAVE COMPLETED THE CONCUSSION BRAIN BOOK TRAINING, PLEASE SIGN BELOW. ** STUDENT SIGNATURE: ___________________________ PARENT SIGNATURE: ____________________________ YEAR COMPLETED: ____________________ 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 they go 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.)

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I have read the Concussion Fact Sheet:

Student Signature

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HIPAA 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

EXPIRATION DATE: This authorization will expire on . If no date or event is stated, the expiration

date will be six years from the date of this authorization.

.

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YUMA UNION HIGH SCHOOL DISTRICT

EMERGENCY CONTACT FORM

Student Name:

Nickname:

ID #: Grade: Age: Birth date:

Parent/Guardian Name:

Home Address: City: Zip:

Home #: Cell #: 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

___________________________________________________________ ____________________

ATHLETIC OFFICE SIGNATURE (Must be signed to clear) Date Cleared

Fall Sport: ____________________

Winter Sport: ___________________

Spring Sport: ___________________

OFFICE USE

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REPLACEMENT COST FOR EQUIPMENT

FALL SPORTS

CROSS COUNTRY

Equipment Bag $40.00

Tank $40.00

Shorts $35.00

Warm-Up Top $40.00

Warm-Up Bottom $40.00

FOOTBALL

Helmet $200.00

Shoulder Pads $125.00

Practice Pants $25.00

Practice Jersey $25.00

Hip Pads $25.00

Thigh Guards $25.00

Girdle $10.00

Knee Pads $20.00

Equipment Bag $40.00

Home Jersey $100.00

Away Jersey $100.00

Game Pants – Gold $50.00

Game Pants – Black $50.00

Game Belt $10.00

Spider $15.00

Neck Roll $20.00

Rib Protection $20.00

Tailbone Pads $20.00

GOLF

Golf Bag $100.00

VOLLEYBALL

Jersey $40.00

Shorts $30.00

Bag $45.00

Warm-Up Top $40.00

Warm-Up Bottom $40.00

WINTER SPORTS

BASKETBALL

Jersey Top $65.00

Home Jersey $60.00

Away Jersey $60.00

Practice Jersey $30.00

Home Shorts $60.00

Away Shorts $50.00

Warm-Up Top $50.00

Warm-Up Bottom $50.00

Bag $60.00

SOCCER

White Jersey $55.00

Black Jersey $55.00

Gold Jersey $55.00

Shorts $35.00

Warm-Up Top $40.00

Warm-Up Jacket $45.00

Warm-Up Bottom $40.00

Bag $60.00

Practice Ball $15.00

WRESTLING

Head Gear $30.00

Warm-up Top $35.00

Warm-up Bottom $35.00

Tights $45.00

Singlets $60.00

Travel Bag $50.00

CHEER

Cheer Top $125.00

Cheer Skirt $125.00

Cheer Bloomer $25.00

Cheer Shirt Male $65.00

Cheer Pant Male $75.00

Cheer Warm-up Tops $85.00

Cheer Warm-up Bottom $85.00

Cheer Bag $75.00

Pom Poms $40.00

Under Armour $50.00

SPRING SPORTS

BASEBALL

Home Jersey $90.00

Away Jersey $90.00

Black Sleeves $25.00

Gold Sleeves $25.00

Pants $55.00

Jacket $75.00

Warm-up Jersey $45.00

Shirt $40.00

Travel Bag $65.00

Helmet

Bat

SOFTBALL

Home Jersey $90.00

Away Jersey $90.00

Warm-up Jersey $45.00

White Pants $50.00

Black Pants $50.00

Travel Shirt $40.00

Travel Bag $60.00

Helmet

Bat

TENNIS

Shirts $35.00

Shorts/Skirts $35.00

Tennis Racquets $50.00

TRACK

Equipment Bag $40.00

Jersey Top $40.00

Shorts $35.00

Warm-up Jacket $45.00

Warm-up Pant $45.00

ALL SPORTS

Late Fee $ 5.00

Lock Fee $ 8.00

(Parent/Guardian Copy)