Paperwork!

Athletic Director: Rich Gutierrez (ext. 489) (661) 252-6110

Dear Student-Athlete and Parents,

Our Mission Statement:

We believe the interscholastic athletic competition should demonstrate high standards of ethics
and sportsmanship and promote the development of good character and other important life skills.
We also believe that the highest potential of sports is achieved when participants are committed to
pursuing victory with honor according to the six core principles: trustworthiness, respect,
responsibility, fairness, caring and good sportsmanship. This code applies to all student-athletes
involved in the Canyon High School Athletic Program.

Welcome to Canyon High School and to the Canyon Athletic Program. Below is a list of forms that
must be completed, signed and submitted to the Coach before the student-athlete can begin practice
for any sport.

• Athletic Clearance Form: Warning to Student-Athlete and Parents, Certificate of Student Insurance, and  Parent Consent and Co-Curricular Agreement.  

• Canyon Sports Web-site Consent-this form allows student’s name to appear on the web-site.

• Athletic Code of Ethics (CIF)- from the office of California Interscholastic Federation (CIF).

• Release from Team Bus –if the parent wants to take their son or daughter home after an event outside of Santa Clarita Valley. In Valley many contests will be one way bus drops, so students will not return to home school.

• Medical History and Certificate of Physical Examination-the medical history form is to becompleted by a parent/guardian before the Certificate of Physical Examination.  The Certificate of Physical Examination form must be signed by a physician indicating that the student is physically fit to engage in Canyon High Athletics.

• Athletic Emergency Form (this form will be kept with the coach at all times and it is the students’ responsibility to transfer the form to the next coach if he or she is participating in another sport) 

RETURN ALL FORMS TO THE COACH

6.3

William S. Hart Union High School District

Athletic Clearance Form

1. Warning to Student-Athlete and Parents                                                   Active Sport(s):

2. Certificate of Student Insurance                                                                Fall                                                              

3. Parent Consent and Co-Curricular Agreement                                            Winter                                                     

                                                                                     Spring                                                                     

You must complete all sections of this form before your daughter/son can participate in Interscholastic athletic practices and contests         

Please print all information

Name ___________________________________________  ID# ______________________       Grade    9    10    11    12

Address__________________________________________ City_____________________________   Zip _____________

Birth Date    __________________      Phone #  _________________

School Attended Last Year  ___________________________________________ 

Sex       M     F

Name of Doctor  ___________________________________________    Doctor Phone (        )                                FAX(        )                          

Address__________________________________________ City_____________________________   Zip _____________

• Warning to Student-Athlete and Parents :

By nature, competitive athletics may put students in a situation where SERIOUS, CATASTROPHIC, and perhaps, FATAL ACCIDENTS may occur.  By granting permission for your student-athlete to participate in athletic competition, you, the parent or guardian, acknowledge that such risks exist.

              Student-Athlete’s Signature                                               Date                                 

___________________________________________________            _________________

              Parent/Guardian’s Signature                                  Date       

__________________________________________           _______________

• Certificate of Student Insurance :

It is the responsibility of the parent/guardian to secure insurance coverage prior to participation in athletics.  Sections 32220-32224 of the Education Code requires that each member of an athletic team have insurance.  I certify that my student is covered by insurance as required and further, said coverage will be in force for the entire current school year.  I understand that the school district has made available an accident insurance program in which my child may enroll and that the program is optional.

Name of Insurance Company   _____________________________________    Policy #        _________________                           

             Myers-Stevens Insurance (optional)  Date mailed :       ______________________                                                                                         

• Parental Consent and Co-Curricular Agreement :

I hereby give consent for my student to participate in Interscholastic Athletics in the Wm. S. Hart Union High School District.  In case of injury to my daughter/son, you are authorized to have her/him treated.  I further understand that in case of injury, the school staff and Associated Student Body is relieved of all liability from medical or hospital bills sustained in participation in interscholastic athletic competition.  I hereby give my consent for my daughter/son to compete in sports and go with a representative of the school on any trip(s).  I have also read the co-curricular policy regarding requirements for participation in school activities and agree to abide by the rules and regulations.  (See “Notice of Rights, Regulations and Responsibilities”)

              Student-Athlete’s Signature                                           Date       

___________________________________________________            _________________

              Parent’s/Guardian’s Signature                                       Date    

___________________________________________________            _________________