SAUGUS HIGH SCHOOL 2012 SUMMER ATHLETIC PROGRAM REGISTRATION PROCEDURES How To Register: Step 1: Complete the following Summer Athletic forms: • Registration Form • Athletic Clearance Form • Certificate of Physical Examination • Medical History • Athletic Emergency Form Step 2: Payment/Registration – select most convenient option Online March 19th – June 1st www.saugusasb.com. Open House March 15th ASB Office 6-8pm School Day Registration May 7th to 11th & May 30th- June 1st in the ASB Office 8am-3pm Mail in completed Summer Athletic forms with receipt before June 1st to: Bring completed Summer Athletics forms with payment. Bring completed Summer Athletics forms with payment. Please check in at front office. Saugus ASB 21900 Centurion Way Saugus, CA 91350 Cash, Checks, and Credit Cards Accepted. Cash, Checks, and Credit Cards Accepted. Debit and Credit Cards Accepted. Step 3: Confirmation of Registration You will receive a registration receipt when you pay in person or online. Save all receipts. Late Payments All payments received after June 1st will be subject to a $25 late fee. Refunds Please see attached Summer Camp Schedule for refund deadlines. You must notify the camp coach or send an e-mail to swarne@hartdistrict.org requesting a refund. No refunds will be given if request is received after the refund deadline. Refund will be total amount minus a $25 processing fee. SAUGUS HIGH SCHOOL 2012 SUMMER ATHLETIC PROGRAM REGISTRATION PROCEDURES PLEASE PRINT LEGIBLY Student ID#: (Transfers from Junior High School) Student’s Name: (First Name) 2012-2013 Grade Level: (check one) (Last Name) 9 10 11 12 Street Address: Zip Code: City: Home Phone Number: E-Mail Address: Cell Phone Number: LIST EACH CAMP YOU ARE REGISTERING FOR: COURSE # SPORT LEVEL COST 1. 2. 3. 4. 5. TOTAL Method of Payment: Cash Check* Credit Card *Please Make Checks Payable to “Saugus ASB” FOR OFFICE USE ONLY Total Received: $__________ Date: __________ Receipt #: __________ By: __________ Online THIS PAGE INTENTIONALLY LEFT BLANK William S. Hart Union High School District ATHLETIC CLEARANCE FORM 1. Warning to Student-Athlete and Parents 2. Certificate of Student Insurance 3. Parent Consent and Co-Curricular Agreement You must complete all sections of this form before your daughter/son can participate in Interscholastic PLEASE PRINT ALL INFORMATION Athletic Practices and Contests: Student’s Name: M (First Name) (Last Name) Student’s Number: F (Sex) Student’s Birthdate: 2012-2013 Grade Level: (check one) 9 10 School Attended Last Year: 11 12 State of School Attended Last Year: Street Address: City: Zip Code: Home Phone Number: E-Mail Address: Cell Phone Number: 1. 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 2. Certificate of Student Insurance: It is the responsibility of the parent/guardian to secure insurance coverage prior to participation in athletics. Sections 3222032224 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 Myers-Stevens Insurance (optional): Yes Policy # No Date Mailed: 3. 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/Guardian’s Signature) Date William S. Hart Union High School District ATHLETIC EMERGENCY FORM PLEASE PRINT ALL INFORMATION Student’s Name: (Last Name) 2012-2013 Grade Level: (check one) (First Name) 9 (Middle Name) 10 11 12 Street Address: City: Zip Code: Cell Phone Number: Home Phone Number: E-Mail Address: Parent/Guardian’s (please check your preferred contact): Name of Contact #1: Cell Phone of Contact #1: Home Phone of Contact #1: Work Phone of Contact #1: Name of Contact #2: Cell Phone of Contact #2: Home Phone of Contact #2: Work Phone of Contact #2: In an emergency (if parents cannot be reached) notify: 1. Cell (Name) (Phone Number) 2. (Phone Number) 3. Home Work (Please check your preferred contact) Cell Home Work (Name) (Phone Number) (Please check your preferred contact) (Family Doctor) (Office Phone Number) (Fax Phone Number) Street Address: City: Work (Please check your preferred contact) Cell (Name) Home Zip Code: NOTE: Please state any pertinent medical information coaches or physicians should know about the student-athlete. (Allergies, medications, or conditions that require immediate emergency treatment such as Epi-Pen, Glucagon, inhalers, etc.) Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination or immunizations for the above-named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious way possible. If said physician is not able to communicate with me, the treatment necessary for the best interest of the above-named student may be given. Permission is also granted to the Certified Athletic Trainer to provide the needed first aid treatment prior to the student’s admission to any medical facility. (Parent/Guardian’s Signature) Date Attention Athletes: At the conclusion of the season, you must take this emergency form to your next coach. If you do not transfer this form, you will have to fill out a new form. 6.4A William S. Hart Union High School District CERTIFICATE OF PHYSICAL EXAMINATION PLEASE PRINT ALL INFORMATION Student’s Name: (First Name) (DOB) (Last Name) (Height) (Weight) (Middle Name) (Pulse) (BP) Please place a “” as either Normal or Abnormal for all findings below. Please describe, in detail, all abnormal findings. NORMAL ABNORMAL COMMENTS Heart Pulses Lungs Neck Back Shoulder/Arm Wrist/Hand Hip/Thigh Knee Leg/Ankle/Foot Other pertinent medical findings: Additional Comments: List any restrictions and duration: was examined by me on I hereby certify that (Student Name) (Date) and found to be physically fit to engage in athletics. (Physician’s Signature) (Date) Stamp name or attach card of medical office here. ⌫ Back side to be completed by parent/guardian before physical exam. William S. Hart Union High School District MEDICAL HISTORY TO BE COMPLETED BY PARENT/GUARDIAN BEFORE PHYSICAL EXAM Student Name: (Last Name) (Student Grade) (First name (School) (Sex) (Age) (DOB) (Sport(s)) Check “YES” or “NO”. If “Yes”, please explain 1. 2. 3. 4. 5. Has the student-athlete had a medical illness or injury since his/her last check up or sport physical? YES Is the student-athlete currently taking any prescription or nonprescription (over-thecounter) medication or using an inhaler? YES NO NO Does the student-athlete have any allergies (for example, pollen, medicine, food, or stinging insects)? YES Has the student-athlete had a medical illness or injury since his/her last check up or sport physical? YES Has the student-athlete ever had a seizure? YES NO NO NO 6. 7. Is there any pertinent medical information coaches or physicians should know about the student-athlete? YES Does the student-athlete wear glasses, contacts, or dental braces? YES NO NO (Parent/Guardian Signature) (Date)