CAMPBELL UNION HIGH SCHOOL DISTRICTSPORT: ______
ATHLETIC PARTICIPATION CARD______
WestmontHigh School______
Name: ______Year in School: 9 10 11 12
Address (street/city/zip):______
List two (2) emergency telephone numbers where parent/guardian may be reached:
Phone # 1______Phone #2______
The student named above has athletic insurance for at least $1,500 for medical and hospital expenses provided by:
Company Name: ______Policy Number: ______
Type of Insurance: ______all sports coverage ______tackle football; or, we have purchased an insurance
program made available through the school ______(check)
Parent/Guardian’s Signature: ______Date: ______
MEDICAL EXAMINATION: I have examined the above-named student and have found him/her physically able to participate in interscholastic sports.
Physician’s Signature:______Date: ______
Please Print Name: ______Phone #: ______
Special health consideration and instructions: ALLERGIES, DIABETES, HEART EPILEPSY, DRUG SENSITIVITY, etc:
______
Current Medication(s): ______
VERIFICATION OF RESIDENCE:
With whom do you reside? ______Parent/Guardian
How long have you resided at this address? ______
WARNING TO ALL STUDENTS AND PARENTS:
By its very nature, competitive athletics may put student in situations where serious and/or permanent injuries may occur. Some forms of athletic competition include physical contact among players, the use of equipment which may be hazardous, strenuous physical exertion, or other exposures to risk of serious and/or permanent injury.
By granting permission for your son or daughter to participate in interscholastic athletic competition, you and your student athlete acknowledge that such risks exist.
Student athletes will be instructed in proper techniques to be used in practice and competition and in proper use of equipment. Students must adhere to these instructions in order to reduce risk of injury. No amount of instruction, precaution, and supervision will totally eliminate all risk of injury.
NOTE: Parents or guardians are requested to exercise due care in filling out this card. It is recommended that you inquire of your insurance agent whether you child is covered for medical, hospital expenses and accidental death in the minimum amounts. If you have any questions about coverage, please notify the school immediately.
Title IX Gender Equity in Education, Athletics, Activities: Title IX of Education Amendments of 1972 is a federal law prohibiting gender discrimination in any school
receiving federal funds. The text of the law states: No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any educational program or activity receiving Federal financial assistance.
Complaint and Formal Complaint Procedures
Complaints regarding the interpretation or application of any district nondiscrimination policy shall be processed in accordance with the following procedures:
1. The superintendent has appointed the building principal, or assistant principal as the contact person on issues concerning the Americans with Disabilities Act (ADA),
Section 504 of the Rehabilitation Act of 1973, Title VI, Title VII, Title IX and other civil rights or discrimination issues:
2. Heidi Reyes, Director of Student Services, 408-371-0960 () Campbell Union High School District, 3235 Union Ave., San Jose, CA 95124 The
superintendent will be informed of any complaints communicated to the district alleging noncompliance with Americans with Disabilities Act (ADA), Section 504 of the
Rehabilitation Act of 1973, Title VI, Title VIII, Title IX, or other civil rights or discrimination issues.If the Director of Student Services is the subject of the complaint, the
individual may file a complaint to the Deputy Superintendent, Ms. Tanya Kraus.
3. Tanya Kraus, Deputy Superintendent, 408-371-0960 () Campbell Union High School District, 3235 Union Ave., San Jose, CA 95124
4. If the Deputy Superintendent is the subject of the complaint, the complaint may be filed with the Superintendent or other designee.
5. Mr. Patrick Gaffney, Superintendent 408-371-0960, () Campbell Union High School District, 3235 Union Ave., San Jose, CA 95124
6. Complaints (Special Education): Parents may file a complaint concerning violations of federal or state law or regulations governing special education related services. To
file a complaint, write a description of the manner in which the parent believes special education programs for handicapped do not comply with state or federal law or
regulations and file with the District official listed below at the following address and telephone: Ms. Lena Bundtzen: Director, Special Education 3235 Union Ave. San
Jose, CA95124 408-371-0960 or
STUDENT CONSENT:
I am absolutely certain that my residence is within the district boundaries. I understand that if the information that I give is incorrect, the team will forfeit all of the games in which I played. Students are expected to read, sign and follow the Training Regulations/Code of Conduct form that they receive form their coach.
Student Signature: ______Date: ______
PARENT OR GUARDIAN CONSENT:
I have read and verify the above information and herby give my consent for ______to compete in interscholastic athletics and to travel with a representative of the school on any trips. In granting permission, I recognize the right of the school administration to establish conditions under which student participation is allowed. These conditions include, but are not limited to, scholarship, health and safety. In case this pupil is injured, I authorize the school or its representative to have him/her treated. I will promptly notify the school in the event insurance coverage no longer applies to my son or daughter.
Parent/Guardian Signature: ______Date: ______