Hillcrest HOSA

Chapter

2022-2023
 What is HOSA?
HOSA stands for Health Occupations Student of America and is a club tailored for
future health professionals. At Hillcrest our goal is to expand interest in health-
related fields, whether they be surgery, forensics, technical support, nursing,
psychology, and much more. Hillcrest HOSA hosts a variety of activities, guest
speakers, and training for high school students who plan to pursue this career, and
gives students the opportunity to excel in healthcare and even earn scholarships.

Meetings:
Hillcrest HOSA meets every Thursday after school in the hosting room (A176)
Meetings may include activities such as optional dissections, CPR training,
professional guest speakers, and preparation for competitions.

Forms and Fees:

All forms along with a fee receipt must be turned in by October 27th, 2022 in order
to be a member. The club participation fee this year will be $60 with an optional
$10 spirit pack containing a patch and sticker. The participation fee will cover
National, Utah, and Hillcrest dues as well as a t-shirt. Each member is required to
purchase a HOSA t-shirt and is encouraged to wear it to meetings.

Competitions:
The State Leadership Conference will cost an additional fee and is an opportunity
to engage and compete in health career activities. HOSA members prepare to
compete in chosen events through the school year and compete in March. There is
no guarantee that every student will go to state. Members must show their
dedication and will be chosen to go to state based on their performance.
International Leadership Conference is the competition you may move onto if you
place top three in your category in Utah. This competition is held in June and
requires travel. More information is available after SLC.

Fundraisers:
HOSA will host various fundraisers throughout the school year and members are
expected to participate in these to the best of their ability, to run a club successfully
we must be able to fund activities and supplies. Students that do not participate in
fundraisers will not be chosen to go to the state competition.
 CLUB OFFICERS

Aryanna Hinckley
Chapter President
Health Professions Events President
Senior
385-414-8994
rainy.hinckley@gmail.com
April 30, 2005

Sowmya Paritala
Chapter Vice President
Testing Events Vice President
Senior
801-244-0047
sowmya.paritala@gmail.com
November 7, 2004

Swetha Iyer
HOSA Manager
Writing & Speaking Events President
Senior
813-580-0089
iyerswetha23@gmail.com
(Birthday)

Taylor Simpson
Secretary
Testing Events President
Senior
801-834-2935
simpsontaylor22@gmail.com
January 24, 2005
Charley Rowe
Historian
Creative Presentation Events VP
Junior
801-680-5981
rowegirls3@icloud.com
September 12, 2006

Benjamin Barinotto
Public Relations/Marketing
Med Terms & Spelling Events
Senior
385-302-7842
ben.barinotto3@gmail.com
May 28, 2005

Acintya Sai Yoganath

Fundraising Coordinator
Technical Presentation Events
Junior
331-385-5441
aries.paintbrush11@gmail.com
April 11, 2006

Kalli Van Dijk

Service Coordinator
Medical Reading President
Senior
385-707-5830
kallivandijk@gmail.com
June 18, 2005
Lukas Rohde
Activities Coordinator & Artist
Creative Presentation Events President
Senior
801-599-7849
lrhode05@gmail.com
May 3, 2005

Manav Singh
Scheduling Manager
Technical Presentation Events
Junior
801-651-5708
mmanav.singhh@gmail.com
April 1, 2006

Sanjana Mahate
Website Manager
Health Professions Events VP
Junior
801-550-0113
sanjanamahate@gmail.com
May 24, 2006

Miles Vlam
Officer
Medical Reading VP
Sophomore
801-597-4875
milesvlam@icloud.com
September 4, 2006
Natalie Dickison
Medical Pathway Coordinator
Medical Terminology & Spelling VP
Junior
801-634-7133
natalie.dickison1@gmail.com
June 18, 2006

This is your 2022-2023 officer team!

HOSA Officers are expected to display the following attributes:
- Honesty
- Integrity
- Thorough communication
- A strong work ethic
- The ability to delegate tasks when necessary
- Active listening skills
- Critical thinking
- Ability to recognize personal bias
- Punctual
- Dependable
Officer Agreement:
I understand that it is a privilege to be part of the officer team.
I understand that I may be dismissed at any time if I am not following the
standards stated above
I promise to speak up when I see issues within our HOSA Chapter
I promise to communicate with my team and include them in any decisions I make
for the club
I will give prior notice when I am unable to attend a meeting
I will respect my fellow officers and lead my team to the best of my ability

Officer Signature
 Event Categories
Testing Events
Taylor & Sowmya
● BH - Behavioral Health
● CDD - Cultural Diversities and
Disparities
● DT -Dental Terminology
● HI - Health Informatics
● HGD - Human Growth and
Development
● MLE - Medical Law and Ethics
● MM - Medical Math
● NUT - Nutrition
● PAT - Pathophysiology
● PHA - Pharmacology
Writing/Speaking Events
Swetha
● EW - Extemporaneous Writing
● HL - Healthy Lifestyle
● JSS - Job Seeking Skills
● OL - Organizational Leadership
● PS - Prepared Speaking
● RPS - Researched Persuasive
Writing and Speaking
Creative Presentation Events
Lukas & Charley
● HCD - Health Career Display
● HCP - Health Career
Photography
● HE - Health Education
● RP - Research Poster
● CA - Community Awareness
Technical Presentation Events
Manav & Acintya
● BD - Biomedical Debate
● CPS - Creative Problem
Solving
● MI - Medical Innovation
● PP - Parliamentary Procedure
High-Capacity Events
Ben & Natalie
● MT - Medical Terminology
● MS - Medical Spelling
Kalli & Miles
● MR - Medical Reading
Kalli
● HB - Hosa Bowl
Health Professions Events
Sanjana & Aryanna
● CN - Clinical Nursing
● PT - Physical Therapy
● SM - Sports Medicine
● CPR - First Aid
● CERT Skills
● EMT - Emergency Medical
Technician
● CL - Clinical specialty
● HHA - Home Health Aid
● MA - Medical Assisting
● NA - Nursing Assisting
● PH - Public Health
 Competition Dress Code
- Black or navy blue suit (we have limited blazers to borrow)
- White closed neck tailored dress shirt
- Maroon or navy long tie
- White blouse
- Knee length skirt or slacks
- Closed toed black dress shoes
- Hose if wearing skirt
- Blue or black belt
- Religious/cultural head coverings allowed
- Minimal jewelry
- Natural makeup
- Hair pulled back/slicked back
- Occupational skill events allow medical scrubs*

2022 State Competition

 Member Information
Legal Name:

Preferred Name:

Grade:

Birthday:

School Email:

Personal Email:

Phone Number:

T-Shirt Size:

Food Restrictions:
Student Name:____________________________________________

Club Name:_______________________________________________

I am the custodial parent or legal guardian of the above named student (“my student”), who
is currently a student at Hillcrest High School. I understand that my student wishes to participate
in the student club or organization named above at the school (“this club”). If a club is authorized
by the school, that authorization allows the club to use certain school premises and facilities, but
does not mean that the club is an organization of the school. I understand that membership and
participation in this club are voluntary. I understand that this club is not sponsored by the school,
and is directed by the student officers of this club. During approved club meetings on school
premises, a district employee will be present for custodial purposes. The role of the district
employee is limited to protecting and overseeing the use of the school’s property and facilities. A
district employee will normally not be present at activities off of school premises.

Clubs are authorized by the school based on its stated purpose and activities as set forth in the
club application and charter. I understand that I may make arrangements to inspect a copy of the
application and charter of this club, which describes the nature, purposes, structure, and other
information about this club. I am satisfied that, by either obtaining information from my student or by
inspecting the charter, or both, I have sufficient information about this club to make an informed decision
regarding my student’s participation in this club. With all of these considerations in mind, I authorize my
student’s participation in this club. I further understand that my consent may be withdrawn at any time
by my notifying the school in writing of that withdrawal of consent.

Signature:____________________________ Date:______________

Name:_______________________________
(Must be signed by custodial parent or guardian)

Address: _

____________________

____________________

Telephone:_________________________________________________
 Utah State Board of Education
Parent/Guardian Consent Form
Sex Education Instruction

Parents must receive this form no later than two weeks prior to the beginning of instruction

Date of Planned Instruction:

Name of Student:
Course: Teacher(s):
School: Telephone Number:

Dear Parents/Guardian:

As part of your child’s education, he/she has enrolled in a course that includes instruction on topics
related to sex education. You are receiving this consent form because instruction and/or discussion of
sex education topics are controlled by state law and Utah State Board of Education rule. Please read the
form carefully, select one option, sign, and return to the teacher above. Your student will not be allowed
to participate in class activities without this completed and signed form on file. Thank you.

Information
All instruction related to human sexuality or sexual activity will take place within the context of Utah
State Law (53G-10-402) and Utah State Board of Education rule (R277-474) as follows:
• The public schools will teach sexual abstinence before marriage and fidelity after marriage.
• There will be prior parental consent before teaching any aspect of contraception or condoms.
• Students will learn about communicable diseases, including those transmitted sexually, and
HIV/AIDS.
Program materials and guest speakers supporting instruction on these topics have been reviewed and
approved by the local district or charter curriculum materials review committee.
The following are NOT approved by the State Board of Education for instruction and may not be taught:
• The intricacies of intercourse, sexual stimulation, or erotic behavior;
• The advocacy of premarital or extramarital sexual activity;
• The advocacy or encouragement of the use of contraceptive methods or devices.

In accordance with Utah State Board of Education Rule R277-474-7-4, teachers may answer spontaneous
student questions to provide accurate data, correct inaccurate or misleading information, or respond to
comments made by students in class regarding human sexuality.

ADA Compliant June 2018

Curriculum for this course includes instruction or discussion about the topics checked below. Pre-checked items
are required for instruction in health education 53G-10-402 (For Teacher Use Only):
sexual abstinence childbirth
human sexuality parenthood
human reproduction contraception
reproductive anatomy HIV and AIDS (including modes of transmission)
physiology sexually transmitted diseases
pregnancy refusal skills
marriage
Factual, unbiased information about contraception may be presented as part of this course only if the box above
is checked. Demonstrations on how to use contraceptive means, methods, or devices are prohibited.

Options: Please read and check only one of the following:

Name of Student:
Option 1
I grant permission for my child to participate in the discussions as described above.
Option 2
I grant permission for my child to participate in the discussions as described above, with the exception of
. I understand that my child will receive an alternative
assignment of equal value and will not attend the regularly scheduled class on the day of this instruction. I
understand my child will be provided a safe, supervised place within the school during this class. It will be
his/her responsibility to report to the pre-arranged location, check in with the teacher or supervisor, and submit
the completed assignment to the appropriate person.

Option 3
Prior to deciding, I will contact you at the school within the next two weeks to arrange a time to discuss the
planned curriculum and review the materials
Option 4
I DENY permission for my child to participate in any of the discussions as checked in the box above. I understand
my child is not involved in the exempted portion of the curriculum, he/she will instead be provided a safe,
supervised place within the school during the class, and will receive an alternate assignment related to other
elements of the course.

This consent form must be sent to parents not less than two weeks prior to instruction of the identified topics.
Under state law, your child cannot participate in the scheduled instructional activity specified above unless and
until this signed letter of permission is returned to the teacher identified on this form. Signed forms will be kept
on file at the school for a minimum of one year.

Please sign and return form to verify you reviewed it and have chosen one option from the preceding list.

Parent/Guardian Signature:

Phone Number: Date:

ADA Compliant June 2018

 Utah HOSA Conduct Code
Signatures Required

A good reputation enables members to take pride in their organization. HOSA members have an excellent reputation. Your
conduct at any HOSA function should make a positive contribution to the reputation that has been established.
1. Your behavior, as a delegate to the State Leadership Conference, should at all times be such that it reflects credit to
you, your school/college, your state and HOSA.
2. Delegate conduct is the responsibility of the delegate, monitored by their local chapter advisor. Delegates shall keep
their advisors informed of their activities and whereabouts at all times. (HOSA Conference name badges shall be worn
at all times at HOSA functions).
3. Delegates may not use personal vehicles to travel to and from the State Leaderships Conference center or any offsite
event facilities. State and District transportation will be provided.
4. Delegates are expected to attend all general sessions and other scheduled conference activities. Please be prompt and
show respect to those in the audience and on stage.
5. Delegates are to report any accidents, injuries or illnesses to their local chapter advisor immediately.
6. Personal prescriptions and over-the-counter drugs must be labeled properly and only administered in the presence of
the local chapter advisor. Sharing of such medications is strictly prohibited.
7. The Utah HOSA State Leadership Conference is a non-smoking conference.
8. Delegates/participants attending the Utah HOSA State Leadership Conference may not purchase, consume or be under
the influence of alcohol or drugs at any time. Violators will be subject to stringent disciplinary action.
9. No individuals from the opposite sex, other local chapters (unless permitted by the Advisor), or outside groups are to
be allowed into delegate hotel rooms.
10. Delegates are expected to observe the designated curfew. (Curfew means that each person must be in own room by
the designated hour.)
11. If a delegate is responsible for stealing or vandalism, the delegate and his/her parents will be expected to pay any and
all damages.
12. Delegates who disregard the rules will be subject to disciplinary action and will be sent home at their own expense.
Parents will be notified as well as School/District Administrators.
13. Any charges to the hotel room(s), restaurant(s) or conference center will be the responsibility of the individual delegate
and/or parents.
14. Delegates are to abide by the HOSA Dress Code at all business sessions, general sessions, competitive events and
other conference activities.
15. As a delegate to the State Leadership Conference, permission is granted to make photographs, videotapes, broadcasts,
and/or sound recordings, separately or in combination, available for reproduction for educational and promotional
purposes by Utah HOSA.
GENERAL SESSION PROTOCOL: The general sessions should be enthusiastic, but delegates must not
be rude or obnoxious to those in the audience or on stage. It is important to remain seated until the end of
the session.
I understand and will adhere to HOSA’s Dress Code Policy for all events and activities of the
State Leadership Conference. I have read the Code of Conduct for HOSA conferences and agree
to abide by these rules.

Print Name of Parent/Guardian Parent/Guardian Signature Date

Print Name of Delegate Delegate Signature Date

School: Advisor:
09212019
 Medical Liability Release Form
Signatures Required
DIRECTIONS: Due to legal restrictions, it is necessary that all delegates, parents/guardians, guests and HOSA Advisors
complete this form to be eligible to attend the HOSA State Leadership Conference. This form should be returned to the
HOSA Chapter Advisor who will make a copy for his/her files and provide a copy to Utah HOSA upon request.

PLEASE TYPE OR PRINT ALL INFORMATION

Delegate Information
Full Name: School:
Home Address:
City: State: Zip:
Parent/Guardian Name:
Parent/Guardian/Telephone: Home: Work:
Delegate’s Physician: Phone:
Physician’s Address:
Alternate Emergency Contact: Relation:
Telephone Number: Home: Work:
Delegate is covered by group or medical insurance: YES NO
If yes, complete the following information:
Name of insured: Insurance Company:
Group #: Policy #:

Please completely describe any medical condition which may recur or be a factor in medical treatment:
a. Allergies: e. Physical Handicap:
b. Convulsions: f. Medicine Reactions:
c. Blackouts: g. Disease of any kind:
d. Heart/lung problems: h. Other (Be specific):
If currently taking medication, please provide the following information:
Name of medication(s):
LIABILITY RELEASE. I certify that the information described above is accurate and complete to the best of my knowledge.
I understand that each individual is responsible for his/her own insurance coverage during this trip. I hereby release the
National HOSA organization, the State and Local HOSA Associations, and any designated individual in charge of the HOSA
group or specific activity from any legal or financial responsibility with respect to my personal or my delegate/child’s
participation in or contact with any known element associated with an activity including competitive events.

PARENT/GUARDIAN: Please check one of the following and sign your name.
❑ I give my permission for immediate medical treatment as required in the judgment of the attending physician. Notify
me and/or any persons listed above as soon as possible.

❑ I do not give permission for medical treatment until I have been contacted.

Parent/Guardian’s Name: Relation:

Parent/Guardian’s Signature: Date:

(Applicable for delegates under the age of 18 and must be signed by the parent or legal guardian.)

Delegate’s Signature: Date:

Advisor’s Signature: Date:

09212019
 Media Release Form
Signatures Required

Release of Rights for Photography and Multimedia Production

Reproduction and Commercial Display and Distribution
Use of Name and Written Quotes in Media and Publications

Utah HOSA outreach materials, including Utah HOSA print publications and video resources.
uthosa.org (including social media) | hosa.org (including social media)
utahCTE.org (including social media) | schools.utah.gov (including social media)
iTunesU.com (education resources) | uacte.org | ACTEonline.org (including social media)

Original Producer/Owner
Utah HOSA | Utah State Board of Education | Utah Career and Technical Education

I hereby grant permission to Utah HOSA, International HOSA – Future Health Professionals, the Utah State
Board of Education, Career and Technical Education, the Utah Association for Career and Technical Education
(UACTE), and the National Association for Career and Technical Education (ACTE) to use my photo and name in any
media, advocacy or marketing efforts to help promote and advocate for Career and Technical Education.

For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the
reproduction and/or authorization by Utah HOSA and the Utah State Board of Education to reproduce and use said
photographs, recordings and/or digital media for use in all domestic markets or in conjunction with other photographs
and digital media for advertising, publicity, commercial or other business purposes. I understand that the term
“photograph” as used herein encompasses still photographs, motion picture footage and digital images of all kinds,
and that the term “recordings” includes analog or digital recordings and reproductions.

Further, I understand that others, with or without the consent of Utah HOSA and the Utah State Board of Education,
may use and/or reproduce such photographs and recording.

I hereby release Utah HOSA and the Utah State Board of Education - Career and Technical Education, and any of
its associates or affiliate companies, their directors, officers, agents, faculty, staff, students and customers and any
and all appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind
on account of such use or reproduction.

Please print:
Name:

Address:

Phone number:

Email:

High School:

Signature of student Date

(Required if student is over 18 years of age)

Signature of parent or guardian Date

(Required if student is under 18 years of age)

09212019
 Utah HOSA Dress Code Information
The following document outlines the official dress code for ALL student member delegates at the State Leadership
Conference (SLC). Student delegates not adhering to the business attire dress policy for all general sessions at the SLC
will not be allowed on stage to receive any awards.

Tips for Appropriate Business Attire

Business attire is crisp, neat, and should look appropriate in any office setting. It should not look like party or picnic attire. Don’t confuse
club attire with business attire. If you would wear it to a club, you probably shouldn’t wear it in a business environment. Avoid tight or
baggy clothing. Everything should be clean and well pressed. Hair should be clean and neat.

Details: No missing buttons, no lint; and don’t forget to remove tags and tacking stitches from new clothes. Perfume or cologne should
be used sparingly or not at all. Don’t smell like smoke.

Tips for men’s business attire:

• Pants/slacks, not jeans.
• Long sleeve shirts or short sleeve shirts with collars. Polo shirts (tucked in, of course) are also acceptable.
• Ties are optional but always appropriate
• Always wear a belt and dress socks.
• Dress should be worn; no sandals, athletic shoes or hiking boots.

Tips for women’s business attire:

• Women can wear casual pants or skirts. Neither should be tight. Colors should generally be solid; navy, black, gray, brown, and
khaki are always safe bets.
• Skirts should come at least to your knees while you are standing. While you are seated, your thighs should be covered. If your
skirt comes to just below the knee, a slit to just above the knee might be acceptable. A very long skirt should not be slit to above
the knee. Slits to facilitate a view of your legs are not appropriate for business purposes.
• In addition to tailored shirts or blouses, tailored knit sweaters and sweater sets are appropriate business attire. Velvets and
shimmery fabrics suitable for parties are not appropriate. Fit should not be tight. Cleavage is not appropriate to business attire.
• Keep your jewelry choices simple and leaning toward conservative. Avoid extremes of style and color.
• Keep makeup conservative and natural looking.
• Shoes should be closed-toe. Thin straps and high-heels are not appropriate. Chunky heels and platform shoes are also not
appropriate in most business settings. Make certain you can walk comfortably in your shoes.
• Hose is recommended if your skirt is knee length rather than calf length.
• If you carry a purse, keep it small and simple.

Competitive Event Dress Code

• Competitors and event personnel follow the event guidelines.
• Dress code for General Sessions is different than for CE but competitors can wear their General Session attire if they want to
when business attire is required.
• Competitors may wear clinical attire for skill event testing.

Official HOSA Casual Dress Code

Appropriate dress for official social functions in conjunction with the SLC will include everything EXCEPT tank tops, halter-tops,
extremely short shorts or skirts and cut-offs. (Shirt straps must be two inches wide and the length of shorts and skirts must be
at minimum to the fingertip.)

Black or Navy-Blue Suit (Required if you plan to attend the International Leadership Conference general sessions):
• With a white shirt (the white shirt can be the member’s choice)
• Closed-toe blue or black shoes (hose optional)
• Male members MUST wear a tie and socks
• Female members may choose to wear knee-length skirt or slacks.

HOSA Uniform
• Tailored navy blazer with emblem affixed over the heart
• Shirt/blouse for females (white tailored or short-sleeve white jewel neck shell
• Shirt for males—white closed-neck, man-tailored dress shirt, suitable for use with a tie
• Accent for female members - maroon HOSA scarf or tie is optional but not required
• Accent for male officers - navy or maroon long tie
• Matching navy slacks for males and matching navy slacks or skirts for females
• Closed-toe blue or black shoes (hose optional for women; men must wear socks)
 Utah HOSA Covid Information Sheet

HOSA is offering an in-person attendance at the 2021 Fall Leadership Conference in Provo, Utah, to affiliated
members, advisors, state staff, and guests pursuant to local government orders permitting such gatherings at
this time. HOSA requires all attendees and staff to comply with safety precautions specified in the state, local
government, and CDC guidelines. Any person refusing to comply with required safety protocols will be asked to
leave the 2021 Fall Leadership Conference at their own expense. Each person should review and personally
assess the following items related to Covid-19 exposure.

I confirm that I have not knowingly been exposed to anyone testing positive or presenting symptoms of COVID-
19 within the last six (6) days before arriving on site.

I confirm I have not myself tested positive or presented any of the symptoms of COVID-19 listed below.
I will not enter the FLC conference area if I am experiencing any signs or symptoms of COVID-19. I
acknowledge that common symptoms of COVID-19 include:
Fever (temperature of 100.4 F or higher)

• Chills • Sore throat

• Cough • Congestion or runny nose
• Shortness of breath or difficulty breathing • Nausea or vomiting
• New loss of taste or smell • Diarrhea

I confirm I will immediately leave the 2021 FLC conference area and notify HOSA Staff if I, or someone I have
been in close contact with, is exposed to COVID-19, exhibits COVID-19 symptoms or receives a positive COVID-
19 test result.

I expressly agree to fully comply with appropriate COVID-19 health and safety measures and protocols set for
attendance at the 2021 FLC, including complying with current face mask policies at all times and maintain
appropriate social distance in accordance with applicable state and local requirements.

While in attendance at the 2021 FLC, I will make every effort to maintain CDC recommended hygiene
procedures at all times, including following the guidelines of frequent hand washing (or suitable hand sanitizer),
avoid touching my eyes, nose, and mouth in public places and covering coughs or sneezes with a tissue or
inside my elbow.

Assumption of Risk: The COVID-19 virus continues to spread from person-to-person contact and other means,
and people reportedly can spread the disease without showing symptoms. Evidence has shown that COVID-19
can cause serious and potentially life-threatening illness and even death. Therefore, if you choose to
participate in the 2021 in-person FLC, you may be exposing yourself to or increasing your risk of contracting or
spreading COVID-19, despite our safety precautions. In exchange for being allowed to participate in the 2021
in-person FLC, I hereby choose to accept the risk of contracting COVID-19 for myself or my family.

Waiver of Lawsuit/Liability: By choosing to attend this conference, I hereby forever release and waive my right
to bring suit against HOSA and its officers, directors, managers, officials, trustees, agents, employees, or other
representatives in connection with exposure, infection, and/or spread of COVID-19 related to my participation
in 2021 Fall Leadership Conference.
 NOTE: Be advised that Hillcrest HOSA students may travel with their own transportation
throughout the school year and summer break, attending camps, conferences, completing
projects, gathering supplies or any other Hillcrest HOSA function.
Students may need to drive to an activity when transpiration is not provided by the district and
we encourage students to participate.
Students may be asked to help with school related activates by advisors that requires them to
drive.

ASSUMPTION OF RISK
PARENT/LEGAL GUARDIAN DISCLOSURE ACKNOWLEDGMENT

Statement of Consent and Acknowledgement

I _________________________________am the parent(s)/legal guardian(s) of

_________________________________ (student), a minor enrolled in Canyons School District.
I hereby grant permission for my student named above to travel from _________________________to
__________________________ on date (s) ______________________________.

I am aware and acknowledge that Canyons School District (District) has made available information
regarding ground or air transportation options in connection with the activity listed below. I knowingly
select alternative transportation for my student;

or

I am aware and acknowledge that Canyons School District does not sponsor or offer transportation in
connection with this activity listed below.

I will be responsible to arrange transportation for my student. I understand that if the activity requires my
student to stay overnight, that my student cannot drive to the activity or ride with another student who is driving
to the activity. Students are not allowed to drive to activities that require an overnight stay.

I agree to assume all risk and responsibility of personal injury and death, or damage to or loss of property, of the
student arising from, or based upon or relating to the student’s travel to and from the activity. I acknowledge
that when a private vehicle is used to transport a student the insurance on the vehicle is primary to any other
insurance.

I hereby waive, release, and discharge the Canyons School District, its Board members, officers, and employees
from any claim, demand, or cause of action arising out of the transportation provided to my student and agree to
indemnify the District and its employees from all claims for loss, damages, or injury sustained by us, my student,
or myself.

________________________________ ________________________________
Student’s Name Student Number

________________________________ ________________________________
Signature of Student Date

________________________________ ________________________________
Signature of Parent/Legal Guardian Date

________________________________ ________________________________
Activity Date of Activity

________________________________ ________________________________
Principal’s Signature Date

DISTRIBUTION OF COPIES: 1- SCHOOL ADMINISTRATION; 2 – ADVISOR/COACH; 3 PARENT/LEGAL GUARIDAN