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TOWNSHIPHIGHSCHOOLDISTRICT214 ATHLETICPERMIT School ID# LastName StreetAddress DateofBirth CountyofBirth EmergencyContactName FirstName City State CurrentYearinSchool EmergencyContactPhone MiddleName State Zip 09 10 Male Female Phone 11 12 Father’sWorkPhone CurrentSemester 01 02 Mother’sWorkPhone 1.APHYSICALFORMMUSTBECOMPLETED,DATED,SIGNEDBYAPHYSICIAN,ANDTURNEDINTOTHEATHLETICOFFICE FORSCHOOLOFFICEUSEONLY Today'sDate ExamVerification PhysicalDate RegistrationVerified 2.SPORTSSELECTION–Check(X)thosesportsinwhichyouwishtoparticipate. BOYSSPORTS GIRLSSPORTS FALL WINTER SPRING FALL WINTER SPRING CrossCountry Basketball Baseball CrossCountry Basketball Badminton Football Swimming&Diving Tennis Golf Bowling Soccer Golf Wrestling Track Swimming Gymnastics Softball Soccer Cheerleading Volleyball Tennis Comp.Cheerleading Track Cheerleading WaterPolo Volleyball Poms/Comp.Dance WaterPolo Gymnastics Cheerleading Poms 3.TRANSFERORFOREIGNEXCHANGESTUDENT–Pleaseprovidethefollowinginformation. OFFICEUSEONLY Previous HighSchool NameofSchool TransferInformationVerified StreetAddress City State 4.SPORTSAGREEMENT TheAthleticProgramprovidessportswhichareinteresting,wholesome,stimulatingandenjoyableforallstudentsforthepurposeofdevelopingphysicalfitness;sports knowledge,skills,andunderstanding;sportsmanship;andaspiritofcompetitionineachparticipatingstudent. Astudentmusthavehis/herparent’sorguardian’sandphysician’spermissiontoparticipateintheathleticprogram.TheathletemustabidebytheIHSAeligibilitybylaws found at http://ihsa.org/AbouttheIHSA/ConstitutionBylawsPolicies.aspx. To insure the proper atmosphere for athletic excellence, the athlete and his/her parent(s) or guardian(s) must understand and cooperate in helping establish that atmosphere by adhering to all school rules and regulations. An athlete may be suspended or dropped from a team for the remainder of the season for violating any of the following standards: (1) falsification of physician’s signature on the athleticpermit;(2)use,possession,ordistributionofalcoholortobaccoortheabuseofanycontrolledsubstance;(3)theftordestructionofproperty;(4)repeated unsportsmanlikeconduct;or(5)failuretofollowtrainingrulesassetforthforindividualsportsbycoachesandasapprovedbytheAssistantPrincipalforStudent Activities.Finally,allathletesaresubjecttotheprovisionsoftheDistrict214Co-curricularCode. Onceastudentbecomesamemberofanathleticteamtheathletecannotquitandbecomeamemberofanotherteaminthesameseason.Athleteswhoarecut fromateamareencouragedtotryoutforanotherteam. 5.INFORMEDCONSENT Participation in athletics includes the potential for injury. We realize this and acknowledge that even with the best coaching, the use of the most advanced and safe equipment,andthestrictobservanceofrules;injuriesarepossible.Wealsoacknowledgethatonrareoccasions,injuriescanbesoseverethattheyresultinpermanent disability or death. By signing this form, I am giving my consent for the athletic training staff and medical team to treat my child. Athletic insurance is available at additionalcost. 6.IHSASTEROIDTESTINGPOLICY–CONSENTTORANDOMTESTING Anystudent-athletewhoingestsorotherwiseusesasubstancelistedintheassociation’sbanneddrugclasses,withoutthewrittenpermissionofalicensedphysician,to treatamedicalcondition,violatesIHSABy-law2.170anditssubsections,andissubjecttoIHSApenalties,includingineligibilityfromcompetition.Accordingly,theIHSAwill test certain randomly selected individuals and teams that participate in state series competitions for banned substances. The results of all tests shall be considered confidentialandshallonlybedisclosedtothestudent,his/herparents,andhis/herschool.Bysigningbelow,weconsenttorandomtestinginaccordancewiththeIHSA’s steroidtestingpolicy.Weunderstandthat,ifthestudentorthestudent’steamparticipatesinstateseriescompetitions,thestudentmaybesubjecttotestingforbanned substances.Nostudent-athletemayparticipateinIHSAstateseriescompetitionunlessthestudentandthestudent’sparent/guardianconsenttorandomtesting. 7.ImPACTCONCUSSIONMANAGEMENTSERVICE–CONSENTTOPARTICIPATE District214usestheImPACTsystemtomonitorsports-relatedconcussionsandtoensurerecoveryandpreventrecurrent,cumulative,and/orcatastrophicconsequences from a second concussive injury. Information on IHSA concussion resources can be found at http://ihsa.org/Resources/SportsMedicine/ConcussionManagement/ConcussionResources.aspx. By signing below, Parent/guardian consent is given for students to participateinthisservice,andparent/guardianacknowledgesthattheyhavereadtheIHSAconcussioninformation. 8.MEDICAL/EMERGENCYRELEASE Doesyourstudenthaveanyspecificallergies,routinemedications,chronicillnessesorconditionsthatDistrict214shouldbeawareof?Pleaseindicatehere(ifnone,please specify): Bysigningthisform,youauthorizetheschooltotakesuchemergencyactionthatmaybenecessary,includingtransportationofthestudenttoahospitalormedicalcenter, ifneitherparentnortheabovenamedemergencycontactcanbereachedincaseofsevereinjuryorillness. 9.REQUIREDSIGNATURESOFAGREEMENTBYATHLETEANDPARENT/GUARDIAN Byhis/hersignature,thestudent-athleteagreestoabidebyalloftheconditionssetoutbyDistrict214andtheIHSA.Byhis/hersignature,theparent/guardianofthe student-athletegiveshis/herpermissionforthestudent-athletetoparticipateininterscholasticathleticsunderalloftheconditionsdescribedabove. SIGNATUREOFSTUDENT-ATHLETE SIGNATUREOFPARENT/GUARDIAN THISFORMMUSTBEONFILEINTHEATHLETICOFFICEPRIORTOTHEFIRSTDAYOFPRACTICE DATE Revised3/14MS