Download Athletic Permit 17-18 - Township High School District 214

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