Pre-Participation Checklist 2015-16- (Form 1)

LowellLowell Middle High School School Athletic Athletic Department Department

19250 Cline Athletic Director: Kim Kilmer Lowell, IN 46356 219-696-7701 ext. 1457 [email protected]

Student-Athlete Name (PLEASE PRINT LEGIBLY) ______

Home Street Address Date of Birth

City / State / Zip Parent Email Address

Home Phone Number Cell Phone Number

(Please check each box as you complete each section and attach all forms in order)

□ I have read, understand, and agree to comply with all rules and regulations found in the Lowell Middle School Student-Athlete Handbook, located on the Lowell Middle School Athletic website. □ I have completed the IHSAA Physical Form and submitted it to the office (pages 1-4).

□ I have completed and attached the Student/Parent Code of Conduct Certificate and Consent. (Form 2)

□ I have completed and attached the Medical Consent/Emergency Response Card Form (Form 3)

□ I have read the HEADS UP CONCUSSION fact sheet for Athletes and Students. I have completed and attached the CONCUSSION AND SUDDEN CARDIAC ARREST ACKNOWLEDGEMENT AND SIGNATURE FORM for Parents and Student Athletes. (Form 4)

□ I have read and understand the Insurance Waiver. If the student-athlete does not have insurance, I understand I can obtain Student Athlete Protection through Guarantee Trust Life. (forms in athletic office) (Complete only if you don’t have Insurance - Form 5) □ I have read, completed, and attached the Tri-Creek School Corporation’s Drug Testing Consent Form. (Form 6) □ I have read and understand the Guidelines for Use of Social Networking Media.

□ I have read and understand the Cautionary Statement (sport specific).

You need to submit a total of 5 Forms (6 if you don’t have insurance): Checklist, Code of Conduct, Medical Consent, Concussion/CARDIAC Acknowledgement, and Drug Testing Consent.

Print - Student Name Date Student Signature

Print – Parent/Guardian Date Parent Signature