SNOHOMISH SCHOOL DISTRICT ATHLETICS Welcome to Snohomish School District Athletics

SNOHOMISH SCHOOL DISTRICT ATHLETICS Welcome to Snohomish School District Athletics. The required forms for athletic participation include the attached five pages: 1 – Athletic Emergency & Clearance Form 2 – Athletic Eligibility Form 3 – Athletic/Activity Code 4 – Concussion Form 5 – Physical Examination Form Please note that the physical examination form is valid for 24 months from the physician’s signed date of the exam. However, an exam must be valid for the duration of the entire sport season in order to tryout/begin a sport. All other forms must be filled out yearly, signed, and turned into your school’s athletic office prior to try outs/first practice for each sport. MISSION STATEMENT All high school students are encouraged to participate in the co-curricular and extra-curricular programs at the high school level. It is the responsibility of all students to make learning a top priority and to be accountable for their work and personal conduct at all times. To remain eligible to participate, all students will demonstrate, through their work and attitude that they are working to their fullest potential. Students will exemplify good character in the classroom and in co-curricular and extra-curricular activities. ATHLETIC ACADEMIC STANDARDS Students are expected to maintain satisfactory academic performance in all school courses. Athletes cannot compete unless they are continually enrolled in and passing a minimum of five classes. A student athlete who does not maintain a “C-” grade in each class will be placed on a remediation plan and contract. This contract must be signed by the teacher and returned to the coach on a weekly basis. The student may participate as long as the teacher signs the contract verifying that satisfactory progress is being made or the student’s current grade is raised to a “C-”. ASB CARD / PARTICIPATION FEE / MEDICAL INSURANCE Athletes must purchase an ASB Card. Additionally, a participation fee of $100 is required per sport with both individual and family caps. The athletic participation fee can be waived for students who are approved for Free/Reduced Lunch. The athletic fee is due prior to the team’s first contest and shall be paid (or Free/Reduced Lunch waiver received) by using the Athletic Fee envelope provided by the coach. Refunds will not be provided after the first contest. Lastly, current medical insurance is required for sports participation. CONTACT INFORMATION Glacier Peak High School Snohomish High School Athletic Director: Mark Albertine (360)563-7611 Athletic Director: Mark Perry (360)563-4080 Email: [email protected] Email: [email protected] Athletic Adm Asst: Leslie Bjornethun (360)563-7612 Athletic Adm Asst: Ellen Lipinski (360)563-4078 Email: [email protected] Email: [email protected] Athletic Information Hotline – 360-563-4215 Snohomish School District Athletic Adm Asst: Trisha Palm (360)563-4210 Email: [email protected] Revised 4/15 GREEN 2151F2 Page 1 of 2 SNOHOMISH SCHOOL DISTRICT ATHLETIC EMERGENCY & CLEARANCE FORM ATHLETE’S NAME: (Please Print Clearly using pen) Birth Date: ________________________ Home Phone: ____________________________ Grade _______ Male/Female (Circle One) Parent’s Name(s): ______________________________________________________________________________ Address: City: Zip: _________ Parent’s Email Address: _________________________________________________________________________ Father’s Employer: Business Phone: _____________________ Mother’s Employer: Business Phone: _____________________ Father’s Cell Phone: _________________________________ Mother’s Cell Phone: _________________________ Emergency Contact: ________________________________ Emergency Phone: ___________________________ Alternate Person to be Notified: ________________________________ Phone: ______________________ Physician of Choice: ________________________________________ Phone: ______________________ Preferred Hospital: __________________________________________ Phone: ______________________ Medical concerns/allergies: _______________________________________________________________________ PARENT/GUARDIAN READ AND SIGN My child is covered by the following Insurance Company (Required): _______________________________________________ If the parents and/or authorized physician named above cannot be reached at the time of an emergency, and if immediate observation or treatment is urgent in the judgement of the school authorities, do you authorize and direct the school authorities to send the pupil to the hospital or doctor most easily accessible and for such doctor to render such observation and treatment as immediately as necessary? Yes _____ No _____ Parent/Legal Guardian Signature: _____________________________________________ INSURANCE: I assume financial responsibility for medical expenses that may arise out of my child’s participation and understand that the school district does not provide medical insurance for my child. RIDE PERMIT: I hereby give permission for my child to travel to/from athletic events or activities in transportation arranged by school officials. I also understand that through my written permission my child may be allowed to be transported by another carrier. ATHLETIC CODE: I understand the terms of both the Athletic/Activity Code and the Athletic Eligibility Form including the Warning and Agreement to Obey Instructions. I request the Snohomish School District to permit my child/ward to participate in and/or to try out for his/her school athletic/activity team(s) and to engage in all activities related to the team, including, but not limited to, trying out, practicing, or playing/participating in the sports or activities. Parent/Legal Guardian Signature: ________________________________________________ Date: ________________ OFFICE USE ONLY OFFICE USE ONLY AUTHORIZATION TO PARTICIPATE IN SPORTS This is to verify that the above mentioned student has completed all the necessary athletic/activity forms and they are on file at the school the student is currently attending. He/she is responsible for giving this completed form to the coach, at which time the student is eligible to try out/practice with the team. This form needs to be completely filled out and returned to the coach for each sports season in which the student participates. SPORT: DATE OF STUDENT’S LAST PHYSICAL: ASB CARD: Yes No AUTHORIZED STAFF SIGNATURE: _____ DATE_____________________ Revision Date: May 10, 2011 2151F2 Page 2 of 2 SNOHOMISH SCHOOL DISTRICT ATHLETIC ELIGIBILITY FORM SCHOOL: _________________________ ATHLETE’S NAME: __________________________________________________ (PRINT IN PEN ONLY) Birth Date: _________________ Age: _________ Home Phone: ____________________ Grade ______ Male/Female Please check yes or no to the following questions: (Circle One) Yes No □ □ Are you currently living with your parents? □ □ Do you reside within the Snohomish School District? □ □ Are you enrolled in at least 5 classes at the above school? □ □ Did you pass at least 5 full-time semester classes last semester? □ □ Are you now or have you ever been a foreign exchange student? □ □ Have you repeated a grade or withdrawn from school at any time since entering 7th grade? □ □ Did you receive an attendance variance to attend this school? If yes, what is your neighborhood school? ____________________________________ □ □ Did you transfer from another school during the past two school years? If yes, were you under any conditions of ineligibility when you left your previous school? __________________ List all schools student has attended in the past two school years: _______________ _____________ _____________ PARENT’S NAME(s): __________________________________________________________________ Address: _________________________________________ City: _____________________ Zip: ________ Parent’s Email: ____________________________________ Athlete’s Email: _______________________________ Mother’s Cell Phone: _______________________________ Mother’s Work Phone: __________________________ Father’s Cell Phone: ________________________________ Father’s Work Phone: __________________________ I hereby request that my child be permitted to participate in: _____________ _____________ _____________ (Fall Sport) (Winter Sport) (Spring Sport) WARNING AND AGREEMENT TO OBEY INSTRUCTIONS: I am aware that playing or practicing to play/participate in any sport can be a dangerous activity involving many RISKS OF INJURY. I understand that the dangers and risks of playing or practicing to play/participate in interscholastic sport(s) include but are not limited to death, serious neck and spinal injuries (which may result in complete or partial paralysis), brain damage, injury to internal organs, bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal systems. I understand that the dangers and risks of playing or practicing to play/participate in the interscholastic sport(s) may result not only in serious injury, but also in a serious impairment of my future abilities. Because of the dangers of participating in the interscholastic sport(s), I recognize the importance of following coaches’ instructions regarding playing techniques, training and other team rules, etc, and agree to obey such instructions. I further understand that by following the instructions provided by the Snohomish School District, the risk of injury described above may be reduced, but that due to the nature of the sport I have selected, there is still risk of injury regardless of

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