North Santiam School District

Athletic Participation Permit

2016-17

Please print clearly

Athlete Last Name / First Name / Age / Birth date / Grade

Emergency Information

Parents/Guardians
Street/Mailing Address
City State Zip
Phone Home / Work
Cell Email

In case of emergency, if parents cannot be contacted, notify:

Name / Phone
Name / Phone
Family Doctor / Phone
Preferred Hospital / Known Allergies

My son/daughter has my permission to compete in the below named sports(s) and to go with the coach on any regularly scheduled trips. While I expect school authorities to exercise reasonable precautions to avoid injury, I understand that there is a risk of injury in any athletic activity, and that the school assumes no financial obligation for any injury that may occur. I must present a doctor’s release when my child returns to participation after an injury. I am advised that students are held responsible for all players’ equipment owned and issued by the school. I give permission for my son’s/daughter’s name to be published in articles given to the media or general public regarding the below-mentioned activity.

It is the responsibility of the parent/athlete to inform the school district of special medical needs.

SPECIAL MEDICAL NEEDS (Inhaler, Epi pen, allergies….) ______

I want my son/daughter to have the privilege of participating in the CIRCLED activities listed below:

Football (Boys 7/8) Volleyball (Girls 7/8) Soccer (Boys 7/8) Soccer (Girls 7/8)

Basketball (Girls 7/8) Basketball (Boys 7/8)

Wrestling (Boys 6/7/8) Dance Team (Girls 6/7/8)

Track (Co-ed 6/7/8) Cross Country (Co-ed 6/7/8)

INSURANCE INFORMATION – ALL ATHLETES MUST BE COVERED BY INSURANCE

and provide the following information:

______We have paid for school insurance on (date) ______.

(Parents Initials)

______We do not want school insurance and will assume financial risk. Our insurance coverage is with

(Parents Initials)

Insurance Name ______

Policy Number ______

______

Parent or Guardian signature Date

N. Santiam School District 29J 1155 N. Third Avenue, Stayton, Oregon 97383 Phone (503) 769-6924 Fax (503) 769-3578

North Santiam School District is an Equal Opportunity Employer

NORTH SANTIAM SCHOOL DISTRICT

MIDDLE SCHOOL LEVEL ATHLETIC AGREEMENT

1. I realize that to be eligible to participate in the organized interscholastic athletic program of North

Santiam School District Middle Schools, I must:

·  Be a full-time middle school student in the North Santiam School District.

·  Maintain academic grades in all classes during the sport season.

·  Maintain satisfactory behavior while at school. Any in-school suspension or suspension from school

·  on the day of an athletic contest will mean exclusion from that contest.

·  Demonstrate a belief in the worth and dignity of all opponents, coaches, officials, and teammates.

·  Refrain from using profane or obscene language.

·  Refrain from any actions or words considered insubordinate to coaches or officials.

·  Maintain regular attendance in class, especially the day of and the day following an activity.

·  Demonstrate responsibility and respect for equipment.

·  Maintain appearance and grooming which is neat, clean, and appropriate to the activity.

·  Understand that any violation of the above could result in a suspension from participation.

·  Refrain from possession or use of alcohol, tobacco, illegal drugs or narcotics in any form.

·  Refrain from involvement in criminal activity, including any actions relating to theft or destruction

·  of property. Understand that a first violation for possession or use of alcohol, tobacco, illegal drugs or narcotics, or involvement in criminal activity, will result in a three-week suspension from participation. Further violations will result in exclusion from the activity for the remainder of the season.

2. I know that I must have a valid sports physical on file prior to participation.

3. I realize that it is a privilege to participate in all athletic and interscholastic activities in the North

Santiam School District. I have read, understand, and agree to support and comply with the rules and

expectations explained in the athletic participation packet and those stated in this form.

Student Signature______Date ______

Parent Signature______Date ______

,

N. Santiam School District 29J 1155 N. Third Avenue, Stayton, Oregon 97383 Phone (503) 769-6924 Fax (503) 769-3578

North Santiam School District is an Equal Opportunity Employer

Equal employment opportunity and treatment shall be practiced by the North Santiam School District regardless of race, color, national origin, religion, sex, age, marital status, and disability if the employee, with or without reasonable accommodation, is able to perform the essential functions of the position. Superintendent, Andrew Gardner has been designated to coordinate compliance with these legal requirements, including Title VI, Title VII, Title IX, and other civil rights or discrimination issues, the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973. The superintendent may be contacted at the District Office at 503-769-4928 for additional information and/or compliance issues.