CASCADE SCHOOL DISTRICT

ATHLETIC REGISTRATION PACKET

THE FOLLOWING PACKET MUST BE COMPLETED IN ITS ENTIRETY TO BE ELIGIBLE TO PARTICIPATE,

PARENT OR GUARDIAN MUST INITIAL EACH CHECK POINT BELOW:

1. Athletic Registration

  • Includes:
  • Injury/Risk Parent Permission
  • Mandatory Insurance
  • Medical Emergency Authorization
  • Medical Clearance/Physical
  • Medication Admin Form for school

2. Read and Signed Honor Code

3. Read and Signed Cascade School District Concussion Information

4. Fees

  • ASB (CHS $40, IRMS $25)
  • Sports Fee (CHS $60, IRMS $30)
  • ALL Fees are to be paid BEFORE the FIRST game

5. Administration of Oral/Rescue Medication at School

* IS REQUIRED FOR ANY MEDICATIONS NEEDED TO BE TAKEN AT SCHOOL, INCLUDES ALL SPORTS AND AFTER SCHOOL PROGRAMS.(EX. INHALER, EPIPENS, ANY ORAL MEDICATION)

MUST BE SIGNED BY DR. AND PARENT!

6. Home-Schooled, Vocational Technical, Running Start, and Virtual

School Athletes:

  • Meet with Mr. Coffin to complete proper paperwork.
FEES / ASB / TRANSP / Physical / INSUR / C/C
Fall
Winter
Spring

CASCADE SCHOOL DISTRICT

ACTIVITY REGISTRATION FORM

SECTION I – GENERAL INFORMATION

NAMEPARENT NAME

MAILING ADDRESS

HOME PHONE WORK PHONE CELL PHONE

Date of Birth

CIRCLE SCHOOL ATTENDING: IRMS CHS CIRCLE CURRENT GRADE: 7 8 9 10 11 12

IF YOU ARE A NEW ENROLLEE OR TRANSFER STUDENT – FILL OUT THE FOLLOWING AND MAKE AN APPOINTMENT TO SEE THE ATHLETIC DIRECTOR

NAME/ADDRESS OF LAST SCHOOLATTENDED:

Date Withdrew Date of Enrollment in Cascade School District:

SECTION II – INJURY RISK & MANDATORY INSURANCE / PARENT PERMISSION

My son/daughter has my permission to participate in the following:

Check One: All School Athletic/Activity Programs Only the Following Programs (list below)

List Programs:

MANDATORY INSURANCE

It is required that participants in interscholastic athletics activities carry insurance for injury and/or accident. Many private insurance policies and employer sponsored group insurance plans DO NOT cover interscholastic athletic related injuries. ONE OF THE OPTIONS below must be completed to be eligible to participate in interscholastic athletics/activities.

OPTION 1– I have insurance that covers my son/daughter during interscholastic athletics and school activities.

OPTION 2 –School insurance has been purchased that covers my son/daughter during interscholastic athletics.

SCHOOL TIME PLAN (covers all sports EXCEPT high school football)

FULL TIME PLAN (covers all sports EXCEPT high school football)

FOOTBALL PLAN (covers ONLY football)

SECTION IV – MEDICAL EMERGENCY AUTHORIZATION

(To be completed by Parent/Guardian)

Name of Student/AthleteDOB SCHOOL: IRMS CHS

As Parent or Legal Guardian, I authorize the team physician or, in their absence, a qualified physician to examine the above-named student and in the event of injury to administer emergency care and to arrange for any consultation by a specialist, including a surgeon, he deems necessary to insure proper care of any injury. Every effort will be made to contact a parent or guardian to explain the nature of the problem prior to any involved treatment. I understand that I will assume full financial responsibility for any services rendered.

Please Print and complete all:

Parent’s Home Phone Cellular Phone

Business Phone

Mailing Address:

Emergency Contact: Telephone

Relationship of Contact Person to student

Family Physician’s:Telephone:

Location of Physician’s Office

Medications in Use:

Medicines Allergic to:

Check this box if you and your Dr. have filled out and signed the

ADMINISTRATION OF ORAL/RESCUE MEDICATION AT SCHOOL

(Coaches: If the box is checked you MUST meet with Nurse Joan Zega)

Check this box if you have current up-to-data Immunizations (required by state law) on file with school nurse, also includes Home-Schooled, Vocational Technical, Running Start, and Virtual School Students.

Pre-Participation Sports Physical

Name:______Date of Birth: ______

Age: ______Grade: ______Gender: Male Female School: ______

List all sports planned this year (even if not sure): ______

List last year’s sports, if participated: ______

Any problems/injuries during last year’s sports, if participated: ______

______

Medications: NoneYes: ______

Allergies (medications, food, stinging insects):NoYes: ______

If yes, have you ever needed an Epi-Pen injection (either at home or at the ER?: ______

Do you have any history of major medical problems (requiring multiple doctor visits)?

NoYes: ______

Have you had any medical history of problems with organs such as the eyes, heart, lungs, kidneys, spleen, or testicles?

NoYes: ______

Do you have any history of asthma? No Yes If yes, have you ever used/needed an inhaler? NoYes

Does anyone in your family have asthma?NoYes: ______

Do you ever get wheezing, coughing, or shortness of breath with exercise?

NoYes: ______

Do you have any history of heart trouble?NoYes: ______

Has anyone in your family had a heart condition or heart attack BEFORE age 50?

NoYes:______

--Continue on back—

Does anyone in your family have RHYTHM problems with their heart, or have trouble with suddenly passing out?

NoYes: ______

Have you ever passed out during or after exercise?

NoYes: ______

Do you have pain or pressure in your chest during exercise?

NoYes: ______

Have you ever had surgery?

NoYes: ______

Have you ever had a seizure?NoYes: ______

Have you ever had a head injury or concussion?NoYes: ______

Do you have headaches with exercise?NoYes: ______

Have you ever fractured a bone in your neck or spine?NoYes: ______

Have you had any injury to a bone or joint that CONTINUES to bother you?

NoYes: ______

Has a doctor ever restricted your participation from sports in the past?

NoYes: ______

Femalesonly: Have you started periods yet: No Yes If yes, are they regular or irregular? Reg Irreg

Provider Section:

Height: Weight:BMI:Vision:R 20/ L 20/ (corr/uncorr)

BP:Pulse:

HEENT:NormalAbnormal: ______

Lungs:NormalAbnormal: ______

Cardiovascular:NormalAbnormal: ______

Abdominal:NormalAbnormal: ______

Hernia (male)NoYes: ______

Cervical spine:NormalAbnormal: ______

Upper extremities:NormalAbnormal: ______

Thoracic/Lumbar Spine:NormalAbnormal: ______

Lower extremities:NormalAbnormal: ______

Additional notes/comments: ______

Pre-Participation Physical

---Return this section to Athletic Department at School---

Name:______Date of Birth: ______

Medications:______

Allergies:______

______Cleared for all sports without restriction.

______Cleared for all sports without restriction, with recommendation(s) noted below:

______Not cleared:

______For specific sports: ______

______For all sports.

______Follow-up plan/reevaluation date: ______

Recommendations/Comments:______

______

Physician name: ______

Signature: ______Date:______

Cascade School District

Co-Curricular Honor Code

(A FULL VERSION OF THE HONOR CODE CAN BE FOUND ON THE DISTRICT WEBSITE: )

Dear Students and Parent:

The Mission of the Cascade School District is Continuous Student Development which involves the development of character, scholarship and determination. We believe a student’s participation in co-curricular activities is a positive step to preparing and enriching our student athletes in becoming productive young adults as it adds to their mental, physical, social, emotional, and ethical well-being. The Cascade School District interscholastic activities program, in partnership with the Washington Interscholastic Activities Association, is committed to provide a safe and organized environment for our students to compete and develop as citizens. We are committed to recognize and celebrate student achievement and excellence.

A study in the 2008-2009 school year showed that a student participating in one Co-curricular activity had GPA’s 13% better than those who did not participate in Co-curricular activities. Those who participated in two activities were 29% better and those who participated in three activities posted grades 47% better than those who did not participate in any activities. The Cascade School District has a goal of at least 80% of all students to be involved in a least one activity annually.

We view our honor code program to have three components: clear expectations, consequences, and intervention support. Using the mental model of a “three-legged” stool, if one leg is missing the stool will not stand.

Clear Expectations: Participation in athletics in the Cascade School District is a privilege and not a right. In the exercise of this privilege, all students shall comply with the Cascade School District Athletic Honor Code. The mandatory pre-season parent/student meeting will review these expectations that are detailed in the honor code document.

Consequences: We will view mistakes as a learning opportunity to improve and we are committed support students in their effort to improve not only athletically but academically.

Intervention Support: If a student makes a poor choice involving drugs, tobacco or alcohol, parents and school will work in a team effort to provide each student the needed intervention support to assist them from facing future challenges and consequences

Respectfully,

Cascade School District

Cascade School District Honor Code

Clear Expectations:

  1. Activity Code in Effect. This Honor Code is a year round code. Participants in these programs will be required to observe the provisions of the Honor Code at all times during the year.
  2. Scholarship. Students who participate for Cascade High School must not be failing a class nor can they have a “D” average in more than one class. Students who participate for Icicle River Middle School must not be failing a class nor can they have a “D” average in more than two classes. Off-campus students including Running Start, Home School, Upper Valley Christian School, or North Central Washington Skills Center students may be required to provide documentation of course eligibility at the request of school administration in order to comply with this expectation.
  3. Use and/or Possession of Alcohol, Tobacco, Drugs. A student/participant will not use, possess or sell alcohol or tobacco products in any form. A violation of RCW 69.41.020-69.41.050 (Legend Drugs including anabolic steroids possession, sale, and or use) or RCW 69.50 (Controlled Substance Act) shall be considered a violation of this code. The use of Legend Drugs without a valid doctor’s prescription is a violation of the athletic code.
  4. Events involving illegal use of Drugs and Alcohol. If students/participants covered by this code are at an event and become aware of the illegal use or availability of alcohol, legend drugs, or any illegal substances at that event, those students/participants are required to remove themselves from that event. Athletes who inadvertently find themselves in this type of situation are expected to leave immediately or they will be in violation of the Honor Code.
  5. Illegal Acts. Being convicted of acts contrary to the Laws of the State of Washington; such as acts include misdemeanors; gross misdemeanors and felonies shall be considered a violation of this code. Acceptance by a student of a community supervision program, including but not limited to diversion, deferred disposition, etc, in lieu of prosecution, shall be considered a violation of this code.
  6. Citizenship. A participant shall not intimidate any other student by force, threat by force or emotional duress, including acts of hazing or initiation. A minor violation under this activity code includes, but is not limited to, disruptions in school, vulgarity/profanity, truancy, cheating, willful disobedience, any other violation of the student discipline policy, or conduct unbecoming a representative of the Cascade School District.

Consequences

1st Offense / 2nd Offense / 3rd Offense
Scholarship / 1 week probation. Grade will be checked the following week. Only one probation week per sport season. / 1 week suspension from game/match. Grade will be checked the following week. / Suspension for the remainder of the season.
Use and/Possession of Tobacco
INTERVENTION SUPPORT / 30% of sports season / 60% of sports season / The equivalent of 1 sport season
Use and/Possession of Alcohol or Drugs
INTERVENTION SUPPORT / The equivalent of 1 sport season / 1 calendar year from the date of the second violation / Permanent removal from any and all activities sponsored by the Cascade School District.
Attendance at functions where alcohol/drugs are being illegally used: INTERVENTION SUPPORT There is not a violation under this category if the participant leaves the illegal function immediately. / The equivalent of 1 sport season / 1 calendar year from the date of the second violation / Permanent removal from any and all activities sponsored by the Cascade School District.
Illegal Acts / The equivalent of 1 sport season / 1 calendar year from the date of the second violation / Permanent removal from any and all activities sponsored by the Cascade School District.
Citizenship / Minimum 1 game/match suspension. Student Handbook Progressive Discipline / Removal for the equivalent of 1 sport season. / Permanent removal from any and all activities sponsored by the Cascade School District.

Intervention Support

The Cascade School District endorses a substance abuse policy which will aid students to abstain from the use of drugs and alcohol, intervene quickly when student use is detected, take corrective action when necessary, and assist in after care support for students which may include random urinalysis, peer group, and individual counseling with prevention/intervention counselor.

Furthermore, students who seek immediate attention for an alcohol/drug related problem, prior to school officials gaining information about an incident, will not be denied the opportunity to continue participation in co-curricular activities in the Cascade School District. An assessment will be included as part of this process and the student will be required to follow the recommendation of that assessment.

Intervention Steps: (Full procedures can be found online.)

  1. Submit a drug-test within 48 hours of meeting with school officials.
  2. Complete an assessment from a Youth-specific Drug and Alcohol Counseling Center. Appt. card must be presented to administration within 48 hours of meeting with school officials.
  3. Follow all recommendations from the assessment.
  4. Submit to on-demand drug testing for one calendar year.

If the student-athlete does not submit to the steps above, they will be ineligible to participate in any activities until they comply.

Appeal Procedures

  1. Rights of Appeal and Notification/Due Process. The student accused of violating the activity code, his or her parents or guardian, and the advisor will benotified of the charges within a reasonable time after such violations become known.
  2. Students who wish to appeal the determination of a violation or the consequences applied accordingto the Honor Code by the Athletic Director may appeal to the building Principal. The appeal mustbe made in writing within two school days after receiving notification from the Athletic Director.The building Principal will conduct an appeal hearing in a timely manner and render a decision inwriting within five business days of the hearing.
  3. Students who wish to appeal the outcome of the appeal hearing with the building Principal mayappeal to the Superintendent within two school days after receiving notification from the buildingPrincipal. The appeal must be made in writing within two school days after receiving notificationfrom the building Principal.
  4. Students who wish to appeal the outcome of the appeal hearing with the Superintendent may appealto the School Board within two school days after receiving notification from the building Principal.The appeal must be made in writing within two school days after receiving notification from theSuperintendent.At each step, the request for appeal must be made within two days of notification of the decision at theprevious level. Students who are appealing the determination of a violation may, at the sole discretion ofthe Principal or his designee, remain eligible until the appeal process is completed. Students who are onlyappealing the consequences applied will be ineligible throughout the appeal process.

I have read and understand the above student honor code, realizing once signed it applies for the duration of my participation in Co-Curricular Activities in the Cascade School District, and agree to abide by it.

Signature of ParticipantSignature of Parent/GuardianDate

Print Participant’s Name HereGrade

CASCADE SCHOOL DISTRICT

Concussion Information Sheet

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, allconcussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

  • Headaches
  • “Pressure in head”
  • Nausea or vomiting
  • Neck pain
  • Balance problems or dizziness
  • Blurred, double, or fuzzy vision
  • Sensitivity to light or noise
  • Feeling sluggish or slowed down
  • Feeling foggy or groggy
  • Drowsiness
  • Change in sleep patterns
/
  • Amnesia
  • “Don’t feel right”
  • Fatigue or low energy
  • Sadness
  • Nervousness or anxiety
  • Irritability
  • More emotional
  • Confusion
  • Concentration or memory problems (forgetting game plays)
  • Repeating the same question/comment

Signs observed by teammates, parents and coaches include:

  • Appears dazed
  • Vacant facial expression
  • Confused about assignment
  • Forgets plays
  • Is unsure of game, score, or opponent
  • Moves clumsily or displays incoordination
  • Answers questions slowly
  • Slurred speech
  • Shows behavior or personality changes
  • Can’t recall events prior to hit
  • Can’t recall events after hit
  • Seizures or convulsions
  • Any change in typical behavior or personality
  • Loses consciousness

CASCADE SCHOOL DISTRICT

Concussion Information Sheet

What can happen if my child keeps on playing with a concussion or returns to soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.