Mclean County Unit District No. 5
2017 Normal
McLean County Unit District No. 5
Circle School Year: 9 10 11 12
Student Name ______
Address ______
City______Zip______
Birthdate ____/____/_____
Parent/Guardian Name______
Phone #______
Email Address ______
Emergency Contact______
Relationship/Phone #______
Doctor/Phone #______
Hospital Choice ______
Any current/reoccurring medical conditions? Explain: ______
Any Medication taken? ______
Surgeries, Injuries, Physical Activity restrictions (Brief description and dates: ______
______
Check all that apply:
Heart condition Diabetes Epilepsy Asthma
Requires child to self-administer medication
Requires student to carry EpiPen®;
Allergies: ______
If child requires to self-administer an inhaler or carry an EpiPen, parent must completely fill out Unit 5 Medication Authorization Form. (Attached)
Board policy 7.300 requires each student provide proof of accident insurance coverage.
Name of Insurance: ______
Policy # ______Expiration date: ______
Does this student reside full time with parent, custodial parent or court appointed legal guardian?
Yes______No______
Is this student new to this school or Unit 5 this year?
Yes______No______
Each student and his or her parent/guardian must read and sign this Agreement to participate each year before being allowed to participate in co-curricular athletics. The completed Agreement is to be returned to the Athletic Director.
Transportation for School Activities
Students must utilize school transportation to and from all school activities for which transportation is provided. For these events, parents of the student may transport their student only if specific arrangements are made in advance with the activity sponsor. Transportation may not be provided in some instances. These instances would include, but not be limited to: practices, athletic contests, music events or club activities held within the Bloomington-Normal area when it is deemed more practical for the students to meet the coach or sponsor at the site. In these cases, it will be the responsibility of the parent to arrange safe transportation.
Participation Fees
Students that are identified as being part of an Athletic Team will have a Co-curricular fee for each activity. The McLean County Unit 5 Board of Education has set the following fee for each activity a student participates in: $85.00. Students qualifying for reduced textbooks pay a fee of $42.50 for each activity.
Athletic Code
As the parent/legal guardian of the above-named student, I give permission for him/her to practice and compete in any of the IHSA interscholastic sports or activities offered. By signing below, I grant my permission for my child to receive treatment at my expense from a physician, nurse, or other professional medical personnel including transfer to any hospital reasonably accessible, which may be needed, in my absence due to injuries sustained while participating in athletics for a Unit 5 school. Furthermore, my son/daughter and I have read and understand the Athletic Code as set forth by Normal West High School of Unit District No. 5, and agree to abide by it.
IHSA Steroid Random Testing Policy Consent
As a prerequisite to participation in IHSA athletic activities, we agree that the undersigned student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have read this form and understand that the student may be asked to submit to testing for the presence of performance-enhancing substances in his/her body, and the student does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the(CONTINUED ON BACK)
(CONTINUED FROM FRONT)
results of the performance-enhancing substance testing may be provided to certain individuals in the student’s high school as specified in the IHSA Performance-Enhancing Substance TestingProgram Protocol that is available on the IHSA website at We understand and agree that the results of the performanceenhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject the student to penalties as determined by IHSA. No student-athlete may participate in IHSA competitions unless the student and the student’s parent/guardian consent to random testing.
- I acknowledge reading the eligibility rules of any group or association sponsoring any athletic activity in which I want to participate and I agree to abide by them.
- Before I am allowed to participate, I must: (a) provide the District with a certificate of physical fitness [the Pre-Participation Physical Examination Form from the Illinois High School Association (IHSA) or Illinois Elementary School Association (IESA) serves this purpose], (b) show proof of accident insurance coverage, and (c) complete all forms required by any association sponsoring the interscholastic athletic activity, including whenapplicable and without limitation, IHSA Sports Medicine Acknowledgment & Consent Form, Acknowledgement and Consent.
- I agree to abide by all conduct rules and will behave in a sportsmanlike manner. I agreeto follow the coaches’ instructions, playing techniques, and training schedule as well as all safety rules.
- I understand that Board policy 7.305, requires, among other things, that a student athletewho exhibits signs, symptoms, or behaviors consistent with a concussion or head injury must be removed from practice or competition at that time and that the student will not be allowed to return to play or practice until he or she has successfully completed return-to play and return-to-learn protocols, including having been cleared to return by the treating physician licensed to practice medicine in all its branches or a certified athletic trainer under the supervision of a physician.
- I am aware that with participation in sports comes the risk of injury, and I understand thatthe degree of danger and seriousness of risk vary significantly from one sport to another with contact sports carrying the highest risk. I am aware that participating in sports involves travel with the team. I acknowledge and accept the risks inherent in the sport(s) or athletics in which I will be participating and in all travel involved. I agree to hold the School District, its employees, agents, coaches, School Board members, and volunteers harmless from any and all liability, actions, claims, or demands of any kind and nature whatsoever that may arise by or in connection with my participating in the school sponsored interscholastic sport(s) or intramural athletics. The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator,assignees, and for all members of my family.
- I am the parent/guardian of the above named student and give my permission for my child orward to participate in the interscholastic sport(s) or intramural athletics indicated. I have read the above Agreement to Participate and understand its terms.
- I understand that all sports can involve many risks of injury, and I understand that thedegree of danger and seriousness of risk vary significantly from one sport to another with contact sports carrying the higher risk. I am aware that participating in sports involves travel with the team. In consideration of the School District permitting my child to participate, I agree to hold the District, its employees, agents, coaches, Board members and volunteers harmless from any and all liability, actions, claims or demands of any kind and nature whatsoever that may arise by or in connection with the participation of my child in the sport(s) or athletics. I assume all responsibility and certify that my child is in good physical health andis capable of participation in the above indicated sport or athletics.
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Parent/Guardian Signature Date
______
Student Signature Date