Microsoft Word - Emergency Card 2.doc

Pine Creek High

School

Athletic Director: Eric Hulen, eric.hulen@asd20.org

Athletic Secretary: Jenny Field, jenny.field@asd20.org

2016-2017 Athletic Registration Inf

ation

Dates:

FALL SPORTS

WINTER SPORTS

SPRING SPORTS

CROSS COUNTRY ● FIELD HOCKEY

●

FOOTBALL ● BOYS GOLF

● GIRLS

GYMNASTICS

● BOYS

SOCCER ● SOFTBALL ● BOYS TENNIS

●

VOLLEYBALL

● CHEER

BOYS/GIRLS BASKETBALL

● ICE

HOCKEY ● GIRLS SWIMMING

● WRESTLING ● CHEER

(EXTENDED FROM FALL)

BASEBALL ● GIRLS GOLF ● BOYS

LACROSSE ● GIRLS LACROSSE ●

GIRLS SOCCER ● BOYS

SWIMMING ● GIRLS TENNIS ●

BOYS/GIRLS TRACK & FIELD

Registration Starts:

July 29, 2016 (Fri)

October 7, 2016 (Fri)

January 30, 2017 (Mon)

Deadline:

August 4, 2016 (Thurs) Golf Only

August 11, 2016 (Thurs) Other sports

November 9, 2016 (Wed)

February 23, 2017 (Thurs)

First Day of Tryouts/

practice:

August 8, 2016 (Mon) Golf Only

August 15, 2016 (Mon) Other sports

November 11, 2016 (Fri)

February 27, 2017 (Mon)

Mandatory Parent

Meeting

TBD

SPORTS

REGISTRATION

CHECK

LIST

To complete your

registration

and be eligible for the 1

day of practice, the following must be completed and submitted to

the

Athletic Office no later than the due date

corresponding

the sport

season

ONLY

COMPLETE REGISTRATION

PACKETS WILL BE

ACCEPTED.

Registration Form - Completed and Signed by parent and athlete.

Colorado High School Activities Association (CHSAA) Competitors Brochure – Signed by parent and

athlete.

A current physical, signed and dated by a doctor. Physicals must last through entire sport season and

must not expire at any time during the current sports season of enrollment. NO EXCEPTIONS. Please

note if current physical is on file from a prior sport/activity.

Homeschoolers and/or those that are enrolled in another school which do not offer the sport must fill

out a “Request to Participate” form from Education and Administration Center, 234-1200 prior to

registering for the sport. Please attach the acceptance letter to this registration.

PAYMENT: Check, Cash or through www.PAYFORIT.net. Credit cards will be accepted through

payforit.net. A 2.5% fee is added to all credit card payments. Use your Infinite Campus username and password.

PRINT AND ATTACH RECEIPT TO YOUR

COMPLETE REGISTRATION

FORM AND email, fax or submit in-person.

●$95.00* athletic fee (HOCKEY FEES ONLY: $225.00. For Out of District Hockey players the fee is $337.50.)

●$25.00* athletic fee (CHEER additional winter season)

●$142.50* for Out of District students (student not enrolled at PCHS and live out of the District 20

attendance

area).

PLEASE NOTE BELOW OF MAXIMUM ATHLETIC FEES.

SUBMIT FORMS TO ATHLETIC OFFICE OR ATHLETIC MAILBOX. IF PAID THROUGH PAYFORIT.NET, PLEASE

INCLUDE PAYMENT RECEIPT WITH YOUR REGISTRATION FORM. OFFICE HOURS ARE 7:30 AM TO 2:45 PM

*MAXIMUM

ATHLETIC FEES FOR RESIDENT OR D20

ENROLLED

STUDENTS:

Sport

Per Athlete Per Year

Per Family Per Season

Per Family Per Year

Ice Hockey

$370 maximum

$740 maximum

Non-Hockey

$240 maximum

$480 maximum

(* Fees are refundable if student does not make a team. Fees are not refundable for athletes that choose not to participate once

the season has started.)

PINE CREEK HIGH SCHOOL – EMERGENCY INFORMATION CARD

PLAYER’S NAME________________________________________________________________

AGE________DOB_________________GRADE________SPORT_________________________

PARENT’S OR GUARDIAN’S NAME________________________________________________

ADDRESS________________________________________________________________________

HOME PHONE____________________________ WORK PHONE________________________

CELL PHONE__________________________ EMAIL __________________________________

PHYSICIAN________________________________PHONE_______________________________

HOSPITAL PREFERENCE_________________________________________________________

INSURANCE COMPNAY___________________________ POLICY #_____________________

ALLERGIES_____________________________________________________________________

PRE-EXISTING MEDICAL CONDITIONS___________________________________________

NAME_____________________________________________PHONE____________________________

NEW STUDENT?

LAST SCHOOL

ATTENDED

YES NO

______________________

____________

TRANSFER

WORKSHEET/CHSAA

FORM 7

PHYSICAL DATE

ENROLLED IN 5

CLASSES

INPUT ON ROSTER

ELIGIBILITY

CHECKED

DATE RECEIVED

PAYMENT

RECEIVED

CONTACT IN THE EVENT PARENTS CANNOT BE CONTACTED

OFFICE USE ONLY

ASSUMPTION

OF RISK

AGREEMENT

AND

EMERGENCY

RELEASE

● As the parent/legal guardian of the athlete named here (athlete’s name), I/We

understand that playing or participating in any sport can be a dangerous activity involving risks of injury, which may be serious.

Although serious injuries are not common in supervised programs, it is impossible to eliminate all risk.

By signing this permission form, we

acknowledge

that we have read and understand this warning and understand the inherent risks

associated with this sport activity. We further understand that we are responsible for obtaining any medical, accident, or other

insurance that we deem appropriate; the district does not provide student accident insurance.

Parents/Guardians

and Athletes

who do not wish to accept the risk described in this warning should not sign this

Assumption

of Risk Agreement. The District

makes available to parents, student accident insurance information which may be purchased at parent’s expense.

● I understand that the School District and its employees may have certain legal protections and immunities from liability

with respect to any property

damage

or personal injury that may occur during the activity. The School District and its

employees have not waived these protections and immunities. I understand that the School District and its

employees

may

also have certain legal obligations with respect to the activity. By signing below, the athlete and parent/legal guardian

confirm that the athlete has been deemed physically able to participate in athletic activities by a physician.

● Additionally, by signing below, the athlete and parent/legal guardian, in the event of a medical situation in which the

parent/legal guardian cannot be reached, grant permission to the school or administrator in charge, to secure proper

medical

treatment

for the athlete. Proper treatment may include, but is not limited to first aid, assessment by a district

athletic trainer, referral to a medical provider, ambulance transport, hospitalization and/or surgery.

● Furthermore, by signing below, the athlete and parent/legal guardian understand and agree that Certified Athletic

Trainers employed by Academy District 20 will interact with student-athletes with regard to injury prevention; clinical

evalaution and diagnosis; immediate and emergency care; treatment and rehabilitation; organization and professional

health and well-being; and are qualified to do so by holding the designation of ATC (Certified Athletic Trainer).

● Injured athletes that have been evaluated and/or treated by a physician must submit written clearance from that

physician to the Athletic Trainer or coach prior to the athlete being permitted to resume activity. In circumstances where an

athlete has been removed from play because of a suspected head injury or concussion, the athlete will not be permitted to

return to play until the athlete is evaluated by a healthcare provider, receives medical clearance and written authorization

from that provider. This Authorization shall remain in effect for the current school year.

● Participants must obey all safety rules, report all physical problems to their coaches, follow a proper conditioning program,

and inspect their own equipment daily. The parent/legal guardian and athlete agree to abide by all district/school/camp rules

and comply with the reasonable authority of the staff.

●

his

appli

e f

ollowin

spo

t(s)/

amp(s)/

ity(ies):

Parent/Legal

Guardian: By signing this form, I am not releasing the School District and its employees from any of their legal

obligations. However, on behalf of myself, my

student,

and our family and

representatives,

I release and hold harmless the

School District and its employees from and against all claims for any damages or injuries incurred by my student from any

cause, including but not limited to my student’s own misconduct or the actions or omissions of third parties. I understand that

for purposes of this Release, the term “employees” includes the School District’s directors, employees, servants, and

volunteers.

PARENT/STUDENT

REE

Parent Signature: ____________________________________________________ Date: ____________________

Student Signature: ____________________________________________________ Date: ____________________

Revised Oct. 19, 2016

Per Bylaw 1720.1, parents and participants must be informed,

understand,

and

acknowledge

basic CHSAA eligibility rules and they

must

acknowledge

the risk of participation. This

acknowledgement

must be kept on file with the school.

A student's

participation

in high school activities is dependent on his/her eligibility. Protect that eligibility. Read the following

summary of Colorado High School Activities Association rules that govern a student’s

participation.

Students and parents

alike

need

to review these rules and ask questions of their

coaches/directors,

athletic director and school

administrators.

If a student has any

questions, he/she should seek the answers before

participating

by going first to the coach or athletic director.

**Please review the following information and

acknowledge

your

understanding

of the CHSAA Bylaws by signing at the end and

submitting to your School’s Athletic Director. Click the blue underlined links to be directed to the CHSAA Bylaws.

The CHSAA

The Colorado High School Activities Association has been the governing body of high school athletics and activities (speech, student

council and music) in our state since 1921. Our Code of Ethics is integral to our Mission and Vision. The student’s school is a

voluntary member of the CHSAA and has agreed to follow its rules. Both your school and the Association believe in equal

competition among schools and the close relationship between

academics

and activities.

Discrimination

(300)

student-participant

will not participate in or condone unfair

discriminatory

practices against a fellow participant due to age,

gender, race, ethnicity, religion, sexual

orientation,

or disability, nor shall the student be

discriminated

against under the same

criteria.

II. Hazing & Bullying (1710.2)

As a

student-participant,

I will not be the organizer of, or participant in an activity

constituting

hazing. Hazing is defined as any

conduct or method of initiation, whether on public or private property, which willfully or recklessly

endangers

the physical or mental

health of any student or other person. Such conduct shall include but is not limited to whipping, beating, branding, forced behaviors

involving, food, alcohol, drugs or other

substances,

destruction of property, and/or brutal treatment or forced

physical/sexu

activity which is likely to adversely affect the physical health or safety of the student or any other person.

The CHSAA Rules of Participation

1. Academic (1710)

A school must select one of three options for

determining

the

eligibility of all its students, and schools have the right to

impose stricter standards.

2. Make-up Work (1740)

Each student must be academically eligible in accordance

with the above section at the time of participation and during

the previous semester. Make up work shall not be permitted

after the close of the semester for the purpose of becoming

eligible. (Cases involving special

circumstances

should be

referred to your principal.)

If eligibility has been lost from a previous semester, students

may regain their athletic eligibility for Fall 2014 on October 9

and for Spring 2014 on March 6 by meeting the respective

eligibility

requirements

above.

Summer school credits accepted by the school may be used

to replace credits in subjects failed during previous

semesters.

Dropping a class may make you ineligible. If you play while

ineligible, you may cause your team to forfeit any contests in

which you played.

3. Citizenship (1710)

The school principal must approve the student to be a

representative of the school's standards of citizenship,

conduct and sportsmanship.

4. Conduct – Ejections (2200)

If a student is ejected from a contest for unsportsmanlike

conduct, he/she will be ineligible for the next scheduled

match or contest played at that level including qualifying and

state contests. The student may not

participate

in any

contests at any other level during this period. For the season,

the student will be permitted to compete in one fewer

contest than the maximum allowed each participant in the

sport.

A second ejection during the season shall result in a 2 contest

suspension.

A third ejection will result in a review of the

student's future eligibility by the CHSAA Commissioner.

 
 
If a student is ejected in the final contest of a season, he/she 
is ineligible for the first contest of the next sport in which 
he/she competes and 
completes 
the season.  Players leaving 
the bench during a fight shall be ejected and ineligible for the 
next contest. 
 
5.  Outside Competition (2100) 
As a member of any high school team, a student may practice
 
or compete in that sport during that sport season in a non- 
school event with prior written permission of the principal. 
 
Members of high school teams may compete in non-school 
events in that sport without written permission on the day 
following the completion of the season for the level 
(freshman, 
sophomore, 
junior varsity, varsity) of the team on 
which they are competing. NOTE: A student becomes subject 
to the outside competition rule on or after the first date of 
formal practice, when he or she reports out for practice and 
is in contention for a berth on the team. 
 
6. 
Undergraduate 
(1710) 
A student may not be a graduate of any high school and 
participate 
in high school athletics. 
 
7.  Recruiting (1810) 
Any recruiting based on athletic ability or interest is 
prohibited. 
 
8.  Age (1770) 
A student’s 19th birthday must fall on or after August 1 of the
 
current school year. 
Exceptions 
to this rule, based on 
educational handicaps, may be requested, provided the 
student’s original class has not graduated. 
 
9.  Semesters (1770.2) 
Upon entering high school, a student’s eligibility will continue
 
only until his/her original class graduates. Once entering 
ninth grade, a student has eight 
consecutive semesters 
of 
eligibility.  NOTE: If a student drops out of school or misses 
competition due to an injury, he/she will not receive 
additional eligibility. 
 
10.   Seasons (1700.2) 
A student is allowed a maximum of 4 seasons in any sport. 
 
11.  Physical Exam (1780) 
A student may not practice or compete (music, student
 
council and speech 
participants 
are exempt) without a 
physical exam that is: 
 
•  Signed by an MD, DO, 
chiropractor 
who is school 
physical certified (DC, SPC), nurse 
practitioner 
or 
physician’s 
assistant licensed by the State of 
Colorado. 
•  Current within the last 12 months.
 
•  On file with principal or athletic director prior to first
 
practice. 
 
12.  Practice (2310) 
A total of 5 different days of practice is required before 
participating 
in any 
interscholastic 
game or scrimmage 
(except football which needs 9 days). OTHER 
EXCEPTIONS: 
(A) 
Golf, skiing, softball and tennis players. (B) 
Participants 
in state
 
playoff games completed on or after the first day of formal 
practice. 
 
No contact between a coach and player is allowed 
on 
Sundays
 during the school year unless it is for a social, 
academic or service related activity that is strictly voluntary. 
A student cannot be required to practice or compete outside 
of the season as a condition of making the team. 
 
13.   Transfer Rule (1800) 
A student who 
participates 
in a formal practice at the 
beginning of the school year and then transfers without a 
parental move will be ineligible for varsity competition for the 
remainder of that sports season. 
 
-  Athletic Transfer (1800.6) 
Any transfer 
substantially 
motivated by athletic
 
considerations 
will cause the student to be ineligible for 
varsity competition for one calendar year from the date of 
the transfer in any sport(s) they participated in during the 
twelve months prior to the transfer. 
 
-  Summer Transfer (1800.5) 
A transfer from one high school to another during the
 
summer without a permanent change of domicile by the 
student and his/her family to the 
attendance 
area of the new 
school will render the student ineligible for varsity 
competition for the first half of the season in any sport in 
which the student competed during the previous 12 months. 
The student may practice with the team and play at the sub- 
varsity level during this period of restricted participation. 
 
-  Mid-year Transfer (1800.6) 
A student who transfers after the start of the school year 
without an 
accompanying 
family move shall: 
•  Have restricted 
(sub-varsity) 
eligibility for the 
remainder of that school year in sports played in the 
last 12 months. 
 
•  In the next school year, the student will have only 
sub-varsity eligibility for the first 50% of the season 
in those sports played 12 months prior to the move 

- Transfer with Club Coach or Previous Coach (1800.6)

A student

transferring

or moving for any reason to a new

school where the student’s non-school coach is also a coach

of the school team, is considered to be attending for athletic

purposes. The student, as a result of this transfer, will be

ineligible for varsity competition for one calendar year from

the date of the transfer in any sport(s) they participated in

during the twelve months prior to the transfer. If a student

transfers to a school where his/her previous coach is a coach

of the current school team, that move will be deemed

motivated by athletic consideration.

As used in this Rule, the coach may be a former school coach

or non-school coach and the term “coach” includes any

person who coaches,

volunteers (regardless

of compensation)

or assists in any capacity with the coaching or training of the

school or non-school team.

- General Transfer Information (1800)

It is the student’s responsibility to know the CHSAA Transfer

Rule and how it affects that student’s eligibility. The CHSAA

Commissioner

may grant

exceptions

to this rule in unusual

cases. Only schools may submit a waiver. If a waiver of the

transfer rule is requested, the student is not eligible until the

waiver is approved by the CHSAA Commissioner.

Transfer cases involving separation and/or divorce

proceedings should be reviewed with the school

administration.

15. Awards (2010)

Individuals participating

in any

interscholastic

athletic/activity

sponsored and/or approved by the Association shall not

accept cash or

merchandise

awards. Awards must

be symbolic

in nature with no functional or intrinsic value with a cost of

no more than $50.00.

16. Amateur (2000)

If a student

participates

in a CHSAA approved sport, in other

than CHSAA

competition,

his/her amateur status is

determined by the rules of the amateur governing body of

that sport. Amateur status of Colorado high school athletes

applies only to sports sanctioned by the CHSAA.

17. Bullying & Hazing (1710.2)

The Colorado High School Activities

Association,

conjunction with its member school, prohibits bullying,

hazing, intimidation or threats. Hazing includes humiliation

tactics, forced social isolation, verbal or emotional abuse,

forced or excessive

consumption

of food or liquids, or any

activity that requires a student to engage in illegal activity. I

understand that hazing of any type is not permitted in any

CHSAA sanctioned activity. I will not engage in any of the

prohibited conduct. I further understand that it is my

responsibility

to immediately report any acts of hazing that I

become aware of to a sponsor, teacher, counselor, school

support staff, coach or

administrator

in my school.

After reviewing the above

information,

if you still have

questions,

please contact your school’s athletic

director. This list is by no means inclusive; however, it is

intended to outline the most common questions and

bylaws. For more

information,

please visit our website

CHSAANow.com.

Checklist for Student Eligibility

If a student cannot check any of the items, he/she needs to contact the athletic director or principal.

[ ] At least 5 full credit classes.

[ ] (Choose 1) Option A (Failing no more than one class)

Option B (Passing a minimum of 5 full-credit classes)

Option C (Approved alternate academic program)

Complied with first two items last semester.

[ ] Physical exam within the last calendar year.

[ ] Parent permit form on file at the school.

[ ] Have not changed schools during the current school

year without a

corresponding

move by parents.

[ ] Will not or have not turned 19 before August 1.

[ ] Has not been in high school longer than 8

consecutive semesters.

[ ] Will not play more than 4 seasons in any sport. [ ]

Will not compete or practice in any non-school

events in my sport once reporting out for the team, without

the permission of my principal.

[ ] Has complied with all other school, district, and local

eligibility requirements.

I have read and understand the CHSAA Eligibility Rules as

documented

here as well as

specifically

read in the CHSAA Bylaws. I

understand and

acknowledge

the inherent risks of

participating

in Athletics and by signing this

acknowledgement,

I affirm my

responsibility

to prevent and report hazing. I also understand that any violation of this could result in school or team

consequences

that could include dismissal from the activity or further

disciplinary consequences

and/or referral to law

enforcement.

Signed: _ (Parent)

_ (Participant)

STUDENT ELIGIBILITY INFORMATION

FORM

and

CHSAA

Anti-Hazing Policy

I hereby give my consent for

to compete in athletics for High School

in Colorado High School Activities Association approved sports, except as noted on the Physical Examination

and Parent Permit Form, and I have read and understand the general guidelines for eligibility as outlined in the

CHSAA Competitor’s Brochure (as found on the CHSAANow.com website).

Parent or Guardian Signature Date

I have read, understand and agree to the General Eligibility Guidelines as outlined in the CHSAA

Competitor’s Brochure.

Student Signature Date

No student shall represent their school in interschool athletics until there is a statement on file with the

superintendent or principal signed by his/her parent or legal guardian and a signed physical form certifying that

he/she has passed an adequate physical examination within the past year, noting that in the opinion of

the examining physician, physician's assistant, nurse practitioner or a certified/registered chiropractor, (DC, Spc.) is

physically fit to participate in high school athletics; that student has the consent of his/her parents or legal guardian

to participate; and, the parent and participant have read, understand and agree to the CHSAA guidelines for

eligibility.

CHSAA

Anti-Hazing Policy

The Colorado High School Activities Association prohibits bullying, hazing, intimidation or threats. Hazing includes,

but is not limited to humiliation tactics, forced social isolation, verbal or emotional abuse, forced or excessive

consumption of food or liquids, or any activity that requires a student to engage in illegal activity. I understand

that hazing of any type is not permitted in any CHSAA sanctioned activity.

I will not engage in any of the prohibited conduct. I further understand that it is my responsibility to immediately

report any acts of hazing that I become aware of to a sponsor, teacher, counselor, school support staff, coach or

administrator in my school.

By signing this acknowledgement, I affirm my responsibility to prevent and report hazing. I also understand that

any violation of this could result in school or team consequences that could include dismissal from the activity or

further disciplinary consequences and/or referral to law enforcement.

Student Athlete Signature Date

PINE CREEK HIGH SCHOOL ATHLETIC DEPARTMENT

PARENT /STUDENT ATHLETE HANDBOOK ACKNOWLEDGEMENT

We, _____________________________________and _______________________________

Parent/Guardian Printed Student Name

have received and read the Pine Creek High School Parent/Student Athlete Handbook.

We understand the rights and responsibilities pertaining to students and agree to support and

abide by the rules, guildelines, procedures and policies of School District Twenty and Pine

Creek High School.

____________________________________________________

Parent/Guardian Signature

__________________________________________________________________________________

Student Signature

____________________________________

Date