Make sure your margins are set as wide as possible when you print these forms!

ATHLETIC CHECK-IN INFORMATION

Only One packet is needed for the current school year

WHAT YOU WILL NEED:

COMPLETED ATHLETIC CHECK-IN PACKET Pages 1-6 must be completed and turned in to your school Athletic Office

(EVERY LINE ON ALL 6 PAGES MUST BE FILLED IN)

MUST HAVE A CURRENT PHYSICAL WITH PHYSICIAN’S SIGNATURE (Physicals are good for 12 months)

$90.00 ATHLETIC FEE (each season) TRANSFERS (if you have attended another high school)

PICK UP TRANSFER PAPERWORK FROM YOUR SCHOOL ATHLETIC OFFICE

CHECK WITH YOUR SCHOOL ATHLETIC OFFICE FOR ANY ADDITIONAL REGISTRATION FORMS

REQUIRED BY YOUR SCHOOL

ATHLETES WILL NOT BE ALLOWED TO PARTICIPATE UNTIL ALL 6 PAGES

ARE COMPLETE AND TURNED IN WITH THE $90.00 FEE TO YOUR

SCHOOL ATHLETIC OFFICE

ACCIDENT INSURANCE – If you are interested in obtaining student accident insurance for your athlete call or Email Clinton Whatley, District Insurance Liaison at 720-554-5063-Office or 720-775-8332-Cell, cwhatley2@cherrycreekschools.org

REFUND POLICY – A full refund will be made to the athlete who is cut or leaves the sport on or before the fifteenth (15th) calendar day from the starting date of that sport.

2012-2013 LAST REFUND DATES*

Fall Sports August 28, 2012 Winter Sports November 26, 2012 Spring Sports March 12, 2013

*If an athlete leaves the team after these dates no refund will be given. The athletic fee refund must be requested by the athlete on or before the closing date of the season that his/her sport was offered in. If the athlete does not request the refund by the dates listed below no monies will be refunded.

2012-2013 CLOSING DATES

Fall Sports December 8, 2012 Winter Sports March 16, 2013 Spring Sports May 25, 2013

DEFINING A CONCUSSION

The Cherry Creek School District values the safety of all our students and understands the importance of educating our student athletes and parents about the seriousness of concussions. As reported to the National Federation of State High School Associations (NFHS) each year it is estimated that over 140,000 student athletes across the United States suffer a concussion (data from the NFHS Injury Surveillance System). It is important to understand what a concussion is and how to manage concussions. Following are a few facts regarding concussions, signs and symptoms of concussions, and the roles and responsibilities as an athlete and parent regarding concussions.

What is a Concussion? A concussion is a brain injury which results in a temporary disruption of normal brain function. A

concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a result of a blow to the head

or body. This can occur from contact with another player, hitting a hard surface such as the ground, court or getting hit by a

piece of equipment such as a bat, stick or ball.

Concussion Facts- Taken from NFHS “A Parent’s Guide to Concussion in Sports” and CDC – “Heads x Concussion in High

School Sports”

Concussion can occur in any sport, male or female sports, any age.

An athlete does not need to lose consciousness “knocked-out “to suffer a concussion.

Concussion symptoms may last from a few days to several months.

Concussions can cause symptoms which interfere with school, work, and social life.

A concussion may cause multiple symptoms. Many symptoms appear immediately following the injury, while others may

develop over the next several days or weeks. The symptoms may be subtle and are often difficult to fully recognize.

Signs and Symptoms –You cannot see a concussion, but you might notice some symptoms right away. Other

symptoms can show up hours or days after the injury.

Signs Observed by Coaches, Parents, Teachers, Teammates Symptoms Reported By Athletes Appears dazed or stunned Headache

Is confused about what to do Nausea

Forgets plays Balance problems or dizziness

Is unsure of game, score, or opponent Double or fuzzy vision

Moves clumsily Sensitivity to light or noise

Answers questions slowly Feeling sluggish

Loses consciousness Feeling foggy or groggy

Shows behavior or personality changes Concentration or memory problems

Can’t recall events prior to hit Confusion

Can’t recall events after hit

The Colorado High School Athletic Association (“CHSAA”) has established by-laws related to student athletes who are removed from

athletic participation due to head trauma. By-law 1790.21 states, “If at any time, during participation, a student athlete is removed

from participation due to head trauma, the student-athlete must obtain a written release from a licensed practitioner before

participating again. A school or school district may impose stricter standards.” In accordance with the CHSAA C.R.S. 25-43-

101, et. seq. requirements, the Cherry Creek School District requires that the student must present a written release from a licensed

practitioner, to include a licensed physician, Doctor of Osteopathy, licensed nurse practitioner, or licensed physician assistant,

before the student will be allowed to participate in the athletic program again.

Cherry Creek School District

Student Athlete/Parent Concussion Responsibility and Acknowledgment

(form to be completed and returned to School Athletic Office)

I understand that it is my responsibiltiy to report all my injuries and symptoms to my parent(s) and/or

guardian(s), coach and athletic trainer. I must be an active partipant in my own health.

I have read and understand the “HEADS x UP - Concussion in High School Sports A Fact Sheet for

Athletes/Parents”.

After reading the “HEADS x UP - Concussion in High School Sports Fact Sheet for Athletes /Parents”.

I am aware of the following information:

______ A concussion is a brain injury which I am responsible for reporting to my parents, Athletic Trainer,

(initial) and/or coach.

______ A concussion can affect my ability to perform everyday activities, alter my mood, and effect

(initial) classroom and athletic performance.

______ You cannot see a concussion,but you might notice one or more symptoms right away.

(initial) Other symptoms can show up hours and days after the injury. ______ Following a concussion the brain needs time to heal. Both physical/mental rest are needed. You

(initial) are much more likely to have repeated concussions if you return to play before your symptoms

resolve.

______ I will not return to play in a game or practice if I have recived a blow to the head or body that

(initial) results in concussion/related symptoms until I am cleared to return.

______ I understand the CHSAA By-law and C.R.S. 25-43-101, et. seq. and will need medical clearance

(initial) in order to return to play.

______ If I suspect a teammate has a concussion, I am responsible for reporting the possible injury to

(initial) my coach and/or athletic trainer for the good of my teammate.

______ If I have questions, I will contact my medical provider, school nurse, trainer and/or coach to get

(initial) more information regarding concussion; or visit www.cdc.gov/concussion.

By signing below, I acknowledge that I have read and understand the information regarding concussions. I

acknowledge that I have received HEADS x UP - Concussion in High School Sports A Fact Sheet for Athletes

and HEADS x UP - Concussion in High School Sports A Fact Sheet for Parents. I know and understand that I

should notify the proper individuals (parents,medical provider, ATC, nurse and/or coach) when I suspect I may

have sustained a concussion.

__________________________________ ___________________________________

Signature of Student Athlete Date Signature of Parent/Guardian Date

Page 1 of 6

ATHLETIC REGISTRATION 2012/2013

(HAND CARRY TO ATHLETIC OFFICE WITH FEE – NO MAIL-INS ACCEPTED)

FALL ____________________ WINTER ______________________ SPRING___________________ ID# ______________

(Name of Sport) (Name of Sport) (Name of Sport)

NAME ______________________________________________________________________________ GRADE ______

(Last) (First) (MI)

Street ____________________________________________ City ____________________________________

DOB ______________ M _____ F______ Phone ____________________________________________________ (Home) (Cell)

Father’s Name ____________________________________________ Phone: _____________________________________ (Last) (First) (Business) (Cell)

Email:_________________________________________________

Mother’s Name ____________________________________________ Phone: ____________________________________ (Last) (First) (Business) (Cell)

Email:_________________________________________________

Last School Attended _______________________________ If transferred, date of transfer _____________

Reason for transfer __________________________________________________________________________________________

Do you currently attend a private school? ________ School Name_________________________________________

Are you home-schooled? Yes ______ No ______ Name of Program:____________________________________

STATEMENT BY PHYSICIAN OR APPROVED HEALTHCARE PROVIDER (MD, DO, NP, PA)

FOR INTERSCHOLASTIC PARTICIPATION

I hereby certify that I have examined the above mentioned student and find him/her physically fit to engage in high school baseball, basketball, cross

country, field hockey, football, golf, gymnastics, lacrosse, soccer, softball, swimming, tennis, track and field, volleyball, wrestling, cheerleading and

pom pons. (Please cross out any activity in which this student should not participate.)

Signature of Physician/Approved Provider:_____________________________________Credentials: __________________Date:____________

INTERSCHOLASTIC ACTIVITIES INSURANCE WAIVER

This statement releases the Cherry Creek Schools of financial responsibility in case of accident/injury to my son/daughter while he/she is

participating in interscholastic activities. I fully understand the Cherry Creek Schools do not provide accident or health insurance coverage for my

son/daughter while he/she is participating in interscholastic activities. However, accident insurance is made available by the School District through

an authorized agent. I further understand that it is my responsibility to provide health/accident insurance coverage for my son/daughter.

OPTIONS: (Circle A. B. or C, and complete signature line.)

A. I feel my present insurance coverage is adequate. Our Health Insurance carrier is __________________________________________________

B. I am purchasing student accident insurance for the above named student through the authorized agent for the School District.

C. I do not have accident or health insurance coverage for the above named student. I fully understand that I am responsible for any

medical bills related to his/her participation in interscholastic activities while representing Cherry Creek School District schools. (If you are

interested in obtaining student accident insurance for your athlete call or Email Clinton Whatley, District Insurance Liaison at O:720-554-5063, C:720-775-8332 or email: cwhatley2@cherrycreekschools.org)

______________________________________________________________________________________________________________________________________

PARENT/GUARDIAN SIGNATURE Date

Page 2 of 6

CHERRY CREEK SCHOOL DISTRICT #5 2012/2013 TRANSPORTATION AWARENESS – SITE MANAGEMENT – CONSENT AND RELEASE

The Cherry Creek School District #5 (the District) provides District transportation for students to and from a great many activities, events, matches

and games. However, the District is unable to provide District transportation in all circumstances and to all events. The nature of some sports,

needing off-campus practice and meet sites, limits the district’s capacity to bus on every occasion. In such instances, whether for practices or

scheduled meets, it is the responsibility of the parent/guardian of the student to arrange the student’s transportation to and from the event.

When District transportation is not available and other alternative forms of transportation are utilized, the District cannot and does not assume any

responsibility for the safety, training of drivers, condition of vehicles, adequacy for the use of purpose intended or any other matters related to any

non-District transportation.

Be further advised that school district personnel may not supervise certain golf practices, matches and tennis practices. Participation in the practices

or matches rest with the student and their parent/guardian. The school district will not assume responsibility for the student’s conduct or safety in

connection with these practices and/or matches.

Therefore, we, the undersigned parent/guardian and student, hereby acknowledge, agree and understand that the District does not insure, endorse,

approve or sponsor any form of non-District transportation, whether by parents, student or otherwise, to and from District off-campus activities or

events. We further acknowledge it is our responsibility to provide or arrange for our/my child’s transportation to District events when District

transportation is not available. As such we consent to our child’s use of alternative means of transportation, including private vehicles driven by

parents, and, if applicable, consent to our child’s use of a vehicle to transport himself/herself to off-campus events. We hereby waive, release,

discharge and agree to hold harmless and indemnify the District, its agents, employees, insurers and Board of Education, from any claim, cause of

action, damage, injury, or demand of any nature, including bodily injury, property damage or death, arising from or sustained during or as a result of

my/our child’s utilization of or participation in any non-District transportation, whether furnished by us, our student, parent or otherwise.

As a student participant in the Cherry Creek Schools athletic programs, I recognize the dangers associated with the issues described and I agree to

assume the risk involved while participating.

STUDENT SIGNATURE_____________________________________ Date _________________________

As the parent/guardian of the above-named student, I recognize the dangers associated with the issues described and consent to the

participation of the above-named student.

PARENT/GUARDIAN SIGNATURE_____________________________________ Date ___________________

CCSD INTERSCHOLASTIC PARTICIPANT - STUDENT AND PARENTAL ADVISEMENT

No pupil, upon entering high school, shall participate in interscholastic activities until there is on file with the appropriate office, a statement signed

by his/her parent or legal guardian, and a licensed practitioner certifying that the pupil is physically fit to participate in high school interscholastic

activities, and that he/she has the consent of his/her parents, or legal guardian, to participate. WARNING: By its nature, participation in

interscholastic athletics includes a risk of injury, which may range in severity from minor to disabling to even death. Although serious injuries are not

common in supervised school athletic programs, it is impossible to eliminate this risk. All student athletes should follow safety rules and the

fundamental skills taught by their coaches to perform with the least chance of injury. Students should inspect their own equipment daily. Parents or

students who do not wish to accept the risks described in this warning should not sign the Colorado High School Activities Association Statement by

Physician and Parent for Athletic Participation nor their individual school participation card.

As evidenced by my/our signatures below, I/we understand and agree the coaches, trainers and/or other school designees may use their own judgment

in securing medical aid and ambulance service in case of emergency or in mild injuries where parents cannot be reached, and that school officials are

hereby authorized to take whatever action is deemed necessary. I/we further understand and agree that I am responsible for any expenses associated

with ambulance transport and medical treatment administered in a medical facility as a result of any such emergency. Also, I/We agree the team

trainer, coach and/or other school designee may apply first aid treatment until the family physician can be contacted.

I/We have read the foregoing, acknowledge the “WARNING” above, accept the risks described and agree to abide by the principles and regulations

contained in this advisement.

_____________________________________________ __________________________________

STUDENT SIGNATURE Date

I/We have read the foregoing, acknowledge the “WARNING” above, accept the risks described and hereby give consent for the above-named student

to participate in interscholastic athletics within the Cherry Creek School District No. 5.

_____________________________________________ ____________________________________

PARENT/GUARDIAN SIGNATURE Date

I have read the foregoing, as well as the Interscholastic Activities handbook, and will abide by the principles and regulations contained therein.

________________________________________________________________________________________________________________

STUDENT SIGNATURE Date

I have read the foregoing, as well as the Interscholastic Activities Handbook, and approve participation for the above named student.

________________________________________________________________________________________________________________

PARENT/GUARDIAN SIGNATURE Date

Page 3 of 6

CHERRY CREEK SCHOOL DISTRICT NO. 5

HIGH SCHOOL SPONSORED ATHLETICS AND ACTIVITIES

PARTICIPATION AGREEMENT

In exchange for the opportunity to participate in the Cherry Creek School District No. 5’s High School Sponsored Athletics and Activities Programs, (referred to as “HSAAP”) and in accordance with applicable Board of Education Policies, I understand and agree to the following:

Scope of Rules From the day a student first participates in a Cherry Creek School District HSAAP until that student graduates from high school, these rules remain in effect, throughout the school year, including weekends, vacations, and holidays, and regardless if the student is on or off school district property.

The consequences outlined in this Agreement are in addition to, not instead of, those the student may receive under the district’s Student Conduct and Discipline, Rights and Responsibilities handbook, the Colorado High School Activities Association (“CHSAA”) By-laws, coaches’ team rules, or other sources. They represent minimum

sanctions; the Principal or his/her designee may increase or modify these consequences in particular cases or in general as he or she deems appropriate.

Because students who participate in HSAAP are held to higher behavioral expectations, the principal or his/her designee may determine that a student’s conduct

constitutes grounds for imposing an HSAAP penalty under these rules, even when that conduct does not result in suspension or expulsion under the conduct and discipline code.

General Expectations Students participating in district HSAAP are expected to comply with all applicable Cherry Creek School District No. 5 Board of Education Policies,

including but not limited to Policy JJI, Interscholastic Athletics, and its accompanying Regulation JJI-R.

Students participating in district HSAAP are considered to be representatives of himself/herself, fellow team members, coaches, sponsors, teachers, the

school, its student body, and the Cherry Creek School District. For these reasons, the participating student is expected to display the highest form of

character, behavior and sportsmanship. If at any time, a student’s actions bring harm or discredit to the organization of which the student is a member or to

the school, the student may be subject to disciplinary action, including suspension and/or removal from the HSAAP.

Students participating in district HSAAP are expected to maintain appropriate academic eligibility as described below.

Academic Expectations Eligibility for participation in athletics and specific activities as determined by CHSAA guidelines, the Centennial League, and applicable district policies.

In accordance with Policy JJI, Interscholastic Athletics, a student is ineligible for most of the following quarter if h/she has failed more than one subject the

semester preceding the season of competition.

If the student is failing more than one course weekly, he/she will be ineligible for competition/participation through the following week.

Each participating student must be enrolled in a minimum of five hours of credit (2.5 Carnegie Units or equivalent) per semester. If not, the student is

immediately ineligible to participate in the athletic/activity program.

Behavior Expectations Students participating in district HSAAP agree to maintain an appearance and exhibit conduct in the classroom, school and community which is appropriate

at all times.

Students participating in district HSAAP agree not to violate district conduct and discipline policies, including but not limited to, district

drug/alcohol/tobacco and weapons policies.

Students participating in district HSAAP agree not to engage in behavior which is detrimental to the safety, welfare or morals of himself/herself, other

students or school personnel.

Consequences The following minimum consequences will result whenever the principal or his/her designee concludes that a student has engaged in a violation of school board policy or expectation under this agreement:

1. Referral to the appropriate coach or sponsor for disciplinary review and action.

2. Placement on probation for a number of days and/or upon such conditions as deemed appropriate.

3. Suspension from participation in a specific number of athletic or activity events. Such sanctions may include but not be limited to:

First Offense: For Athletics/Activities with 11 or fewer regular season contests/events, the student will be suspended for the next contest/event;

for those with more than 11 regular season contests/events, the student will be suspended for the next two contests/events. These suspensions

will be imposed whether or not the next contest/event is regular season or outside the regular season.

Second Offense: For Athletics/Activities with 11 or fewer regular season contests/events, the student will be suspended for the next two

contests/events; for those with more than 11 regular season contests/events, the student will be suspended for the next four contests/events. These

suspensions will be imposed whether or not the next contest/event is regular season or outside the regular season.

Third Offense and/or continuing offenses: Additional sanctions which could include some or all of the following: suspension from all

HSAAP for one full year from the date of infraction; denial of the opportunity to obtain awards in the sport or activity; suspension from HSAAP

for the remainder of the school year and/or extending into succeeding school years.

Nothing in these rules/expectations prohibits the Principal or his/her designee, or individual coaches from establishing and enforcing additional rules applicable to participation in district HSAAP. Notice of the imposition of sanctions shall be made in a timely manner by the Principal or his/her designee to the participating student

and his/her parent(s)/guardian(s).

As evidenced by our signatures below, we acknowledge and agree we have read the terms and conditions of the above-referenced Cherry Creek School District High School Athletics and Activities Participation Agreement, and understand and agree that all participating students are subject to the terms and conditions contained in this

Agreement, as well as the provisions of applicable school board policies while participating in these district programs.

_________________________________________ ___________________________________

PARENT/GUARDIAN SIGNATURE Date

________________________________________ ___________________________________

STUDENT SIGNATURE Date

Page 4 of 6

ATHLETIC EMERGENCY INFORMATION 2012/2013

Fall Sport ______________________ Winter Sport _______________________ Spring Sport __________________________ (Name of Sport) (Name of Sport) (Name of Sport)

Grade __________ M _____ F ______

_________________________________________________________________ __________________________ ____________________

Last Name First Middle Initial Home Phone DOB

_________________________________________________________________________________________________________

Address City Zip Code

_________________________________________________________________________________________________________

Mother’s Name Day Phone Night Phone Cell/Pager

_________________________________________________________________________________________________________

Father’s Name Day Phone Night Phone Cell/Pager

If a student’s parents cannot be contacted, please contact:

____________________________________________ _____________________________ __________________________

(1) Name (Relationship to Student) Phone Cell/Pager

____________________________________________ _____________________________ __________________________

(2) Name (Relationship to Student) Phone Cell/Pager

Family Doctor _____________________________ Phone __________________ Height ______ Weight ______

Hospital___________________________________________________ Phone _________________________________

INSURANCE INFORMATION

___________________________________________________________________________________________ Name of Insurance Carrier Policy # Group # Primary Person Insured

___ Allergies ___ Allergies: Life Threatening __________________________________ Other _________________________________

___ Asthma ___ EpiPen ___ Medications: Current ______________________________________________________________

___ Diabetes ___ Orthopedic ___ Last DT/DPT Immunization _____ (mo) _____ (yr)

AUTHORIZATION STATEMENT (Please read and sign below)

This statement releases the Cherry Creek Schools of financial responsibility in case of accident/injury to my son/daughter while he/she is

participating in interscholastic activities.

I fully understand the Cherry Creek Schools do not provide accident or health insurance coverage for my son/daughter while he/she is participating in

interscholastic activities. However voluntary student, accident insurance is made available by the School District through an authorized agent and

may be purchased by you for your son/daughter. I further understand that it is my responsibility to provide health/accident insurance coverage for my

son/daughter.

AUTHORIZATION STATEMENT – I DO HEREBY AUTHORIZE OFFICIALS OF THE Cherry Creek School District to contact directly the

persons named on this form in an emergency for the health of said child. In the event that parents/guardians or other persons named on this card

cannot be reached, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of aforesaid

child. If there is a medical emergency and the school is unable to reach me, I understand that 911 Emergency will be called and my child will be

transported by ambulance to the designated medical facility or the nearest medical facility and given medical treatment by a qualified physician at my

expense.

Date ____________________ PARENT/GUARDIAN SIGNATURE____________________________________________

Page 5 of 6

Cleared for competition

(OFFICE USE ONLY)

Cleared for competition

(OFFICE USE ONLY)

Cleared for competition

(OFFICE USE ONLY)

Cleared for competition

(OFFICE USE ONLY)

CCSD SPECTATOR CODE OF CONDUCT

Remember that you are at a contest to support your team and to enjoy the skill and competition; not to intimidate or

ridicule the other team and their fans, officials, or coaches from your own team.

Student/athletes are involved in organized sports for their enjoyment. Make it fun!

Encourage the student/athletes to play by the rules. Remember that children learn best by example, so applaud the good

plays of both teams.

By showing a positive attitude toward the game and all of the participants, all players will benefit. Do not embarrass any

athletes by yelling at players, coaches, or officials.

Emphasize Sportsmanship through your verbal and physical behavior.

Know and study the rules of the sport, and support the officials on and off the field/court. This approach will help in the

development and support of the game. Any criticism of the officials only hurts the game.

Applaud a good effort in both victory and defeat, and enforce the positive points of the game.

Recognize the importance of coaches. They are important to the development of athletes and the sport. Communicate

with them and support them.

Be a positive role model during and after all events.

Remember participating in athletics and being a fan in the stands is a privilege, not a right.

If in violation of any of the Spectator Code of Conduct, you will be either given a verbal warning or instructed to leave

the sporting event by school personnel.

I have read the foregoing and will abide by the principles contained therein.

STUDENT SIGNATURE / Date PARENT/GUARDIAN SIGNATURE / Date

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 CHSAA site). http://chsaa.org/sgarcia/about/2011CompetitorsBrochure.pdf

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 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 or approved health provider, 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 Cherry Creek School District Policies and CHSAA guidelines for eligibility.

Page 6 of 6

Colorado High School Activities Association