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San Bernardino Unified School District

The following steps must be taken to secure athletic clearance and participation at any San Bernardino City Unified School District high school:

1) Complete and sign every part of this application. Please remember that to be

academically eligible for participation in any sport the student must be passing in a

minimum of four (4) classes, have a GPA of 2.0 or higher in the previous grading period.

2) Complete a physical examination. Under California Education Code,. The physical must be

dated May 1st or after and is valid for the entire school year.

3) Complete the Emergency Medical Information and Transportation Permit Card.

4) Read and Understand the San Bernardino City Unified School District Athletic Code.

5) All the above materials must be presented to the Athletic Director and be on file in that person’s

office. No try-outs, practice, or participation of any kind may take place prior to receiving

approval from the Athletic Director. By CIF rule, information provided by the student or his/her

parent which proves to be false may result in the loss of as much as 24 months of athletic

eligibility.

CHECK ACTIVITIES IN WHICH YOU PARTICIPATE

FALL WINTER SPRING

Performance Group Cross Country Basketball Baseball

Pep Squad, Tall Flags, etc Football Soccer Golf

Girls’ Tennis Girls’ Water Polo Softball

Club Sport Boys’ Water Polo Wrestling Swimming

Girls’ Golf Tennis

Volleyball Track

FAILURE TO COMPLETE ALL ITEMS WILL RESULT IN DELAY OF APPROVAL TO PARTICIPATE

**REQUIREMENTS FOR SPORTS PARTICIPATION** Dear Parent/Guardian: A physical packet is required for every student to participate in athletics. Please fill out the paperwork in black or blue ink. ALL PHYSICALS MUST BE ON THE DISTRICT FORM PROVIDED IN THE PACKET AS PER C.I.F. STATE REGULATIONS. YOU CANNOT ATTACH A COPY FROM YOUR DOCTOR’S OFFICE. THE ATHLETIC INSURANCE PAPER MUST BE FILLED OUT EVEN IF YOU HAVE YOUR OWN INSUR-ANCE. If you need to purchase Insurance through Myers/Stevens, you must pick up the Insurance forms from the school site and we will mail it.

Do not leave any blank spaces. If you have any questions, please call Mr. Imbriani (475-5513).

Please make a copy of the physical and keep it

for your own records in case the original gets

lost. If your student plays or tries out for more

than one sport, each coach will need a copy of

the physical portion of the packet.

If you know you are going to be playing a sport,

then get your physical done May 1st or after and

it is good for the entire school year. Do not wait

until your season to get it done or it may delay

when you can start practicing.

Copies of our schedule and information are available at at

www.cajonathletics.com

A

A What school did you attend last year? ( include dates) Name of High school

While attending the above school, my address was:

City: State:

While attending the above school I lived with: Both Parents Father Mother Relative (specify)

Other (specify)

While attending my previous school, I participated on the following athletic teams (please identify each sport, level and year of participation)

ATHLETES REGISTRATION CARD & RESIDENTIAL ELIGIBILITY Student I.D # 1

Student Name: Sex: Date:

Address: Age: Date of Birth:

City: Zip Code: Home Phone:

Parent Cell Phone: Email:

Father’s Name: Employer: Phone:

Mother’s Name: Employer: Phone:

Current Grade: Date First Entered 9th Grade (Mo/Yr):

Verification of residential eligibility under CIF rules for students participating in sports in the San Bernardino City

Unified School District is very important. To evaluate each student’s status, the information requested must be

completed HONESTLY and ACCURATELY by the student and the parent/guardian. Any false information could cause

a student to be classified as ineligible and/or cause the team to forfeit contests in which the student participates.

Have you attended any high school other than this one?

If YES (complete Sections A and B below)

If NO (complete Sections B only below)

B Date of entry at this school ( Month/Year)

While attending this school my home address is:

City: State:

I am living with: Both Parents Father Mother Stepfather Stepmother Legal Guardian Foster Parent

Relative (specify) Other (specify)

Is this the same Parent(s)/Guardian(s)/Other(s) with whom you lived while attending the previous high school in section A above?

YES NO NOT APPLICABLE

TO PARENT OR GUARDIAN: you are requested to sign this participation form in order that the student concerned may

engage in an extracurricular activity. Participation forms are not required in the case of curricular or regular school activ-

ities because of insurance provisions which are made by the Board of Education. Constitutional and statutory provisions

deny the right of this Board to make similar provisions for extracurricular activities, hence the requirement for special

participation approval. The Board of Education deems many of the extracurricular activities to be worthy for students but does not require them

of students. These activities are voluntary on the part of students and a signed participation form is necessary before

participation. No penalty other than non-participation will be assessed if the participation form is not signed. Parent Authorization: In signing this form I/we are aware that this activity is an extracurricular activity held under

school supervision. It is not a required activity. I/We understand that the Board of Education, the school district or its

employees will not be held liable for injuries resulting from participation of my child in this activity or from transporta-

tion related thereto. Our signatures below verify we have read and understood the assumption of risk. The above information is true and accurate to the best of my knowledge. Student Signature: Date Parent Signature: Date

CIF State 4658 Duckborn Drive

Sacramento, CA 95834

916-236-4477

ANDROGENIC/ANABOLIC STEROIDS PROHIBITION STATEMENT As a condition of membership in the CIF, all schools shall adopt policies prohibiting the use of androgenic/

anabolic steroids. All member schools shall have participating students and their parents, legal guardian/

caregiver agree that the athlete will not use steroids without the written prescription of a fully licensed physi-

cian (as recognized by the AMA) to treat a medical condition (Bylaw 523).

By signing below, both the participating student-athlete and the parents, legal guardian/caregiver hereby agree

that the student shall not use androgenic/anabolic steroids without the written prescription of a fully licensed

physician (as recognized by the AMA) to treat a medical condition. We also recognize that under CIF Bylaw

202, there could be penalties for false or fraudulent information. We also understand the San Bernardino City

Unified School District policy regarding the use of illegal drugs will be enforced for any violations of these

rules.

CIF Southern Section 10932 Pine Street

Academics * Integrity * Athletics Los Alamitos, CA 90720

562-493-9500

Athlete’s Code of Ethics

Athletics is an integral part of the schools total Educational program. All school activities, curricular and extra-

curricular, in the classroom and on the playing field, must be congruent with the schools stated goals and

objectives established for the intellectual, physical, social and moral development of its students. It is within

context that the following Code of Ethics is presented.

As an athlete, I understand that is my responsibility to:

1. Place academic achievement as the highest priority.

2. Show respect for teammates, opponents, official and coaches.

3. Respect the integrity and judgment of game officials.

4. Exhibit fair play, sportsmanship and proper conduct on and off the playing field.

5. Maintain a high level of safety awareness.

6. Refrain from the use of profanity, vulgarity and other offensive language and gestures.

7. Adhere to the established rules and standards of the game to be played.

8. Respect all equipment and use it safely and appropriately.

9. Refrain from the use of alcohol, tobacco, illegal and non-prescriptive drugs, anabolic steroids or any sub-

stance to increase physical development or performance that is not approved by the United States Food and

Drug Administration, Surgeon General of the United States or American Medical Association.

10. Know and follow all state, section and school athletic rules and regulations as they pertain to eligibility and

sports participation.

11. Win with character, lose with dignity.

Our signatures attest to our understanding and agreement to both state and southern sections provisions.

Athlete’s Signature Date Parent’s Signature Date

A copy of this form must be kept in the Athletic Director’s office at the local high school on an annual basis and the Principal’s statement of Com-pliance must be on file at the CIF Southern section office.

2

3 San Bernardino City Unified School District

Athlete’s Code of Conduct

As an athlete of a San Bernardino City School, I understand that I represent my school and fel-

low teammates on and off the field, in school and in the community. Furthermore, I agree with

the CIF Philosophy that it is a privilege, not a right, to participate in athletics for my school

and that my academic achievement is a priority.

Therefore, I agree at all times, I will:

1. Respect my teammates, opponents, officials, coaches, and spectators.

2. Respect my classmates, teachers, administrators, and security personnel.

3. Abide by the rules of my school, team, sport, and CIF.

4. Make academic achievement a priority; focus on my classes and attendance.

5. Adhere to the CIF Southern Section Code of Ethics for Athletes. (Page 3)

6. Refrain from the use of profanity, vulgarity, offensive gestures and fighting.

7. Make an effort to attend and be punctual to class, games, practices, and team functions.

8. Communicate in a timely manner with my coach if I am or will be absent.

9. Immediately inform my coach/school of any injury to myself and communicate the status of

my injury to my coach on a consistent basis.

10. Follow the school district’s transportation policy (players may not drive themselves to or

from athletic events held off site; they may be transported only by their own parent/

guardian with prior permission from the school).

11. Work hard and have a positive attitude on and off the field.

12. Respect, properly use, maintain, and return all equipment and school property.

13. Not use or encourage the use of alcohol, tobacco, illegal substances, steroids, or non-

prescriptive drugs.

14. Abide by CIF Rule 600: “No Outside Competition” during same season sport.

15. Support and follow the guidelines described in each school’s “Student-Athlete, Parent, and

Coach Communications” pamphlet.

By signing below, I acknowledge that I have read and agree to abide by the San Bernardino

City Unified School District Code of Conduct. I also understand that if I fail to comply with

this code of conduct, my team, coach, or school personnel may request that my athletic status

be reviewed, and at the discretion of my coach, athletic department, and/or school administra-

tion, I may be suspended or removed from athletics for up to one year depending upon the in-

fraction.

_____________________________ ____________________________ ______________

Student Name (printed) Student Signature Date

_____________________________ ____________________________ ______________

Parent/Guardian Name (printed) Parent/Guardian Signature Date

SBCUSD Concussion Management Protocol

Concussions and other brain injuries can be serious potentially life threatening injuries in sports. Research in-

dicates that these injuries can also have serious consequences later in life if not managed properly. In an effort

to combat this injury the following concussion management protocol will be used for SBCUSD student ath-

letes suspected of sustaining a concussion. A concussion occurs when there is a direct or indirect insult to the

brain. As a result, transient impairment of mental functions such as memory, balance/equilibrium, and vision

may occur. It is important to recognize that many sport-related concussions do not result in loss of conscious-

ness and, therefore, all suspected head injuries must be taken seriously. Coaches and fellow teammates can be

helpful in identifying those who may potentially have a concussion, because a concussed athlete may not be

aware of their condition or potentially be trying to hide the injury to stay in the game or practice.

CIF Bylaw 313. Play it Safer A student– athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at the time for the remainder of the day. A student-athlete who has been re-moved from play may not return to play until the athlete is evaluated by a licensed health care provider trained in the evaluation and management of concussion and receives written clearance to return from that health care provider.

San Bernardino City Unified School District

San Bernardino City Unified School District Student-Athlete Concussion Statement

I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or coach.

I have read and understand the CIF/CDC Concussion Fact Sheet.

After reading the CIF/CDC Concussion fact sheet, I am aware of the following information:

Initial each line

A concussion is a brain injury, which I am responsible for reporting to my athletic trainer or

coach.

A concussion can affect my ability to perform everyday activities and affect reaction time,

balance, sleep, and classroom performance.

You cannot see a concussion, but you might notice some of the symptoms right away. Other

symptoms can show up hours or days after the injury.

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

athletic trainer or coach.

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

results in concussion-related symptoms.

Following concussion the brain needs time to heal. You are much more likely to have a repeat

concussion if you return to play before your symptoms resolve themselves.

In rare cases, repeat concussions can cause permanent brain damage and even death.

Signature of Student-Athlete Date Signature of Parent/Guardian Date

Printed Name of Student-Athlete Printed Name of Student-Athlete

4

5

CONSENT FOR STUDENT TO PARTICIPATE AND BE TRANSPORTED TO ACTIVITIES/EVENTS/

TRIPS 2012 -2013 SCHOOL YEAR

Student: Grade: School: Transportation to and/or from events may not always be provided by the District. Parents/guardians are responsible for en-

suring that their student arrives and departs events as noticed. By signing this form you acknowledge that the District as-

sumes no responsibility for transportation of the student to and/or from the event. If you approve of your student's par-

ticipation in school activities/events/trips, so indicate by signing and returning this consent form.

By signing this form you acknowledge that your student may be a passenger in a private car (not driven by a student), and

hereby give my permission for that transportation to take place. I understand that the SAN BERNARDINO CITY UNI-

FIED SCHOOL DISTRICT has on file a School Driver Certification Form from the person providing the transporta-

tion. As stated in California Education Code Section 35330, I understand that I hold the San Bernardino City Unified

School District, its officers, agents and employees, harmless from any and all liability or claims which may arise out

of or in connection with my child's participation in these activities.

Students are expected to conduct themselves in a manner that reflects pride in themselves, their school, and the San Bernar-

dino City Unified School District. The District policies and regulations which govern student’s conduct shall be the guide-

lines for student behavior during these activities/events/trips. Students who violate existing policies and regulations are

subject to disciplinary action upon their return. The policies and regulations, among others, prohibit:

1. Use or possession of alcoholic beverages, narcotics, dangerous drugs, or weapons.

2. Smoking by students on campus or in other areas in which school activities are taking place.

It is important for you to understand that the District does not provide medical insurance for students. You must therefore

provide proof of medical insurance coverage. However, if you do not have medical insurance, low cost student medical in-

surance is available through the school office.

In the event of illness or injury, I do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental

diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon,

or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing

medical or dental services.

Signature of Parent/Guardian Relationship to Student Today's Date

Student’s Signature Date of Birth Today's Date

Address

Home Phone Business Phone

Medical Insurance Carrier Policy No. Phone

A special note to Parent/Guardian: (I) All drugs must be registered on this form; (2) All drugs, except those which must be

kept on the student's person for emergency use, must be kept and distributed by the staff; (3) ( ) Check here if there are

special problems that the staff should be aware of and no drugs are required on the trip; (4) If any medication or drugs are

to be taken by student, list them here: (Name of drug and reason)

San Bernardino City Unified School District 6

7

SAN BERNARDINO CITY UNIFIED SCHOOL DISTRICT

Parent Code of Conduct

Parental Support of our athletic team is vital, and greatly appreciated. In order to provide a posi-

tive climate for coaches and players to do their best, eliminate distractions that might negatively

impact the program, model good sportsmanship, and comply with CIF Rules, we are asking for

your support of the following Parental Code of Conduct.

We Strongly encourage your active, positive support of your child, and look forward to your at-

tendance at the games and other sponsored activities. The concept of sportsmanship, however,

must be taught, modeled and reinforced by adults. The parent/guardians of athletes must main-

tain self control and demonstrate proper perspective as it relates to winning and losing. It is im-

portant to remember that an athletic contest is ONLY A GAME– NOT A MATTER OF LIFE

AND DEATH. Accordingly, we are asking all parent/guardians, and spectators who attend

games to abide by the following:

Please show respect for others by refraining from booing or shouting/ yelling derogatory

comments or remarks from the stands towards our opponents, coaches or officials. Personal

insults or abusive, foul language will not be tolerated. Violations may result in penalties

against the team and ejection of the offender.

Parents shall not confront or seek to conference with coaches or officials during or immedi-

ately after games, except in cases of injuries or emergency medical treatment for their child.

Conferences with the Coach to discuss or critique their game preparation, coaching, strategy,

or the status of other players will not be held. Any conference to discuss your child’s status

must be scheduled with the Coach in advance.

Other forms of behavior that are disruptive to the game or others enjoyment of the game will

not be allowed. This includes, but is not limited to, approaching the bench area while the

game is in progress, or attempting to coach your child or direct other players during games

or practice.

Be supportive of your child's efforts and the efforts of his/her teammates-be encouraging ra-

ther than negative regardless of the outcome of a game.

Parent/Guardian Signature Date Parent/Guardian Signature Date

CAJON COWBOYS CODE OF CONDUCT As an athlete of Cajon High School, I understand that I represent my school and fellow Cowboys on and off the field, in school, and in our community. Furthermore, I agree with the CIF Philosophy that it is a privilege, not a right, to participate in athletics for my school and that my academic achievement is a pri-ority.

Therefore, I agree at all times, I will:

Respect my teammates, opponents, officials, coaches, and spectators.

Respect my classmates, teachers, administrators, and security personnel.

Abide by the rules of my school, team, sport, and CIF.

Make academic achievement a priority; focus on my classes and attendance.

Adhere to the CIF Southern Section Code of Ethics for Athletes.

Refrain from the use of profanity, vulgarity, offensive gestures, and fighting.

Make an effort to attend and be punctual to class, games, practices, and team functions.

Communicate in a timely manner with my coach if I am or will be absent.

Immediately inform my coach/school of any injury to myself and communicate the status of my

injury to my coach on a consistent basis.

Follow the school district’s transportation policy (players may not drive themselves to or from ath-

letic events held off site; they may be transported only by their own parent/guardian with pri-

or permission from the school).

Work hard and have a positive attitude on and off the field.

Respect, properly use, maintain, and return all equipment and school property.

Not use or encourage the use of alcohol, tobacco, illegal substances, steroids, or non-prescriptive

drugs.

Abide by CIF Rule 600: “No Outside Competition” during same season of sport.

Support and follow the guidelines described in the SGHS “Student-Athlete, Parent, and Coach

Communications” pamphlet.

By signing below, I acknowledge that I have read and agree to abide by the Cajon Cowboys Code of Con-duct. I also understand that if I fail to comply with this code of conduct, my team, coach, or school per-sonnel may request that my athletic status be reviewed, and at the discretion of my coach, athletic de-partment, and/or school administration, I may be suspended or removed from athletics for up to one year depending upon the infraction. _____________________________ _______________________________ __________ Student Name (printed) Student Signature Date

8

San Bernardino City Unified School District

Waiver of Liability, Assumption of Risk, and Indemnity Agreement & Drug Test Authorization Form

Name of Student: Address:

Grade: DOB: Telephone:

School: Activity/Sport:

(Parent/Guardian Initial each Box) Waiver: In consideration of being permitted to voluntarily

Student Name

participate in the above named Activity/Sport/Club/Program hereinafter called “ The Activity.”

I, for myself, my child , heirs, personal representatives, or assigns, do hereby release, agree to

hold harmless, waiver any claim against, discharge from liability, and covenant not to sue the San Bernardino City Uni-

fied School District, its officers, employees, volunteers, and agents for liability from any and all claims including the negligence of

the San Bernardino City Unified School District its officers, employees, and agents, with respect to any and all personal injury, acci-

dents, illnesses (including death or catastrophic injury), or property loss or property damage arising from, but not limited to, partici-

pation in The Activity.

Assumption of Risks: Participation in The Activity carries with it certain inherent risks of injury that cannot be eliminated

regardless of the care taken to avoid injuries. The specific risks of injury vary from one activity to another, but may range from

and include, but not limited to: 1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury or loss

of sight, joint or back injuries, heart attacks, and concussions; 3) catastrophic injuries including paralysis and death.

Indemnification and Hold Harmless: I also agree to INDEMNITY AND HOLD the San Bernardino City Unified school

District HARMLESS from any and all claims, actions, suits, procedures, cost expenses, damages and liabilities, including attor-

ney’s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred in defense of

such claims or actions.

Severability: the undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intend-

ed to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held inva-

lid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

The Activity: I hereby acknowledge that The Activity includes participation in the activity set forth above, as well as any

preparatory activities associated therewith, such as setting up materials or equipment, breaking down equipment or materials,

practices, tryouts, training, conditioning, and travel to and from events associated with The Activity.

Acknowledgement of Understanding: I have read this waiver of liability, assumption of risks, and indemnity agreement, fully under-

stand its terms, and understand that I am giving up substantial rights , including my right to sue. I acknowledge that I am signing the

agreement freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the extent

allowed by law. I have explained this agreement to the student, who understands his/her obligations.

Signature of Parent/Guardian of Minor Date

As the student/participant, I understand and agree to all of the obligations placed on me by this Agreement.

Signature of Student/Participant Date Student/Participant’s Age (if minor)

The San Bernardino City Unified School District’s high schools have a tradition of athletic excellence. Our student athletes represent

a source of pride to their schools, their families and the community. The first priority of the school district in supporting student ath-

letes is to ensure their safety. Athletes who abide by the standards, rules and policies of the San Bernardino City Unified School Dis-

trict demonstrate positive attitudes and promote good citizenship on and off campus, support fellow team members, are drug free,

and are committed to their academic studies. In order to preserve the safety of all athletes, each student athlete and his/her parent/guardian must sign a Drug Authorization Form

to participate in a high school athletic sport. We have read and support the San Bernardino City Unified School Districts rules and policies for student athletes. We authorize the San Bernardino City Unified School District to conduct tests on urine specimens provided by the student athlete to

determine drug use. We also authorize the release of information concerning the results of the test to the San Bernardino City Uni-

fied School District and to the parent/guardian of the student.

Pursuant to the Family Education Right to Privacy Act, our signature authorizes the release of drug test results to the parties named

above. Student Signature Parent/Guardian Signature (required if student is under 18 years) Street Address (city) (state) (zip) Date

9

10 GENERAL RELEASE

For Community Access Cablevision,

Photographs, Videotaping, Interview Comments, and Posting on the Internet TO: Parents FROM: Principal's Office Occasionally, the District and organizations/associations connected with the District would like to use the name, photograph(s), video recording, and/or interview comments of students for educational and promotional purposes, including District-generated news articles and brochures. Such images and comments are used for news purposes only and not for comer-cial use. As part of each school's parent/community informational program, a school may wish to place students' pictures and/or names on the Internet or the school's web page. All photography, video recording, student comments, and posting on the Internet is done by legitimate news media personnel or School District personnel. In order to use such material, parental consent is necessary for any student under 18 years of age.

General Release Please fill out this form and return to your school

Please indicate below if you give permission for your child's name, image, or comments to be used: In District brochures and press releases (press releases and accompanying photos may be published by local, state, or national media) YES NO District-sponsored Internet site/web page YES NO Student Name:____________________________________

School:_________________________________________

Grade:__________________________________________

Parent/Guardian Signature: _________________________

Date:___________________________________________

SAN BERNARDINO CITY UNIFIED SCHOOL DISTRICT SU-267 (Rev. l/06)

Cajon Uniform and Equipment Agreement 11

As a participant for Cajon High School, I assume the responsibility for all of the equipment required to

participate in my sport.

I hereby understand that if I am removed from the team for any reason I will turn my equipment in

coach of the team that I am on. I will not leave it in a locker or give to anyone other than the Coach. I

will not loan my equipment to anyone. I will receive my equipment card back as a receipt for returning

my uniform and/or equipment.

Here is a list of some of the equipment and/or uniforms and the replacement costs. (If your equipment

is not listed below, you are still responsible for the cost of replacement):

Football:

Riddell Revolution Helmet $225.00 Biolite Vent Air Body/Girdle Pads $15.00

Chin Strap $15.00 Polyester Girdle Shell $20.00

Shoulder Pads $165.00 Practice Pants $30.00

Knee Pads (Pair) $10.00 Practice Jersey $20.00

Thigh Pads (Pair) $15.00 Game Jersey $100.00

Belt $5.00 Game Pants $100.00

If all items are not returned, you could be charged in accordance with the table above. All items total $720. Possible items not included above: Back Plates $80.00, Mouth Pieces $1.00, Rib

Vest $35.00.

Other Sports:

Cross Country Top $25.00 Cross Country Shorts $25.00

Basketball Practice Uniform $80.00 Basketball Uniform $100.00 Minimum

Soccer Uniform $100.00 minimum Track Uniform $70.00

Girls’ Tennis Uniform $100.00 Boys Tennis Uniform $50.00

Volleyball Uniform $50.00 Volleyball Knee Pads $25.00

Water Polo Caps $25.00 Water Polo/Swim Parkas $150.00

Wrestling Singlet $80.00 Wrestling Headgear $40.00

I understand that I am responsible for any charges that occur for not following the above

procedures.

________________________________ ________________________________________

Athlete Signature Date Parent Signature Date

COWBOYS… BUY YOUR ASB CARD!!!

SAVE $$$... SUPPORT ATHLETICS… SHOW SCHOOL SPIRIT The past 7 years, it has not been mandatory for athletes to purchase an ASB card or pay for transportation in order to participate in sports… thus, there has been a decrease of approximately $200,000 in ASB funds… so we need everyone’s help!!! PLEASE BUY YOUR ASB CARD!!! So what do you get for your $30 ASB Card?

FREE admission to all regular season home games (including football, basketball, and wrestling… except tournaments)… up to $50 in savings

FREE admission to all CBL games, home or away, except league finals… discounts at most away pre-season games … over $50 in additional savings

Discounts and/or FREE admission to Cajon dances including football homecoming and winter formal, prom… over $50 in additional savings

FREE athletic awards including letters, patches, medals… quite possibly another $50 or more (please see

pricing of athletic awards below for students who do not purchase an ASB Card) As well as additional ASB promotional savings throughout the school year

That’s a savings of approximately $250 or more if you buy your ASB Card!!!

Below is the approximate cost per item if you choose to not purchase an ASB card and still wish to receive the athletic award: Green or Gold Letter “C” $10.00 Team Patches $13.00 Individual Awards $13.00 CIF Playoffs (team quarterfinals or better) $13.00 Multiple Sports Letterman Patch $10.00 Scholar Athlete Patch (Fr, So, Jr, and Sr) $10.00 All-CBL Individual Patch Paid by CBL

Thank you for everyone’s support and efforts in making Cajon High School the best school in CIF. We can only maintain our suc-cess and programs if we work together! Please consider purchasing an ASB card early so that you may take advantage of all of the savings listed above! We are looking forward to another championship year for the Cowboys… so don’t miss out! Buy your ASB Card and we will see you at the games! Thanks again and GO COWBOYS! Sincerely, Richard Imbriani Athletic Director

12

ATHLETE’S NAME ( PRINT )___________________________________

CAJON HIGH SCHOOL PARENT ATHLETE CONTRACT

ATHLETE'S RESPONSIBILITIES

1. Maintain eligibility according to CIF-SS and District standards for the season of sport. Each athlete shall be enrolled in a minimum of four classes, accumulate 20 credits the proceeding quarter, and maintain a

2.0 GPA with four passing classes.

2. Athletes must have a physical packet completed before you tryout for a sport. The packet includes a

physical form, athlete responsibility form, consent to participate form, code of ethics form, transportation form and proof of insurance form. These forms must be completed, signed, and returned to the Coach.

Athletes who are playing more than one sport must get cleared for each sport that they participate in.

3. Upon making the team you must obtain a clearance card from the Athletic Director’s office. An equipment

card will be issued after all charges that you may have incurred, (lost books, lab fees, etc.), have been cleared. Purchasing an ASB card is highly recommended. Cajon accepts CASH OR MONEY ORDERS

ONLY and you must bring your school identification. (Before school and at lunch only.)

4. Be responsible for all equipment checked out to you for your sport. The loss of equipment, which has

been issued to you, must be replaced or paid for. Equipment must be returned within one week after the athlete has finished the season of sport or pay for it. A $1.00 per day fee will be charged for

uniforms and equipment not turned in on time. Each athlete is responsible for returning his/her own uniform and /or equipment to the Equipment Attendant or their respective coaches. When the ath-

lete returns the uniform and/or equipment , they will receive their equipment card back as a receipt.

5. Maintain good classroom attendance. The athlete must attend school on game days or he/she may not

play in the game or contest.

6. Attend all practice sessions. If you miss a practice, you are to notify your Coach prior to the missed prac-

tice, if at all possible.

7. Conduct yourself in a proper manner whenever playing or representing your team. Uniforms are to be worn in the correct manner, (ex: shorts at the waist not pulled down). Uniforms will be worn only by the

person who checked them out.

8. Report any and all injuries to your coach immediately or as soon as possible.

9. Athletes must use the transportation provided for the team unless special permission is requested by the

parent for emergency reasons only. Requests will be made to the Athletic Director in writing prior to the event.

I have read and fully understand the above responsibilities. I realize that failure to comply with any of these

responsibilities and eligibility qualification can result in immediate action by the Coach, Athletic Director, or Administrator.

_______________________________ ______________________________________

Athlete’s Signature Date Parent/Guardians Signature Date

13

Preparticipation Physical Questionnaire

History Must be completed by Parent/Guardian before examination to the best of your knowledge

HISTORY (Complete before submitting to the doctor)

Explain “YES” answers in the space provided. Circle questions you don’t know the answer to.

1. Has a doctor ever denied or restricted your participation in sports for any reason.

2. Do you have an ongoing medical condition (like diabetes or asthma?

3. Are you currently taking any prescription or nonprescription (Over-the-counter) medicines or pills?

4. Do you have allergies to medicines, pollens, foods, or stinging insects?

5. Do you think you are in good health? 6. Have you ever passed out or nearly passed out DURING exercise?

7. Have you ever passed out or nearly passed out AFTER exercise?

8. Have you ever had discomfort, pain, or pressure in your chest during exercise?

9. Does your heart race or skip beats during exercise?

10. Has a doctor ever told you that you have (check all that apply)

High Blood Pressure A heart infection

High Cholesterol A heart murmur

11. Has a doctor ever ordered a test for your heart? (example, ECG, echocar-diagram)

12. Has anyone in your family died for no apparent reason?

13. Does anyone in your family have a heart problem? 14. Has any family member or relative died of heart problems or sudden

death before age 50?

15. Have you ever spent the night in a hospital for yourself? 16. Have you ever had surgery?

17. Have you ever had an injury, like a sprain, muscle or ligament tear, or

tendinitis that caused you to miss a practice or game? If yes, circle be-low:

18. Have you ever had any broken or fractured bones or dislocated joints? If yes, circle below

19. Have you had a bone or joint injury that required x-rays, MRI, CT, sur-

gery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? If yes, circle below:

20. Have you ever had a stress fracture?

21. Have you been told that you have or have you had an x-ray for

atlantoaxial (neck) instability? 22. Has a doctor ever told you have asthma or allergies?

Head Neck Shoulder Upper Arm Elbow

Forearm Chest Upper back Lower back Hip

Thigh Knee Calf/Shin Ankle Foot/Toes

*****This student has family insurance Yes No

If yes, medical insurance company name and policy number

Note: History and all consent forms must be completed prior to physical examination

I (we) hereby state, to the best of my (our) knowledge, my (our) answers to the above questions are complete and correct.

Athlete Signature: Parent/Guardian Signature: Date

23. Do you cough, wheeze, or have difficulty breathing during or after exer-cise?

24. Is there anyone in your family who has asthma?

25. Have you ever used an inhaler or taken asthma medicine? 26. Were you born without or are you missing a kidney, an eye, a testicle, or

any other organ?

27. Have you ever had a head injury or concussion? 28. Have you been hit in the head and been confused or lost your memory?

29. Have you ever had a seizure?

30. Do you have headaches with exercise? 31. Have you ever had numbness, tingling, or weakness in your arms or legs

after being hit or falling?

32. Have you ever been unable to move your arms or legs after being hit or

falling?

33. When exercising in the heat do you have severe muscle cramps or become

ill? 34. Has a doctor told you that you or someone in your family has sickle cell

trait or sickle cell disease?

35. Do you wear glasses or contacts? 36. Do you have concerns that you would like to discuss with a doctor?

37. Record the dates of your most recent immunizations (shots)

Tdap_______________ “Booster” Shot for tetanus_______________

Hepatitis B__________________ Measles

FEMALES ONLY

38. The date of your last menstrual period? ________________ 39. How old were you when you had your first menstrual period?

Explain “Yes” Answers Here: (Attach additional sheets as needed)

Yes No

I hereby give my permission for my son/daughter to participate in competitive athletics and go with a representative of

the school on any trips. In case this pupil is injured, you are authorized to have him/her treated. I will assume the finan-

cial responsibility.

Parent/Guardian Signature

Name Sex Age Date of Birth

Grade School Sport(s)

Address

Personal Physician In case of emergency, contact

Name Relationship Phone (H) (W)

This section is to be carefully completed by the student and his/her parent (s) or legal guardian (s) before participation in interscholastic athletics in

order to help detect possible risks.

Yes No

14

15 PHYSICAL EXAMINATION FORM

Name Date of Birth

Height Weight % Body fat (optional) Pulse

BP / ( / , / ) Vision R 20/ L 20/ Corrected Y N

Pupils: Equal Unequal

MEDICAL Normal Abnormal Findings

Appearance

Eyes/Ears/Nose/Throat

Hearing

Lymph Nodes

Heart

Murmurs

Pulses

Lungs

Abdomen

Genitalia (males only)

Skin

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/Forearm

Wrist/hand/fingers

Hip/Thigh

Knee

Leg/Ankle

Foot/Toes

PHYSICIAN CLEARANCE

Name of Physician (print) Date

Address Phone

Signature of Physician , MD, DC or DO

Medical License No. or Stamp

Cleared for Athletic Participation YES NO (IF NO FILL-OUT BELOW)

Cleared after completing evaluation/rehabilitation for:

Not cleared for: Reasons:

SAN BERNARDINO CITY UNIFIED SCHOOL DISTRICT

2014-2015 INTERSCHOLASTIC ATHLETIC INSURANCE COVERAGE CERTIFICATION 16 Dear Parent or Guardian: Before your son or daughter is eligible to participate in interscholastic athletics, insurance coverage for medical, hospital, and dental expenses resulting from accidental bodily injury in an amount of at least $1,500.00 for all services is required according to the Education Code Sections 32220 and 32221 and must be obtained by you for the student who expects to participate. Please read carefully the following affidavit, and if, and only if, you presently have the required coverage for your child, sign the affidavit.

AFFIDAVIT I, _______________________________________________________________________________________, parent or guardian (Name of Parent or Guardian) of ____________________________________________________________________, do hereby declare that he/she is insured (Name of Student) in accordance with Education Code Sections 32220 and 32221, through:

MY OWN INSURANCE: ________________________________________________________

(Health Insurance Company Name - $1500.00 Minimum)

I WISH TO PURCHASE: (indicate with check mark and get brochure from the Athletic Director):

1. MYERS-STEVENS & TOOHEY & CO., Athletic Coverage

(Coverage in season of sport only. Please send the brochure with payment to the school and make checks payable to Myers-Stevens and Toohey & Co., Inc.) Interscholastic tackle football PLEASE CHECK Low Option………………………………………………………………………………………………….. $235.00 □

Mid Option………………………………………………………………………………………………..…. $295.00 □ High Option………………………………………………………………………………………………….. $339.00 □ All Sports except tackle football (see #2 below)

2. MYERS-STEVENS & TOOHEY & CO., Inc. – Student Accident Insurance (Includes regular student accident medical/hospital/dental benefits for all sports, except does not provide coverage for tackle football, for grades 9 through 12. Please send the with payment to the school and make check payable to Myers-Stevens and Toohey & Co., Inc.) 7th through 12 grades School Time 24-Hour Low Option $53.00 □ $225.00 □ Mid Option $68.00 □ $276.00 □ High Option $79.00 □ $328.00 □ Dental $24.00 □ I understand that the aforesaid law requires that the above coverage apply to members of athletic teams and non-competitors who preform duties in connection with inter-school athletic events while such persons are engaged in or preparing for an athletic event promoted under the sponsorship or arrangement of the school district or student body association to or from or other place of instruction and the place of the athletic event. I declare that I will maintain this insurance and will notify, in writing, the principal of the appropriate school immediately if the policy is canceled or is in default. I declare under penalty of perjury the foregoing is true and correct.

_________________________________________ __________________

(Signature of Parent or Guardian) (Date)

OR