Luling Independent School District
Gerdes High School Cheerleading Handbook 2016-2017
Table of Contents PURPOSE .....................................................................................................................................................................4 ORGANIZATION ..........................................................................................................................................................4 CHEERLEADING YEAR..................................................................................................................................................4 UIL & TEA ....................................................................................................................................................................4 TRYOUT – ELIGIBILITY & REQUIREMENTS ..................................................................................................................4 COMMITMENT............................................................................................................................................................5 TRYOUT GUIDELINES ..................................................................................................................................................5 SQUAD MAKEUP .........................................................................................................................................................5 JUDGES .......................................................................................................................................................................5 CLOSED TRYOUTS .......................................................................................................................................................5 JUDGING GUIDELINES.................................................................................................................................................6 TRYOUT PROCEDURES ................................................................................................................................................6 Tryout Practices/Clinic ............................................................................................................................................6 JUDGE’S PANEL TRYOUTS .......................................................................................................................................6 INJURY & USE OF VIDEO .............................................................................................................................................6 FINAL DETERMINATION & NOTIFICATION ..................................................................................................................6 MEDICAL .....................................................................................................................................................................6 CHARACTER ................................................................................................................................................................6 ATTENDANCE ..............................................................................................................................................................7 CHEERING ACTIVITIES .................................................................................................................................................7 CAMP ..........................................................................................................................................................................7 UNIFORMS & APPEARANCE........................................................................................................................................8 PRACTICE ....................................................................................................................................................................8 Appearance at Practice ..........................................................................................................................................8 PEP RALLIES AND HALL RALLIES..................................................................................................................................9 GAMES ........................................................................................................................................................................9 AT THE END OF THE GAMES .......................................................................................................................................9 SPIRIT STICKS AND SIGNS ...........................................................................................................................................9 FUNDRAISING .......................................................................................................................................................... 10 HEAD CHEERLEADER ................................................................................................................................................ 10 Selection of Head Cheerleader(s) ........................................................................................................................ 10 Duties and Responsibilities of Head Cheerleader(s) ........................................................................................... 10 MASCOT ................................................................................................................................................................... 10 REPLACEMENT OF SQUAD MEMBERS ..................................................................................................................... 10 ELGIBILITY – MAINTENANCE.................................................................................................................................... 11
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LETTERING OF VARSITY SQUAD MEMBERS ............................................................................................................. 11 CONDUCT GUIDELINES ............................................................................................................................................ 11 EXTRACURRICULAR STANDARDS OF BEHAVIOR ...................................................................................................... 11 CHEER STANDARDS OF BEHAVIOR .......................................................................................................................... 12 Major Infraction................................................................................................................................................... 14 Minor Infraction .................................................................................................................................................. 14 PERMANENT DISMISSAL .......................................................................................................................................... 14 INCLEMENT WEATHER............................................................................................................................................. 14 TRANSPORTATION & TRAVEL .................................................................................................................................. 14 FINANCIAL RESPONSIBILITY ..................................................................................................................................... 15 CIVILITY .................................................................................................................................................................... 15 FEMALE CHEER EVALUATION .................................................................................................................................. 16 MALE CHEER EVALUATION ...................................................................................................................................... 17 MASCOT EVALUATION............................................................................................................................................. 18 Cheerleading Handbook Parent/Student Acknowledgement ................................................................................. 19 Medical Release Form ............................................................................................................................................. 20 Inherent Risk Form .................................................................................................................................................. 21 Parental Information and Consent Form for Concussions ...................................................................................... 22 Parental Release Form............................................................................................................................................. 24 Extracurricular Standards of Behavior Contract ...................................................................................................... 25 Preparticipation Physical Evaluation—Medical History .......................................................................................... 26 Preparticipation Physical Evaluation—Physical Examination ................................................................................. 27 Medication Request Form………………………………………………………………………………………….……………………………29
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PURPOSE Cheerleaders and mascots are student leaders who exemplify and promote school spirit, pride, and sportsmanship. Cheerleaders enhance a positive school climate by exhibiting leadership skills, such as respect for individual differences, building consensus, academic excellence, and modeling appropriate behaviors at all times, both in and away from school. Cheerleaders are expected to be mentally and physically fit and athletically skilled in the field of cheerleading. They are first and foremost representatives of their school. Because of these responsibilities, members of the cheerleading squad will be expected to maintain a higher standard of behavior both on and off campus than that of their peers. In or out of uniform, cheerleaders are representatives of the cheerleading squad and the school. As leaders, cheerleaders and mascots are expected to set good examples and demonstrate high moral standards for other students. Respect for the school, other members of the squad, and the coach(es) and his/her authority will be maintained at all times. ORGANIZATION This handbook has been written and adopted for the Gerdes Junior High School Cheerleaders. Gerdes Junior High School and the Gerdes Junior High School Cheerleaders govern the squad and its handbook. The purpose of Gerdes Junior High School Cheerleading is to: o Create school spirit, pride, and loyalty. o Promote interest in school activities and perform at school games. o Develop responsibility, teach self-respect, encourage honest effort, strive for perfection and develop character. o Teach teamwork and pride in a quality performance through maintaining high standards. The coach(es) will be hired by the Luling Independent School District upon recommendation of the Principal. Coach(es) will be responsible for the daily running and activities of the Gerdes Junior High School Cheerleaders. Coach(es) will be responsible for administering all disciplinary procedures. Coach(es) may place certain restrictions on squad members. CHEERLEADING YEAR The rules and procedures outlined in these guidelines are in effect from the time the student is selected to the cheerleading squad until the next tryout date. UIL & TEA It is the practice of Luling Independent School District to utilize the University Interscholastic League (UIL) guidelines to regulate and govern the cheerleading program with regard to no pass/no play, eight-hour practice limitations, athletic periods, and all other applicable regulations. The cheerleading program will follow the eligibility requirements as outlined by TEA and UIL. TRYOUT – ELIGIBILITY & REQUIREMENTS A student must be enrolled in Luling ISD and be in attendance by the first day of the second semester. A student must be UIL eligible in order to tryout. A student must meet state guidelines for compulsory attendance. A student must have no outstanding balance for prior year financial obligations. A student must have never received deferred adjudication and/or a conviction for a Class B misdemeanor or higher-class crime conviction. Students who have been expelled or sent to DAEP on mandatory placements during the current school year are ineligible to tryout.
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A student is not eligible who has resigned or been dismissed from a cheerleading squad in the previous year. However, if he/she resigns due to circumstances out of his/her control, the coach(es) will determine whether he/she may be considered for tryouts the following year.
COMMITMENT Candidates selected to be a member of the cheerleading squad are expected to make a commitment to the activity for the full cheerleading year. Any cheerleader who voluntarily quits the squad before the end of the cheerleading year will not be allowed to tryout for the next year on any LISD campus. TRYOUT GUIDELINES Procedures for cheerleader selection are based on the guidelines in this handbook. Parents will not be allowed in the building during any phase of the tryouts. Candidates and parents must attend an orientation meeting scheduled by the cheer coach(es). Candidates must wear a white T-Shirt (no midriff), black Soffee shorts, white socks, and white bow. Hair shall be worn up and out of the face. The mascot candidates will be required to do a 1.5 minute routine using props, signs, etc. The mascot will keep the Eagle head on at all times. Since the mascot is part of the Varsity traveling squad, they are required to be an incoming 10th through 12th grader. Candidates and parents must sign a form stating that they understand and will comply with all information in the packet and in this handbook prior to the student being allowed to participate in the tryout process. The following forms must be signed and turned in to the coach(es) before Mock Tryouts: Cheerleading Handbook Parent/Student Acknowledgement Medical Release Form Inherent Risk Form Parental Information and Consent Form for Concussion Parental Release Form Extracurricular Standards of Behavior Contract Participation Physical Evaluation—Medical History Participation Physical Evaluation—Physical Examination Medication Request Form SQUAD MAKEUP The squad will be made up of up to 12 cheerleaders. A minimum of one mascot will be determined by tryouts. JUDGES Judges will be selected from UCA. Judges should not be hired if they have tutored or taught the cheerleader candidates during the current school year. It is best practices to hire judges who have not worked with students in the Luling area; however, with the hundreds of camps in the state of Texas, attended by thousands of cheerleaders and taught by hundreds of instructors, it may be possible at some time that a member of the judging panel may have had some contact with a candidate. CLOSED TRYOUTS Tryouts are closed to everyone except judges, principals, cheer coach(es). There will be no students, parents, or existing cheerleaders in the tryout areas, nor will they be involved in the collection or tabulation of scores. No parents are allowed in the gym during tryouts. Students and coach(es) may not utilize electronic devices or texting during tryouts. Any deviation from the tryout requirements by the candidates may result in the disqualification of the candidate.
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Any student who arrives at the tryout site after tryouts have started will not be allowed to try out. JUDGING GUIDELINES
Judges alone will elect candidates. There will be up to 3 independent UCA judges. Judges are referred to Luling ISD through UCA. Each judge is given a complete rating sheet (see attachment).
TRYOUT PROCEDURES Tryout Practices/Clinic (See attached sheet for practice dates and times) Mandatory Parent Meeting Practices Mock Tryout Tryouts JUDGE’S PANEL TRYOUTS
The candidates will try out in their groups of 3 to 4 for the following required elements: cheer, chant, and dance. Candidates will individually be required to do three jumps to demonstrate versatility/technique. Candidates will also be required to perform some sort of entrance individually that may include tumbling, limited spiriting, a jump, etc. Please keep the entrance brief (no chants).
INJURY & USE OF VIDEO A candidate for the cheerleading squad may show a video of his/her performance for the judges only if he/she is incapable of required physical activity. Coach(es) must receive a doctor’s note the day after the injury stating the reason(s) for the inability to tryout. The medical doctor’s note must indicate the specific skill the student is incapable of performing as well as any limitations associated with the injury. The video to be shown must be approved by the coach(es) and should be no more than three to six months old. The final determination of eligibility to tryout using a video will be at the coach(es) discretion. The video will be judged using the same criteria as outlined in this handbook. FINAL DETERMINATION & NOTIFICATION Candidates will receive notification of results on the day of tryouts. Election results will be posted on the outside doors of the Luling High School gym. The results will be posted after school. Cheer candidates may request their scores through the cheer coach(es). By law, all other student scores are protected and cannot be shared. Rank scores will not be shared. Original judges’ score sheets will not be released to parents or students. Judges written comments will be shared with each candidate individually. All records and scores will be purged prior to the next year’s tryouts. MEDICAL Members must have a physical exam on file with the trainer’s office in compliance with the Luling Independent School District’s policy regarding athletes. Members must have a completed medical emergency form on file with the squad coach(es).
CHARACTER Members should be leaders within the school and set a good example at all times. Members should maintain good personal appearance and habits.
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Members must abide by the Student Code of Conduct adopted by the Luling Independent School District and the Luling ISD Athletic Code. Members must be courteous and friendly to other squad members as well as members of the student body and faculty. Members must be courteous and friendly to other teams, visitors, and officials of sporting events.
ATTENDANCE Members who participate in extracurricular events must not have an unexcused absence from school the day of the event. Members are expected to be in attendance and participate in all scheduled practice sessions and fundraising events. Members who fail to live up to their duties are subject to disciplinary action. Students must be present at least one-half of the school day to participate in an activity. Excused absences—Illness or a family emergency will be considered an excused absence provided that the coach(es) are contacted prior to the absence by the cheerleader/mascot or a parent and appropriate documentation is provided. Unexcused absence—An unexcused absence is missing a meeting, practice, or game for any reason when the coaches have not been contacted by the cheerleader/mascot or a parent prior to the absence. If a cheerleader has an unexcused absence from a practice, meeting, or game she will be assigned a consequence as explained in the Cheer Standards of Behavior. Any cheerleader who is not present when practice begins will have a consequence at the discretion of the coach(es). Cheerleaders may not leave a practice or any other cheer related activity at any time unless approved by the coach(es). o Any absence must have the prior approval of the coach(es) o Prior notification of conflicts with school activities will be addressed with the coach(es) and, when appropriate, the principal. o Work is not considered an excuse for an absence. CHEERING ACTIVITIES All cheerleaders and mascot will be expected to attend all practices set up by the coach(es). Cheerleading practices and performances are under the umbrella of UIL time limit restrictions. Special practices may be called by the coach(es) when necessary. However, due to UIL procedures, the eight-hour limit will apply to practice held outside of the school day.Participation in other sports events, community activities, and social occasions will be at the discretion of the coach(es).
Cheer at football, volleyball and basketball games Students must be present at least one-half of the school day to participate in an activity. Cheerleaders may not leave a practice or any other cheer related activity at any time unless approved by the coach(es). Any absence must have the prior approval of the coach(es). Prior notification of conflicts with school activities will be addressed with the coach(es). Work is not considered an excuse for an absence.
CAMP Members are required to attend a professionally conducted camp chosen by, and arranged for, by the advisor each year. Members will be accompanied by the coach(es) to camp and all camp-related activities. Transportation to and from camp will be provided for campers through arrangements made by the advisor and approved by the principal. There will be a mandatory bag check of all cheerleader belongings before departing for camp.
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The week prior to camp we will hold daily practices to prepare for stunting and camp competitions.
UNIFORMS & APPEARANCE All uniform and practice attire is approved by the coach(es). While performing, each member is expected to:
Wear proper attire as directed. The uniform is worn to official functions only, and a member may perform only if he/she is in the complete required uniform. If the cheerleader or mascot is not in proper uniform (including, but not limited to, secured hairstyle, ribbons, sweatshirts, cold weather attire), he/she will not perform. Appropriate clothing for practice is expected. Keep uniforms clean, pressed, and mended at all times. Reflect grooming standards as directed by the coach(es), including, but not limited to: o Makeup that is natural and wholesome looking o Secured hairstyle with ribbons o Approved briefs only o Cheer shoes o No jewelry, including body piercing o No visible tattoos o No gum chewing or candy The coach has final approval on all apparel deemed to be cheerleader attire: game and pep rally uniforms, camp wear, and special theme day attire. Members will be responsible for maintaining their uniforms in an appropriate manner in order to ensure good grooming. Members will be responsible for adhering to the uniform guidelines as set by the advisor and squad members. The mascot is responsible for properly maintaining care and control of the mascot suit. The mascot suit may not be loaned to others for any purpose since replacement costs are so high. Cheerleaders need to be sure the cheer bag contains necessary uniform pieces, bows, and weather gear for the week. Be prepared.
PRACTICE Practice is intended to be practice. Members should be dressed out in a manner that allows them to run, stretch, tumble, build, cheer, and dance. All members should have the appropriate shoes on. Members will warm-up together prior to the start time of practice. Bathroom, food, and drink breaks should be before and after practice. Do not waste the time of others with your breaks. Horseplay and talking should be at a minimum. Practices may be either open or closed. The coach(es) will inform the squad on their decision for each practice. Not Participating—Any cheerleader not participating fully during practice, unless ill or injured (must have doctor note), will be given a consequence deemed appropriate by the coach(es). Persistent problems during practice will result in a consequence deemed appropriate at the discretion of the coach(es). Squad members are expected to be respectful to captains, coaches, and other squad members at all times. If a cheer coach is not present, cheerleaders are not permitted to stunt. Restrictions placed on participant by a health care professional for physical conditions, which might endanger the health of the participant, may require activities to be limited by the coach(es). For the restrictions to be lifted, the participant must bring a written release from the health care professional. Appearance at Practice Appropriate attire must be worn at practice (no t-shirts with sleeves cut out). Cheer shoes Hair secured No cut-off T-Shirts No jewelry
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No gum or candy
PEP RALLIES AND HALL RALLIES Members are expected to be on time set by the coach(es), dressed out in the appropriate attire, and stretched/warmed up. If members are not dressed for the theme during the pep rally or school day, or are late to the pep rally, members will receive consequence at the discretion of the coach(es). If members are not dressed in uniform and on time to set up for the pep rally, members will receive consequence at the discretion of the coach(es). GAMES Bathroom breaks before the game, at half time, and after the game, no exceptions. The squad is expected to be actively cheering at all times during the game. Food and drink breaks will be before the game, at half time, and after the game. The squad is expected to be actively cheering at all times during the game. Squad members are allowed to have water on the sidelines for quick sips between cheers and stunts. No food is allowed on the field at any time--gum and candies are included. Not Participating—Any cheerleader not participating fully during performances, unless ill or injured, will be pulled from the sidelines to sit with the coach(es) for one quarter of the game. During half time, cheerleaders should take their breaks in a uniform manner, and act in a socially appropriate way. Before the game members should stand at attention during the school song of our team and the school song of the opposing team. Likewise, the squad should remain at attention, hands to themselves, and quiet during the national anthem and moment of silence. At all times, squad members should handle themselves in a socially appropriate manner. Do not stretch or goof around in a way that can be deemed “tacky” and “unclassy.” This includes dance moves that are not part of an approved dance. Hatefulness and bad behavior towards the band, other schoolmates, or the general crowd will not be permitted. No cell phone use is permitted while cheering. Cell phones will be collected before events by coaches and returned after event is completed. Any squad members who fail to comply with the above expectations be given a consequence deemed appropriate by the coach(es). If a cheer coach is not present, cheerleaders are not permitted to stunt. Restrictions placed on participant by a health care professional for physical conditions, which might endanger the health of the participant, may require activities to be limited by the coach(es). For the restrictions to be lifted, the participant must bring a written release from the health care professional. AT THE END OF THE GAMES Each member will verbally check with the coach(es) that they have completed their responsibilities and are allowed to leave the field. Failure to check out with the coach(es) will result in extra duties/consequence at the discretion of the coach(es). Coaches will signal squad members when it is time to leave the field at the end of each game. At that time, members are expected to load all gear and meet in a timely manner. Anyone who does not help unload and load will be assigned consequences deemed appropriate by the coach(es). SPIRIT STICKS AND SIGNS If a squad member has been appointed to keep up with supplies or create supplies such as signs or spirit sticks, the member is expected to do it! If a member forgets supplies, that member will have to recover or replace the supplies within five days and be assigned a consequence at the discretion of the coach(es).
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FUNDRAISING Each cheerleader and the mascot shall participate in fundraising activities. Fundraising activities must support the goals of the squad. Fundraising will be coordinated by the coach(es), and/or Booster Club officers, approved by the building principal. Coach(es) are required to keep a detailed account of income and expenditures of student money, with all transactions processed through a campus activity account. If cheerleader does not meet the minimum requirement for fundraising, extra financial responsibility is required. HEAD CHEERLEADER There are head cheerleader(s) for both Varsity and JV squads. Selection of Head Cheerleader(s)
All cheerleaders interested in trying out for head cheerleader will submit an application to coaches. Team members will then vote on applicants. Votes and application will then determine selection of head cheerleader.
Duties and Responsibilities of Head Cheerleader(s) Squad leader(s) will take a leadership role in the day-to-day activities of the squad with prior approval of the coach(es). Communicates information to squad members regarding upcoming activities, such as uniform requirements and practice schedules. Teaches and starts all cheers and routines for camp, pep rallies, and games. Consults with the coach(es) in planning all pep rallies. Organizes the creation, placement, and removal signs, including locker signs, throughout the school and stadium. Carries out all other duties assigned by the coach(es). Head cheerleaders may be removed from the position for conduct that occurs on or off campus that is detrimental to the school or squad as determined by the coach(es). MASCOT There will be one mascot. The mascot is a member of the varsity squad and an integral part of the spirit program at the school. His/her main responsibilities are to provide interaction with the crowd at all functions by incorporating them in cheers and skits and to work closely with all organizations to enhance the spirit of the school. The mascot will follow all cheer guidelines. Additional responsibilities include: Work closely with the athletic department and cheer coach(es) to foster school spirit Be familiar with game rules to make appropriate responses with the crowd at sporting events Create skits with appropriate themes to foster spirit, in conjunction with the cheerleaders Dress in creative attire, when appropriate, with coach(es) approval REPLACEMENT OF SQUAD MEMBERS Should a member resign from or be removed from the squad before the squad attends camp, the member will be replaced by the alternate. Should a member resign from or be removed from the squad after the squad attends camp, the member will not be replaced. Should a member resign or be removed from the squad, the member will NOT be allowed to try out for future LISD Cheerleading Squads.
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ELGIBILITY – MAINTENANCE The Cheerleading program will follow the eligibility requirements as outlined by TEA, UIL, and the Luling ISD Athletic Code. Any 8th grade student who is selected for cheerleader and is subsequently not promoted to the next grade level will automatically be removed from the squad. Any deposits made up to the time of removal will not be refunded. LETTERING OF VARSITY SQUAD MEMBERS All members of LHS Varsity Cheer are eligible to receive a letter jacket, if one has not been received previously. All eligible members will receive a packet with ordering details. In order to receive a letter jacket, the cheerleader/mascot must have participated in at least 70% of the fall activities, including eligibility for grades. (Additional patches are at the cheerleader’s expense.) CONDUCT GUIDELINES Upon the completion of tryouts, selected cheerleaders will be subject to all rules, expectations, and discipline consequences associated with the new squad. All discipline actions will affect the cheerleader’s standing on his/her squad after tryouts and throughout the following academic year. Any member failing to abide by rules and regulations as set forth under the provisions may be subject to review by the coach(es). Dismissal from the squad may result from that review. The guidelines for student discipline are outlined in the Student Code of Conduct adopted by the Luling Independent School District Board of Trustees. Additional standards of behavior for students involved in extracurricular activities are:
UIL Guidelines Extracurricular Standards of Behavior Cheerleading Standards of Behavior Luling ISD Athletic Code
EXTRACURRICULAR STANDARDS OF BEHAVIOR Student participation in extracurricular activities is encouraged. Luling ISD makes extracurricular activities available as an extension of the regular school program, with an important difference: participation in the regular curriculum is a right afforded to each student, while participation in the extracurricular program is a privilege that carries additional expectations for acceptable conduct. Students who engage in extracurricular activities represent not only themselves, but also other students and the District when performing, competing, or participating in extracurricular activities and while wearing uniforms or other clothing that identifies the student to the community or public in any setting as a Luling ISD student. Behavior must be exemplary and reflect the finest attributes of the Luling ISD student body at all times and in all places. Important goals of the extracurricular program are to give students direction in developing self-discipline, responsibility, pride, loyalty, leadership, teamwork, respect for authority, and healthy living habits. Since participation in extracurricular activities is a privilege and not a right, Luling ISD is authorized to set higher standards for participants of extracurricular activities than for students who choose not to participate in extracurricular activities. The expectations for extracurricular activities extend beyond the Luling ISD Student Code of Conduct, not only in types of behavior prohibited, but also in corresponding consequences and jurisdiction for imposing discipline. Extracurricular expectations apply to all students participating in extracurricular activities, regardless of whether: School is in session; The offense occurs on or off school property or at a school-related event; The student is directly involved with the extracurricular activity at the time the prohibited conduct occurs;
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The extracurricular activity is in-season; and Regardless of where or when the conduct occurs.
It is possible that a student who violates the Luling ISD Student Code of Conduct will incur consequences from both the appropriate school administrator and from his or her coach or sponsor for the same particular violation. It is also possible that a student participating in extracurricular activities may violate the Extracurricular Standards and be subject to discipline or sanctions by a coach or sponsor without having violated the Luling ISD Student Code of Conduct. CHEER STANDARDS OF BEHAVIOR Nothing in the Extracurricular Standards of Behavior limits the authority of a coach(es) to impose reasonable sanctions for students who breach program conduct expectations that are not Student Code of Conduct breaches. Signing the Cheerleading Handbook Parent/Student Acknowledgement is receipt and agreement to the expectations outlined in the Extracurricular Standards of Behavior. Decisions of the coach(es) and principal are final. Issues not covered on this consequences chart may arise that will be handled on an individual basis at the discretion of the cheerleader coach(es) and principal. (Consequences could consist of, but are not limited to: sitting out a portion of a game or the entire game, sitting out a pep rally, demotion from performance privileges, etc.)
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MAJOR VIOLATIONS *Note: Major violations will be handled according to the consequence listed. The third major violation will result in removal from the program. However, if text messages, photos, and/or published social media are deemed unlawful, threating, or sexual in nature immediate dismissal is possible. A student will still be in athletics while the suspension from the program occurs, but will not be able to compete/perform in any extracurricular activities. BEHAVIOR Truancy (Failure to Attend School)
CONSEQUENCE
Vandalizing school property Altering school records Placement in DAEP Alcohol and drug use Stealing I.S.S./O.S.S Inappropriate text messages, photos, and/or published social media Tobacco
Suspension from competition/performance for 30 calendar days after documentation is filed with court. If the student is 18 and reaches the amount of days to be filed on then they receive a 30 calendar day suspension from the competition/program. Suspension from competition/performance for 30 calendar days after school disciplinary assignment is complete. Suspension from competition/performance for 30 calendar days after school disciplinary assignment is complete. Suspension from competition/performance for 30 calendar days after DAEP assignment is complete. Suspension from competition/performance for 30 calendar days after school disciplinary assignment is complete. Suspension from competition/performance for 30 calendar days after school disciplinary assignment is complete. Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Suspension from the program for 15 calendar days.
MINOR VIOLATIONS
BEHAVIOR Miss part of a day of school on pep rally/game day without a doctor’s note (unless approved by coach(es)/director and principal) Late to practice Unexcused absence from class or practice Violation of appearance Violation of practice rules Violation of travel rules School dress code violations Disrespectful coach(es) or teammates Classroom issues (Coach(es) were contacted by teachers) Ejection from athletic competition
CONSEQUENCE Not able to participate that day or night.
Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es). Appropriate consequence assigned by coach(es).
END-OF-THE-YEAR SUSPENSIONS: If a student’s suspension from participation in extracurricular activities is not completed by the end of a school year, the student shall complete the assigned period of suspension during the first semester of the following school year. Calendar days between the last instructional day of one school year and the first instructional day of the following school year shall not be included in the suspension period.
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INFRACTION SYSTEM Major Infraction All major infractions will be dealt with as stated on the above behavior chart. Each major infraction will result in one written infraction. All major infractions will result in the cheerleader being removed from performance privileges for the remainder of the cheer season. Three major infractions will result in removal from the squad. Removal from Performance Privileges One major infraction will result in removal from performance privileges for the reminder of the season, and cheerleader will return all uniforms provided by school. Performances include, but are not limited to: pep rallies, games, cheer clinics/camps, etc. Cheerleaders are still required to attend and participate in all practices and events. Cheerleaders will sit on the sideline with coach(es) during squad performances. Minor Infraction Each member will have their own consequence documentation sheet in order to keep a record of consequences assigned by the coach(es). Squad members will have up to three consequences per minor behavior issue before receiving a written infraction. Documentation for each consequence will be kept by the coach(es). If a squad member receives more than three written infractions they will be removed from the squad. The purpose of the consequence chart is to correct the behavior before it escalates and a written infraction must be given. **In all cases, if a cheerleader or mascot is made to sit out a pep rally or game, the member of the squad is expected to sit with the coach(es) fully dressed out and cheering along with his/her counterparts. If a member of the squad is on suspension, that member is required to attend ALL assigned events and complete any duties assigned by the coach(es). PERMANENT DISMISSAL If a cheerleader is dismissed for misbehavior, that student will not be entitled to reimbursement of funds nor allowed to try out for future squads. Any cheerleader who violates the code of conduct by committing three major offenses, as identified in the previous chart, may be removed from the squad. INCLEMENT WEATHER In the event of inclement weather, it will be the responsibility of the coach(es), in collaboration with the campus principal, to make the decision to leave the event. If a student voluntarily leaves a cheerleading event, they will be subject to the penalties outlined in the guidelines. TRANSPORTATION & TRAVEL If a cheerleader/mascot is going to have to leave after a game with his/her parents, he/she must request a transportation form from the coach prior to the game. A parent will also need to approach the coach at the game site before the cheerleader/mascot will be dismissed. If the parents cannot attend and wish for their child to leave with another adult, the parent must sign the designated district alternate transportation form that requires administrator signatures. Please view the LISD website or the athletic department for one of the forms. Anyone who leaves before being released by the coach will be assigned a consequence deemed appropriate by the coach(es).
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FINANCIAL RESPONSIBILITY
See information sheet for financial responsibility for cheer participation. Final Balance must be paid before camp in order to cheer. CIVILITY Parents are partners with the school and are expected to support the cheerleading program, cheerleaders, and coach(es) through attending performances, meeting financial obligations in a timely manner, and assisting in fundraising, among other supportive measures. Mutual respect is imperative, and lack of civility will not be tolerated. Individuals who speak in a demanding, loud, insulting or demeaning manner, or otherwise disrupt operations, will be directed to leave the school or district property.
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FEMALE CHEER EVALUATION LHS Female Cheer Evaluation Candidate Number ___________ Category Motion Technique Voice Projection Sharpness
Possible Points Points Earned Comments Cheer and Chant—30 Possible Points 10 10 10 Jumps—10 Possible Points
Form
4
Variety
2
Height
4
Rhythm
5
Technique
10
Sharpness
10
Enthusiasm
Showmanship—25 Possible Points 10
Dance—25 Possible Points
Smile/Eye Contact Poise
5 5
Engages the Crowd
5 Tumbling—10 Possible Points
Timing
2
Strength
4
Technique
4
Total Possible Points—100 Points
Total Points Earned _____________
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MALE CHEER EVALUATION LHS Male Cheer Evaluation Category
Possible Points
Candidate Number_________________ Points Earned
Comments
Cheer and Chant—30 Possible Points Motion Technique
10
Voice Projection
10
Sharpness
10 Jumps—10 Possible Points
Form
4
Variety
2
Height
4 Partner Stunting—25 Possible Points
Technique
10
Stability
10
Dismount
5 Showmanship—25 Points
Enthusiasm
10
Smile
5
Eye Contact
5
Poise
5 Tumbling—10 points
Timing
2
Strength
4
Technique
4 Total Possible Points—100 Points
Total Points Earned _____________
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MASCOT EVALUATION LHS Mascot Evaluation Category
Possible Points
Showmanship
50
Creativity
25
Character Development
25
Total Possible Points-100
Points Earned
Candidate Number ___________________ Comments
Total Points Earned ____________
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GERDES JUNIOR HIGH SCHOOL 214 E. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Cheerleading Handbook Parent/Student Acknowledgement Cheerleader/Mascot Agreement: I have carefully read and considered the Cheerleader/Mascot Constitution and Behavior Standards. I have also had the opportunity to ask questions about it. I agree that I will abide by the rules and regulations stated in the guidelines at all times as long as I am a member of a cheerleading squad at Luling High School. I realize that failure to comply with these rules can result in suspension or dismissal from the squad. I will adhere to all policies outlined in the LHS Cheerleading Handbook, LISD Student Code of Conduct, LHS Student Handbook, and the LHS Athletic Code.
Cheerleader Signature
Date
Parent Agreement: I have carefully read and considered the Cheerleader/Mascot Constitution and Behavior Standards. I have also had the opportunity to ask questions about it. I understand that if my child is selected as a cheerleader or mascot, he/she will be expected to follow all the rules and regulations stated in the guidelines. I agree as a parent to help my child follow these rules and regulations. I also realize there will be a financial responsibility on my part. I will require my child to comply with all the policies outlined in the LHS Cheerleading Handbook, LISD Student Code of Conduct, LHS Student Handbook, and the LHS Athletic Code.
Parent Signature
Date
Approved By
_____________________________________________ LHS Principal Date
____________________________________________ Cheer Coach Date
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GERDES JUNIOR HIGH SCHOOL 214 E. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Medical Release Form Student’s Name:___________________________________________________ Grade:________________ I certify that___________________________________________________ is physically capable and able to fulfill requirements needed to be a cheerleader/mascot. I understand that this form legally releases all obligations and responsibilities for the medical treatment of my son/daughter in the event of illness or injury during any squad-related activity when either parent cannot be reached. If there is any physical or medical reason why he/she should not participate fully, the school requires a doctor’s release. Furthermore, the school is not liable for any injury incurred during cheerleading. Parent’s signature:___________________________________________________________ Date:__________ Medical Treatment Permission In the event of an emergency occurring while my son/daughter is on a school-sponsored practice, performance, or trip, I grant my permission to the school and its employees to take whatever action necessary. In the event that I cannot be reached, I hereby authorize the school and/or its employees to give consent for my son/daughter, ________________________________________________________, to receive medical treatment. Home phone:_________________________________ Business phone:_________________________________ Address:___________________________________________________________________________________ City:________________________________________ State:______________________ Zip:______________ Person to be notified other than parent or guardian in an emergency: Name:_________________________________________ Phone:______________________________________ Family doctor: ___________________________________________ Phone:_____________________________ If you do not grant permission/authorization for consent to medical treatment, what procedure should be followed?___________________________________________________________________________________ ___________________________________________________________________________________________ Insurance company:___________________________________ Policy number:___________________________ Parent signature:______________________________________________________ Date:__________________ Medical Information
Circle One Circle One Heart condition/disease Yes No Asthma Yes No Diabetes Yes No Allergic to medication Yes No Convulsions disorder Yes No Allergic to insect bites Yes No State allergies:_______________________________________________________________________________ ___________________________________________________________________________________________ Date of last Tetanus shot:__________________ Medications currently taking:____________________________ Additional pertinent medical information:__________________________________________________________ _______________________________________________________________________________________
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GERDES JUNIOR HIGH SCHOOL 214 E. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Inherent Risk Form Inherent Risks of Cheerleading Cheerleading is reasonably safe as long as certain guidelines are followed, but there is the inherent risk of injury as in any athletic activity. Cheerleading is an anaerobic/aerobic activity that includes jumping, stunting, motions, and tumbling. All physicals must be on file in the school office before you may participate in practices and games. Keep your coach informed of all injuries and/or chronic conditions. Although the probability of injury is minimized if you practice correctly, there is always the possibility of one occurring. Injuries that can occur in cheerleading include, but are not limited to, the following: blisters, muscle strains, joint and muscle soreness, abrasions, contusions, stress fractures, broken bones, spinal cord injuries involving paralysis, and even death. However, if you take certain precautions, the possibility of such injuries will be largely decreased. Cheerleaders should consistently abide by the following guidelines: 1. Never stunt or tumble unless a coach or coach’s designee is present. 2. Always practice in the presence of a qualified coach 3. Always warm-up appropriately before cheering (practice and games) by jogging and stretching. 4. Do not attempt a stunt that you do not know how to perform safely and that has not been checked off by the coach. 5. Always use attentive spotters when stunting. 6. Always cheer in an area free from obstruction. 7. Always use mats or a grassy area when stunting during practice. 8. Do not stunt on uneven ground, wet surfaces, or concrete, and do not stunt in cold or rainy weather. 9. Never talk, laugh, or mess around when performing a stunt. 10. Report all injuries to the coach as soon as they occur. 11. Follow all trainer and doctor recommendations. 12. Lift weights to increase strength and guard against injuries. 13. Always wear shoes and clothing appropriate for cheerleading. 14. Never wear jewelry of any kind or chew gum when cheering (practice and games). 15. Always have your hair pulled back from your face and shoulders. 16. Eat nutritious meals and get plenty of rest. 17. Ask for assistance or advice at any time. I have read the preceding warning and thoroughly appreciate and understand the assumption of risks inherent in cheerleading participation. I acknowledge that I am physically fit and that I am voluntarily participating in this activity. Student name (print)_________________________________________________________________________ Student signature_________________________________________________________ Date______________ Parent signature__________________________________________________________ Date______________
21
GERDES JUNIOR HIGH SCHOOL 214 E. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Parental Information and Consent Form for Concussions What is a concussion? A concussion is an injury to the brain. It is caused by a bump, blow, or jolt to either the head or the body that causes the brain to move rapidly within the skull. The resulting injury to the brain changes how the brain functions in a normal manner. The signs and symptoms of a concussion can show up immediately after the injury or may not appear for hours or days after the injury. Concussions can have serious long-term health effects, and even a seemingly mild injury can be serious. A major concern with any concussion is returning to play too soon. Having a second concussion before healing can take place from the initial or previous concussion can lead to serious and potentially fatal health conditions. What are the symptoms of a concussion? Signs and symptoms of a concussion are typically noticed right after the injury, but some might not be recognized until days after the injury. Common symptoms include: headache, dizziness, amnesia, fatigue, confusion, mood changes, depression, poor vision, sensitivity to light or noise, lethargy, poor attention or concentration, sleep disturbances, and aggression. The individual may or may not have lost consciousness. What should be done if a concussion is suspected? 1. Immediately remove student from practice or game 2. Seek medical attention right away 3. Do not allow the student to return to play until proper medical clearance and return to play guidelines have been followed. The permission for return to play will come from the appropriate health care professional or professionals. If you have any questions concerning concussions or the return to play policy, you may contact the athletic trainer at your school. What should the athlete know about playing with a concussion? Teach athletes it’s not smart to play with a concussion. Rest is the key after a concussion. Sometimes athletes, parents, and other school or league officials wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don’t let your athlete convince you that they’re “just fine.”
22
What are the risks of returning to activity too soon after sustaining a concussion? Prevent long-term problems. If an athlete has a concussion, their brain needs time to heal. Don’t let them return to play the day of the injury and until a health care professional, experienced in evaluating for concussion, says they are symptom-free and it’s OK to return to play. A repeat concussion that occurs before the brain recovers from the first – usually within a short time period (hours, days, weeks) – can slow recovery or increase the chances for long-term problems. What can happen if my child keeps on playing with a concussion? Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athletes will often under report symptoms or injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for studentathlete’s safety. Liability Provisions The student and the student’s parent or guardian or another person with legal authority to make medical decisions for the student understands this policy does not: 1. waive any immunity from liability of a school district or open-enrollment charter school or of district of charter school officers or employees; 2. create any liability for a cause of action against a school district or open-enrollment charter school or against district or charter school officers or employees; 3. waive any immunity from liability under Section 74.151, Civil Practice and Remedies Code; 4. create any liability for a member of a concussion oversight team arising from the injury or death of a student participating in an interscholastic athletics practice of competition, based only on service on the concussion oversight team. Parental Consent By signing this form, I understand the risks and dangers related with returning to play too soon after a concussion. Furthermore, in the event that my son/daughter is diagnosed with a concussion, I give my consent for my son/daughter to participate in and comply with the Luling ISD return to play protocol. The undersigned, being a parent, guardian, or another person with legal authority, grants this permission. Athlete’s Name (print)________________________________________________________________ Parent’s or Guardian’s Name (print)____________________________________________________ Parent’s or Guardian’s Signature_______________________________________________________ Date________________________________________________________________________________
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GERDES JUNIOR HIGH SCHOOL 214 e. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Parental Release Form Student’s name:_____________________________________________________________________________ School:_______________________________________________________________ Grade:______________ I, the undersigned, have read and fully understand the rules and regulations that will govern my son/daughter if he/she chooses to represent Luling Independent School District as a cheerleader. I further understand that this is an extracurricular activity and that attendance at all practices, games, special functions, and summer camp is a requirement of the elected cheerleader. I hereby give my consent to my son/daughter, ____________________________________________, to tryout for cheerleader at _________________________________________________________ and recognize his/her responsibilities and requirements as a leader of his/her school. I understand that, if chosen, my son/daughter will be required to pay for summer cheerleader camp and uniforms. Parent name (print)__________________________________________________________________________ Parent signature____________________________________________________________________________ Parent Contact Information
Address___________________________________________________ Phone (cell)________________________ (home)________________
If I am elected as a cheerleader, I shall fulfill all of the requirements to the best of my ability as set forth in the LISD Cheerleader Handbook. I have read these policies and understand that if I fail to maintain these rules, I will be reprimanded according to these guidelines and possibly removed from the squad. Candidate’s name (print)_______________________________________________________________________ Candidate’s signature__________________________________________________________________________ Candidate’s Contact Information
Address____________________________________________________ Phone (cell)_________________________ (home)_________________
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GERDES JUNIOR HIGH SCHOOL 214 e. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Extracurricular Standards of Behavior Contract I, _____________________________________, understand I must conduct myself with utmost integrity and honesty as a student involved in co-curricular/extracurricular activities in the Luling Independent School District. I understand that my position as a student involved in co-curricular/extracurricular activities means that I am held to a higher standard of behavior, and therefore, may receive greater consequences than those outlined in the Luling ISD Student Code of Conduct regardless of whether such conduct occurs on or off school property and/or at a school-sponsored or school-related event. I further understand that if I represent my organization in an unfavorable, questionable, or illegal manner through electronic media (i.e., websites, personal home pages, blogs, camera phones, digital photos, electronic descriptions, text messages, chat rooms, social media, or similar websites/files accessible through a server or Internet), I will be subject to the disciplinary action determined appropriate by school officials. I understand that if I violate the Luling ISD Student Code of Conduct, I may receive consequences in accordance with those outlined in the Code of Conduct, as well as additional consequences as a result of my participation in co-curricular/extracurricular activities. I understand and agree that consequences assigned under this contract will be assigned at the discretion and determination of the campus administrator and sponsor/coach of the activity and may include, but are not limited to, disciplinary consequences in, suspension from, removal from, and/or prohibition from future participation in all co-curricular/extracurricular activities. I understand that as a participant in a co-curricular/extracurricular activity, I must follow the LISD Student Code of Conduct in addition to all rules, regulations, and schedule commitments, as required by the sponsor/coach of the activity. I have read this LISD Extracurricular Standards of Behavior Contract and agree to all of the terms and consequences stated herein. Students name (print)________________________________________________________________________ Student signature_____________________________________________________ Date__________________ Parent name (print)__________________________________________________________________________ Parent signature_____________________________________________________ Date___________________ Student Contact Information
Address__________________________________________________ Phone (cell)_________________________ (home)_________________
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GERDES JUNIOR HIGH SCHOOL 214 e. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Participation Physical Evaluation—Medical History This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition that would make it hazardous to participate in an athletic event.
Student's Name: (print) _________________________________________ Sex _______ Age____________ Date of Birth _______________ Address ___________________________________________________________________________ Phone_________________________ Grade_______________________________________ School ______________________________________________________________ Personal Physician__________________________________________________________Phone__________________________________ In case of emergency, contact: Name __________________________________ Relationship _______________________ Phone (H) _______________ (W) ___________ Explain "Yes" answers on the back of this form. Circle questions you don't know the answers to. Any “Yes” answer to italicized questions requires further medical evaluation that may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games, or matches.
Yes
No
Have you ever passed out during or after exercise? Have you ever had chest pain during or after exercise? Do you get tired more quickly than your friends do during exercise? Have you ever had racing of your heart or skipped heartbeats? Have you had high blood pressure or high cholesterol? Have you ever been told you have a heart murmur?
Has any family member or relative died of heart problems or of sudden unexpected death before age 50? Has any family member been diagnosed with enlarged heart,(dilated cardiomyopathy), hypertrophic cardiomyopathy, long QT syndrome or other ion channelopathy (Brugada syndrome, etc.), Marfan's syndrome, or abnormal heart rhythm? Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month?
Do you have any allergies (for example, to pollen, medicine, food, or stinging insects)? Have you ever been dizzy during or after exercise? Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, or blisters)? Have you ever become ill from exercising in the heat? Have you had any problems with your eyes or vision? Have you ever gotten unexpectedly short of breath with exercise Do you have asthma? Do you have seasonal allergies that require medical treatment? Do you use any special protective or corrective equipment or devices that aren't usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)? Have you ever had a sprain, strain, or swelling after injury?
Has a physician ever denied or restricted your participation in sports for any heart problems?
Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious, or lost your memory? If yes, how many times?_____________________ When was the last concussion?_______________ How severe was each one? (Explain on back of form.) Have you ever had a seizure? Do you have frequent or severe headaches?
Have you ever had numbness or tingling in your arms, hands, legs, or feet? Have you ever had a stinger, burner, or pinched nerve? Are you missing any paired organs?
Are you under a doctor’s care? Are you currently taking any prescription or non-prescription (over-thecounter) medication or pills or using an inhaler?
Have you had a medical illness or injury since your last check up or sports physical? Have you been hospitalized overnight in the past year? Have you ever had surgery?
Yes
No
Have you broken or fractured any bones or dislocated any joints?
Have you had any other problems with pain or swelling in muscles, tendons, bones, or joints? If yes, check appropriate box and explain on back of form. Head Elbow Hip Neck Forearm Thigh Back Wrist Knee Chest Hand Shoulder Finger Ankle Shin/CalfUpper Arm Foot Do you want to weigh more or less than you do now? Do you lose weight regularly to meet weight requirements for your sport?
Do you feel stressed out? Have you ever been diagnosed with or treated for sickle cell trait or sickle cell disease? Females Only When was your first menstrual period? When was your most recent menstrual period? How much time do you usually have from the start of one period to the start of another? How many periods have you had in the last year? What was the longest time between periods in the last year?
It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League nor the school assumes any responsibility in case an accident occurs. If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse, or school representative. I do hereby agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said student. If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the school authorities of such illness or injury.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL. Student Signature: ____________________________________________Parent/Guardian Signature:______________________________________________ Date: _________________ THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER SCHOOL. For School Use Only: This Medical History Form was reviewed by: Printed Name____________________________________________ Date______ Signature______________________________________
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GERDES JUNIOR HIGH SCHOOL 214 E. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
Participation Physical Evaluation—Physical Examination Student's Name ___________________________________ Sex ________ Age _______ Date of Birth _________________________ Height ________ Weight__________ % Body fat (optional) __________ Pulse ____________ BP____/____ (____/____, ____/____) brachial blood pressure while sitting
Vision: R 20/______ L 20/___
Corrected: Y N
Pupils: Equal Unequal
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specific questions on the student's MEDICAL HISTORY FORM on the reverse side. Local district policy may require an annual physical exam.
NORMAL
ABNORMAL FINDINGS
INITIALS MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart—Auscultation of the heart in the supine position Heart—Auscultation of the heart in the standing position Heart—Lower extremity pulses Pulses Lungs Abdomen Genitalia (males only) Skin Marfan’s stigmata (arachnodactyly, pectus excavatum, joint hypermobility, scoliosis) MUSCOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot CLEARANCE Cleared Cleared after completing evaluation/rehabilitation for: ___________________________________________________________________ _________________________________________________________________________________________________________________ Not cleared for:________________________________________ Reason: _________________________________________________ Recommendations: _________________________________________________________________________________________________ _________________________________________________________________________________________________________________ The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners, or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner will not be accepted.
Name (print/type) ______________________________________________________ Date of Examination:__________________________ Address:_________________________________________________________________________________________________________ Phone Number: ___________________________________________________________________________________________________ Signature:________________________________________________________________________________________________________ Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches.
27
GERDES JUNIOR HIGH SCHOOL 214 E. Bowie St Luling, Texas 78648 Phone 830.875.2121 Fax 830.875.5482
REQUEST TO PROVIDE MEDICATION DURING EXTRA CURRICULAR ACTIVITIES ACETAMINOPHEN AND IBUPROFEN IMPORTANT INFORMATION FOR PARENTS/GUARDIANS: In order for your child to receive medication while participating in extra curricular activities (i.e. cheerleading, esquires, twirling, etc.), your written consent is required. In addition to your consent, it is your responsibility to provide any medications that may need to be administered to your child. Please complete the entire form. By signing below, you acknowledge the following: o o
You have reviewed the information and agree that your child may safely take the medications according to the recommended dose by weight. A licensed prescriber’s authorization will be required if: o Your child requires more than 5 doses of acetaminophen and/or ibuprofen in a 30 day period; o Your child requires more than 5 consecutive doses of acetaminophen and/or ibuprofen. o Your child’s medication may be provided by a nurse, an unlicensed health technician, or other school personal, determined competent to provide medication as required by Texas law.
PARENTAL CONSENT FOR ACETAMINOPHEN AND/OR IBUPROFEN: I gave permission for (Name of Child) To receive the following medication: Acetaminophen (Tylenol) Reason(s): Headache Dental Pain General Discomfort
Ibuprofen (Advil) Menstrual Cramps Muscle or Joint Pain Other
My child has taken acetaminophen before (Circle): My child has taken ibuprofen before (Circle): Please notify me before my child takes medications (Circle): Please notify me the day my child takes medication (Circle):
Contact Name
Yes Yes Yes Yes
No No No No
Phone Number
28
My child is taking other medication at this time (Circle):
Yes
No
Please list medications:
My child is under the care of a physician for the following:
Special instruction concerning my child:
Signature of Parent/ Guardian
Date
29
