Basketball
Open to eligible Grade 7 and 8 students
Tryouts scheduled for November 13, 2007
Please complete the attached Permission Form, Authorization for Emergency Treatment and bottom of letter from Mr. Monteiro to the School Nurse at the Junior High prior to tryouts.
Boys Coach: Mr. Kirkman
Practices are Monday through Friday 3:45 – 5:45
through Dec 28
Then Monday through Friday 2:15 – 3:45
Girls Coach: Mr. Wenzel
Practices are Monday through Friday 2:15 – 3:45
through Dec 28
Then Monday through Friday 3:45 – 5:45
Game schedules to be announced
Eligibility
As outlined in Student
Handbook, page 4:
To
be eligible to participate in athletics or extracurricular activities at
- Be a registered student at
- Pass at least five (5) academic subjects in the immediately
preceding quarter or the most recent mid term progress report with a
minimum of 3 C’s & 2 D’s. To be
eligible for fall extracurricular activities, a student must have passed
five (5) academic subjects with a minimum of 3 C’s & 2 D’s in their
final grades of the previous academic year.
- In order to participate in athletics, the student must have a
current physical (less than 13 months old) on file in the nurse’s
office. This physical documentation
must state that the student may participate in athletics.
EXTRACURRICULLAR ACTIVITY PERMISSION FORM
STUDENT:__________________ GRADE:_____ DIVISION:_____
ACTIVITY:___________________________________________________
I,
____________________________, give permission for my child to participate in
the above activity. My child has the
following medical needs:
___No medical needs
___Inhaler (type)________________________________________
___Epi-Pen
for__________________________________________
___Other (please specify)___
______________________________
EMERGENCY CONTACT INFORMATION
NAME:_______________ ADDRESS:________________________________
TELEPHONE NUMBER
#1:_________________________
TELEPHONE NUMBER #2:_________________________
NAME:_______________ ADDRESS:________________________________
TELEPHONE NUMBER #1:_________________________
TELEPHONE NUMBER
#2:_________________________
NAME:_______________ ADDRESS:________________________________
TELEPHONE NUMBER
#1:_________________________
TELEPHONE NUMBER
#2:_________________________
PARENT
/ GUARDIAN SIGNATURE:_____________________ DATE:_________
AUTHORIZATION FOR MEDICAL
TREATMENT
I , _______________________, parent / guardian of ___________________________ Date of Birth___________, give my permission for the emergency evaluation and treatment by any duly licensed physician and/or facility in the event of illness / injury. I also authorize transportation via ambulance as determined by emergency responders.
Signature:__________________________ Date:_______
Primary Physician:_____________________________ Telephone #:_____________
Please list all allergies (including medications, foods, insects, etc.) and associated reaction:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Please list all medications including dose and reason for
taking:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Please list any medical conditions not addressed above:
Contact Lenses for sports ___YES ___NO
_____________________________________________
_____________________________________________
_____________________________________________
Please provide insurance
information :
___________________________________________________
Policy Name
______________________________________
Policy Number
______________________________________
Subscriber’s
Name
To facilitate physician / facility acceptance it is recommended that this form be notarized
WARNING, AGREEMENT TO OBEY
INSTRUCTIONS, ASSUMPTION OF RISK AND AGREEMENT TO HOLD HARMLESS
I am aware that sports
participation, including practice, puts the athlete at risk for
injury.
I
understand that these risks include, but are not limited to, death, serious
neck
and spinal injuries that may
result in paralysis, brain damage, serious
injury to the musculo-skeletal system, or other impairments to the body.
I
understand that participation may result in a serious impairment of my future
ability to earn a living, engage in
other business, social or recreational activities, and enjoy life.
Due
to the dangers of participation I recognize the importance of team rules and
following the coach’s instructions regarding playing technique. I agree to abide by the team rules and follow the coach’s instructions.
In
consideration of the Swansea School Department permitting me to try out for the
Joseph Case Junior High School sports team and to engage in all activities
related to that team, I hereby assume all the risks associated with
participation and agree to hold harmless the Swansea School Department, its
agents, employees and representatives, from any debts, claims or demands
related to my participation in sports.
The terms hereof shall serve as release and assumption of risk for my
heirs, estate executor, administrator, and assignees and for all members of my
family.
Participant Signature:__________________________________ Date:_______
Parent / Guardian Signature:_____________________________ Date:_______
To Whom It May Concern:
It
is the responsibility of the parents or the guardian of an injured student to
fill out the Insurance Claim Form (parent’s section) and then to be certain
that the attending physician also fills out the section designated for he or she.
It
is then the responsibility of the physician to forward this claim to the
Insurance Company that provides coverage to the
B.M.I.
Insurance Company
If this is accomplished immediately, the
medical charges will be paid by the above insurance agent, after the primary
insurance coverage has been taken care of.
All bills you receive must be turned into the Junior High School
secretary immediately.
Thank
you for your cooperation.
Sincerely,
Robert
G. Monteiro
Principal
Please sign the bottom portion of this
letter as proof that you understand your responsibilities in this matter and
return it to my office.
______________________________
Date__________________________
Dear Parent:
The Board of Education has purchased insurance
coverage to protect all participants in interscholastic sports against
accidental injury while participating.
This coverage also applies to equipment managers, band members, cheerleaders,
and flag wavers.
The athletic insurance is Full Excess Coverage; i.e.,
you must submit all bills to your own insurance first. The school policy will pick up the unpaid
balances, up to the limit of the policy.
Although this coverage is very broad, there are
restrictions, limitations, and exclusions in this policy. In many situations, medical bills may not be
covered in full. Parents should
understand that medical expenses are their own responsibility, not the Board of Education’s.
Some of the important benefits and limitations of the plan are:
1) Maximum Medical Benefits is
$1,000,000.00
2) Treatment must commence within 90 days of the date
of injury, or there is no
coverage
3) Physical therapy treatment (and
chiropractic treatment) has a limit of $500.00
4) Benefits are payable for up to two
years from the date of injury
5) Hernia, in any form, is not
covered.
All injuries should be immediately reported to the
coach or faculty advisor. Claim forms
will be provided by the school, but it is the parent’s responsibility to:
1) Submit
the claim form with Part 1B filled out completely (any omissions will delay the
processing of the
claim).
2) Submit all itemized bills (monthly
statements will not do).
3) Submit the statement received from your own
insurance company showing
amounts paid and balances due, or a letter of denial stating the claim is
not
covered. One of these
letters is required for any payments to be made.
4) If you have no medical insurance, you
will receive a letter from the company
requesting employee information. Fill this out and return it to
the company immediately and the claim will be processed. Failure to return this letter will result in
a delay or denial of the claim.
It is your responsibility (and to your benefit) to
submit the necessary papers as soon as possible, as the claim cannot be paid
until all papers are submitted.
Only one claim form per accident is required/allowed.
All claim forms, bills , and letters from other insurance companies
are to be forwarded to; and questions regarding coverage answered by:
B.M.I.
Benefits Insurance
1-800-445-3126