Information

MOSES LAKE SCHOOL DISTRICT
MOSES LAKE, WASHINGTON
766-2666
FAX 766-2682


EXTENDED TRIP – PARENT REQUEST FOR DEPARTURE FROM GROUP

As parents, should you request to allow your son/daughter to(a) not return with the group, or (b) depart from the scheduled itinerary, you must complete the following form and return it signed to the administrator at least on week prior to the group’s departure from school.

I, _________________________________, request that my son/daughter,
(Parent Name)
__________________________________, be allowed to depart from the itinerary as
(Student Name)

planned for the __________________________________.
(Group)

Please describe:

Reason for departure: ______________________________________
Date of departure: _________________________________________
Emergency Phone:  ________________________________________
Name and age of adult supervisor that your son/daughter will be with if other than

Departure from the group has been acknowledged by the supervisor, teacher, coach or activity advisor.  PLEASE MAKE SURE COACH/ADVISOR SEES PARENT BEFORE YOU LEAVE ACTIVITY.
__________________________________
Supervisor’s Signature (Coach)

As parent or guardian of the above named student, I promise to hold School District #161 harmless from any liabilities it may incur from the above named departure of the extended field trip, except as may arise because of negligence on the part of School District #161 or its employees.

Parent Signature of Student __________________________________   Date _________

Driver Signature (Non Parent) ________________________________  Date _________

Administrator Signature _____________________________________  Date _________

MOSES LAKE SCHOOL DISTRICT
Concussion Information Sheet

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly.  In other words, even a “ding” or a bump on the head can be serious.  You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.


Symptoms may include one or more of the following:
•    Headaches
•    “Pressure in head”
•    Nausea or vomiting
•    Neck pain
•    Balance problems or dizziness
•    Blurred, double, or fuzzy vision
•    Sensitivity to light or noise
•    Feeling sluggish or slowed down
•    Feeling foggy or groggy
•    Drowsiness
•    Change in sleep patterns    •    Amnesia
•    “Don’t feel right”
•    Fatigue or low energy
•    Sadness
•    Nervousness or anxiety
•    Irritability
•    More emotional
•    Confusion
•    Concentration or memory problems (forgetting game plays)
•    Repeating the same question/comment




Signs observed by teammates, parents and coaches include:
•    Appears dazed
•    Vacant facial expression
•    Confused about assignment
•    Forgets plays
•    Is unsure of game, score, or opponent
•    Moves clumsily or displays incoordination
•    Answers questions slowly
•    Slurred speech
•    Shows behavior or personality changes
•    Can’t recall events prior to hit
•    Can’t recall events after hit
•    Seizures or convulsions
•    Any change in typical behavior or personality
•    Loses consciousness

What can happen if my child keeps on playing with a concussion or returns to soon?

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 athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.

If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new “Zackery Lystedt Law” in Washington now requires the consistent and uniform implementation of long and well-established return to play concussion guidelines that have been recommended for several years:

“a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time”

and

“…may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.

You should also inform your child’s coach if you think that your child may have a concussion Remember its better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to: http://www.cdc.gov/ConcussionInYouthSports/


_____________________________       _____________________________       _____________
Student-athlete Name Printed                  Student-athlete Signature              Date



_____________________________     ______________________________       _____________
Parent or Legal Guardian Printed            Parent or Legal Guardian Signature                Date

Running Start Students and WIAA Eligibility

Students who access the Running Start Program at the community colleges find themselves on a different academic calendar from their high school for academic eligibility.  There could be times during the high school year that Running Start students are not in school or taking academic courses.  To ensure that students remain athletically eligible at their high school, they enter into the following contract with their school and commit to taking and completing the approved academic program at the community college and/or in conjunction with a blended schedule at their high school.

The purpose of this document is to record, in writing, the expectations of the MOSES LAKE School District regarding the Running Start scholastic requirements of _________________, a student/athlete at MOSES LAKE High School, and serve as a safeguard for the MOSES LAKE School District against penalty and sanctions if  ___________________(student) fails to meet the scholastic requirements as a Running Start student during the  2009-2010 school year.

Expectations:
1.    The MOSES LAKE School District verifies the following approved academic schedule with _____________________, a Running Start student at MOSES LAKE High School, that will meet the WIAA and school district academic eligibility requirements.
2.    The student, ______________________, agrees to attend all classes and to make no changes to his/her approved academic schedule without first consulting with his/her high school on the potential eligibility ramifications of such changes.

RUNNING START ACADEMIC PLAN for the 2009-10 School Year:
Normal Credit Hour requirement at High School per Semester________
RUNNING START TERM 1    Credit Hours        HIGH SCHOOL SEMESTER 1    Credit Hours        Total Credits
1             1             Per Semester
2             2             
3             3             
4             4             

RUNNING START TERM 2    Credit Hours                      
1                           
2                         
3                         
4             HIGH SCHOOL SEMESTER 2    Credit Hours        Total Credits
1             Per Semester
RUNNING START TERM 3    Credit Hours        2             
1             3             
2             4             
3                           
4                           


Signed and dated by the high school principal, the high school counselor, high school athletic director, the student/athlete, and his/her parents.  By signing this agreement, the student and family agree to all terms of the agreement, and understand they must adhere to the agreed academic plan for the school year or be subject to WIAA regulations 27.4 which states: if it is determined that the participant/parent/guardian provided the school with false information which caused the school to declare the participant eligible, the participant will be declared ineligible for interscholastic competition for a period of one (1) year.

__________________________________________    __________________
Principal                            Date
_________________________________________    __________________
Counselor                            Date
__________________________________________    __________________
Athletic Director                        Date
__________________________________________    __________________
Parent/Guardian                        Date
__________________________________________    __________________
Parent/Guardian                        Date
__________________________________________    __________________
Student                            Date

27.4.0    USE OF INELIGIBLE PARTICIPANT - The use of a participant who is ineligible by WIAA or local school district rules shall result in forfeiture of contests in which that participant took part, except in situations in which it is determined that the participant/parent/guardian provided the school with false information which caused the school to declare the participant eligible.  In such cases, the participant will be declared ineligible for interscholastic competition for a period of one (1) year.  The one (1) year penalty begins on the day the determination is made that false information had been provided.  The one (1) year penalty may be appealed to the WIAA Executive Director.

GUIDELINES IN ESTABLISHING RUNNING START ELIGIBILITY:
1.    Determine the number of credits required for athletic eligibility at the student’s high school.
Example:  4 classes required in a 6 period school day is equal to TWO semester credits needed for eligibility.

2.    Establish the student’s academic schedule for the year, either entirely as a Running Start student or a student with a blended schedule of classes from both Running Start and the high school.  

3.    Determine the number of credits to be earned in each of the courses.

4.    The credits in the Running Start second term can be used either for the first semester, the second semester, or split between the two semesters.

5.    It is possible that a Running Start Student would not attend any classes during one of the three running start terms and still be eligible provided they took enough credits during the other two terms to meet or exceed the number of credits per semester for athletic eligibility at the high school.

6.    Running Start is a public school educational program offering.  Eligibility is at the public school of residence where the student accesses the Running Start program.  A student could still compete athletically for the private school if they maintain enrollment at the private school for at least 50 percent of the school day at the private school.

LAST                  FIRST                   MIDDLE         BIRTH DATE     GENDER     SCHOOL YR      ASB              

MOSES LAKE SCHOOL  - ATHLETIC ELIGIBILITY
PARENT’S PERMISSION

Please circle the sports the student is interested in: Football-Volleyball-Cross Country- Soccer-Basketball-
Swim-Wrestling-Golf-Softball-Baseball-Tennis-Track-Drill Team-Cheerleading-Girls Bowling

I hereby give my consent that ___________________________may participate in one of the above sports in the Moses Lake Schools and certify that the above information is correct.

My child has a disability resulting from an accident or serious illness which school officials should know about as follows: ______________________________.  If no disability, state NONE.

___________________________________________________________________                                                                 
PARENT FULL SIGNATURE

INSURANCE INFORMATION

He/She will be covered with athletic injury insurance by:  FAMILY INSURANCE                        ___________           
If SCHOOL INSURANCE, company providing the coverage is:        ___________               POLICY # ______________________
It is recommended that the student be covered by the School Accident Coverage or one with the following minimum   provisions:
(1)  Minimum death benefit of $2,500; (2)  A maximum payment of any one  injury of at least in aggregate of $15,000 per accident; (3) Coverage equivalent to the Washington State Industrial Insurance Fee Schedule for doctors’ services or hospitalization with a 30-day minimum for the latter; (4) X-Rays to a minimum of $50.; (5) Dental coverage equivalent to the Washington State Industrial Insurance Fee Schedule to at least $100 per injury; (6) Waiting period provisions following an injury be deleted from approved policies with understanding that written approval of doctor be sufficient evidence to permit student to return to practice or play; (7) All approved policies shall provide that a 90-day limit for completing claims shall be counted from termination of medical service and discharge of patient rather than from date of injury.

I have insurance coverage, which covers Interscholastic Athletics, the equivalent or better than the recommended insurance coverage of the Washington Interscholastic Activities Association, will continue to keep it in force throughout the sports season, and therefore I do NOT wish to enroll ____________in the School Accident Coverage Plan. I accept full responsibility for the cost of treatment for any injury which he or she may suffer while taking part in the program. Please waive this requirement and permit him/her to take part in athletics and sports days.  The Principal is authorized to contact the Company named above to verify coverage limitations.

I accept full responsibility for the cost of treatment for any injury which he/she may suffer while taking part in the program.  Please permit him/her to take part in athletics and sports days.

________________________________________________________________________________________                                                                                 
PARENT/GUARDIAN FULL SIGNATURE