Athletic Handbook

Valor Knights


Valor Athletic Handbook

Angie Taylor

Head of School

Matt Dietrich

Athletic Director

3350 SW 182nd Ave

Beaverton, OR 97006

phone:  503-332-6299  /  fax:  503-649-8031


Table of Contents:

Purpose ………………………………………………                3

Athletic Programs Offered………………………….                3

Communication Guidelines…………………………                6

Code of Conduct……………………………………..                7

Athletic Discipline Policy……………………………                7

Academic Responsibility…………………………….                8

Eligibility Requirements……………………………..                8

Parent Volunteer …………………………………….                8

General Responsibility of Parent……………………                8

Equipment Responsibility……………………………                8

Practice & Game Schedules…………………………                9

Locker Room & Road Trip Policy……………….....                9

Transportation Policy……………………………….                9

Physical Exam………………………………………..                9

Risk of Participation…………………………………                10

Valor Knights Booster Club…….…………………..                10

Letter Requirements…………………………………                10

Team Captains………………………………………..                10

Financial Obligations………………..………………                11

Directions to League Schools…………….………….                11

Forms to be turned into Athletic Director…………..                12

Important Phone Numbers & Emails………………..                13

OSAA Individual Eligibility Info Sheet ……………..                14

Consent to Treat / Waiver Form…………………….                15

Parent/Athlete Handbook Consent Form…………..                16


The VCSI athletic department seeks to glorify God through sports. We will strive to teach our kids to play with integrity, honesty and discipline; helping them realize that in everything they do, they represent themselves, their school, their family, and their Lord. We believe that playing sports can prepare our student-athletes with many real life skills such as learning to set goals, working hard, and coming together as a team to accomplish something greater than oneself. 

In the 2018-2019 academic year, VCSI will compete in athletic contests as a Valley 10 League member of OSAA as well the Metro Christian League.


VCSI views athletics to be an integral part of our educational system. As a student-athlete, our students will know that academics are a priority, and playing sports is a privilege. This will encourage the realization of their dreams through facilitating a path that will lead to long-term success.

This handbook should answer a majority of your questions concerning our athletic program. Enclosed (and on our school website) you will find links to addresses of league schools, physical forms, and code of conduct forms. For this reason, we ask that you please keep this handbook available for reference at all times.

Athletic Programs Offered

Elementary School

The purpose of elementary sports is for students to develop an appreciation and enjoyment of the sport. Priorities at this level are to encourage participation and to build basic individual and team skills. Every student-athlete will be given equal opportunity to play minutes that will impact the game. Everyone should get an equal amount of participation time. The goal is to get as many elementary students involved as possible. Encouraging participation and building basic skills will strengthen the athletic program in the future.

The following are sports that we intend to offer our elementary students:


For 3rd-5th graders we offer a coed soccer program to help them get an early start on developing their skills. Soccer season lasts from the 2nd week of September thru the end of October.  Games will be every Friday night at either 4 or 5pm.  



The 5th grade girls will have the opportunity to play at the middle school level.  Middle school volleyball is an introductory program and all girls are encouraged to join the team whether you have experience in the sport or not.  Coaching emphasis will be placed on learning the game and technique to set a solid foundation.  We will compete as part of the Metro Christian League West (MCLW).  Practices will start early September and the season will run through October.



For our 3rd-4th graders we will compete in the Metro Christian League West.  At this level we will have coed teams with running quarters.  The season will run from the end of February thru spring break.

Middle School

The purpose of junior high sports is for student-athletes to continue to develop enjoyment of the sport and improve basic individual and team skills. Every athlete should get the opportunity to play with minutes that will impact the game. However, playing time will not be equal. Student-athletes should be introduced to the concept that each player has a specific role on the team. The emphasis at this level should shift toward developing the most competitive team possible.

Cross Country

Middle School Cross Country for both boys & girls will seek a meet schedule that competes with area private schools in the Metro Christian League West. The is a Fall sport


Middle School Soccer will not be available through VCSI this year.  Soccer players are encouraged to try out for the THPRD league.


For the 2018-19 school year, the middle school girls will have the opportunity to play competitive volleyball through Metro Christian League West.  This will be a 5th-8th grade program, and focus will be on knowledge of the game and proper technique to build a strong foundation.  The season will start early September and run through October.


For our middle school we will compete in the Metro Christian League West.  We encourage both boys and girls to come out.  Coaches will focus on game knowledge, technique and strengthening skills.  Practices will start after Thanksgiving with games starting in January.

Track & Field

Middle School Track & Field is a great sport for student-athletes at all levels and varying abilities to be part of and have fun while competing. We will seek to put together meets with area private schools in the Metro Christian League West.  Track & Field is a Spring sport running March-May

High School

The purpose of high school sports is for student-athletes to compete in the sport by playing at a competitive yet enjoyable high level of competition. Student-Athletes should be pushed to attain the highest level possible with their God-given abilities. Varsity level players are expected to have a solid grasp of the fundamentals mentally, emotionally and physically.  Coaches are encouraged to develop excellent skills related to their sport, and increase their physical condition necessary to compete appropriately at the varsity level. The concept of teamwork and playing a specific role on a team should be mastered at this level. Playing time decisions for each player at the varsity level are with the coach’s discretion. Playing time is not guaranteed and each student-athlete should understand that God has gifted everyone in different ways. A student-athlete’s goal should be to become the best competitor they can be with those abilities that God has given them within the coach’s oversight.

Cross Country

High School Cross Country will put together a meet schedule together with area private schools in the OSAA Valley 10 League. Cross Country will run September-November.


For this 2018-19 school year, high school soccer players will be encouraged to try out for their local public high school team.  The goal will be to phase in the program to field our own team in OSAA The Valley 10 League (Special District - 6) as we grow.


High School Volleyball girls will compete in The Valley 10 League of OSAA.  Girls will grow in their skill, knowledge and compete at a high level.  Playing time is determined by the coach.


For our High School boys and girls we will field a team and compete in The Valley 10 League of OSAA.  

Track & Field

High School Track & Field is a program open to all students.  Valor will compete against schools in the OSAA Valley 10 League, as well as other schools in varying classifications.  Track & Field is a Spring sport running March-May.


Communication Guidelines

Our Philosophy

Communication Expectations & Protocol

Your Expectations

        It is reasonable to expect your child’s coach to inform you:

  1. When and where practices and contests are held.
  2. About his/her coaching philosophy.
  3. About the expectations he/she has for all athletes on the squad as well as your individual child.
  4. What is required to be a part of the team, i.e. fees, special equipment, off-season conditioning, letter requirements, etc.
  5. If your child is injured during participation in a practice or contest.
  6. Whenever any disciplinary actions result in your son/daughter being denied participation in a practice or contest.

Typical concerns of parents that are appropriate to discuss with a coach are:

  1. Any unhealthy mental or physical strain you detect in your child at home (especially when it affects his/her academic performance).
  2. How you can contribute to your child’s skill improvement and development.
  3. Any dramatic changes you detect in your child’s behavior.

Our Expectations

        It is inappropriate for a parent to discuss with a coach:

  1. Playing time.
  2. Team strategy and game calling.
  3. Other student-athletes.

Coaches often need parents to tell them:

  1. Any specific health concerns about your son/daughter expressed directly and informally to the head coach at a mutually convenient time.
  2. Notification of any schedule conflicts well in advance.
  3. Your commitment to the program and how you plan to make a contribution to the program’s success. For example, one way is to be sure your child is at practice each day on time and to supervise that your child gets enough rest and nutrition at home.
  4. Strategies that have worked for you in dealing with your child being successful in the past.

If you have any concern to discuss with a coach, what procedure should you follow?

  1. High School Level – Student should approach the coach with the concern.
  2. Make an appointment with the coach, student and parent. Never approach the coach after a game unless the coach requests this.  Appointments should be made a minimum of 24 hours after a game, and if necessary or at the coach’s request will be coordinated with the Athletic Director present.
  3. If the coach cannot be reached, call the Athletic Director to set up a meeting with the coach.
  4. Please do not attempt to confront a coach before, during, or following a contest or practice. These can be busy and emotional times for both the parent and the coach; this period does not promote objective analysis of the situation.

What should you do if the meeting with the coach does not result in a resolution to the problem?

  1. Call and set up an appointment with the Athletic Director to discuss the situation.
  2. If the Athletic Director does not satisfy your needs, you may then set up an appointment with the Dean of Students, Rashell Linenberger. Remember the chain of command: Coach, Athletic Director, Dean of Students, Head of School.


Code of Conduct

Listed below are the regulations imposed by the OSAA. This does not however, infer that Valor Christian School International is limited to these regulations as we maintain and enforce our standards.

  1. Athletes and coaches shall at all times conduct themselves in a reasonable sportsmanship manner thus reflecting a positive image of VCSI.
  2. One would be in violation of #1 upon any of the following:
  1. Making any degrading remark about any official, coach, or opposing player.
  2. Protesting any decision or action of any official during or after the game.
  3. Making any degrading remarks or criticism of any official, coach or athlete to any news media.
  4. Using any foul, abusive, or profane language at any time.
  5. Hitting, shoving or striking any official, coach, or athlete at any time.
  6. An ejection from a competition.
  7. The use and/or display of alcoholic beverages, tobacco (including smokeless types), or other controlled substances is strictly prohibited at any OSAA event.
  8. Detaining an official following the contest to request a ruling or explanation of actions taken by the official.
  9. It shall be considered unsportsmanlike conduct for a school official to remove a team from the playing area before the game is complete.

The same Code of Conduct is required during travel to and from events as well as at any off-site event on trips.

Athletic Discipline Policy

Disciplinary action for athletes who violate team and/or school policies will be at the discretion of the coaches, in conjunction with the Athletic Director and the Dean of Students.  All disciplinary issues should be reported to the Athletic Director in writing within 24 hours of the incident.

Academic Responsibilities

Student-athletes are responsible for all assignments that are due regardless of practice and/or game schedules. Athletics, like all extra-curricular activities, are undertaken without the compromise of academics in quality and time schedules. All teachers, however, will assist athletes by being familiar with game schedules and giving enough advance notice of due assignments (i.e. book reports and science projects). All student-athletes are required to attend school and complete all assignments the day following a game regardless of arrival time the night before. Time management is very important in participating in sports. Random checks will be made before the team departs for the event.

Eligibility Requirements

VCSI extra-curricular activities are a vital part of a young person’s life, however, we believe at Valor that academics are more important. With our high academic standards, it is necessary for us to have an academic eligibility requirement for extra-curricular activities. VCSI follows the guidelines written by Oregon School Activities Association (OSAA). Students must be passing classes during the sport season in order to participate in the sport. Students with grades below 70% in any class may be required to attend tutoring to bring up the grade, and may be withheld from participating in team activities, at the discretion of the coach, athletic director and/or head of school.

Parent Volunteers

Parental support is very critical to the athletic program.  The following ways are available for your assistance.  An athletic volunteer will be in contact with you to sign up for help.

  1. Boosters
  2. Concessions at events
  3. Gate admission at home events
  4. Clock / Scoreboard Operator
  5. Gym/Event clean-up
  6. Track & Field/Cross Country event volunteer positions
  7. Fundraising Opportunities

General Responsibilities of the Parent

  1. DIET/NUTRITION – Make sure that your child receives the proper nutrition needed by the body during participation in sports. Rumor has it that pizza and soda (although a staple of the teenage diet) is not considered a healthy meal.  Discuss the importance of water to the body.
  2. PROPER REST – Please see that your child gets at least 8 hours of sleep. This is very critical at least one to two days before a game.
  3. Braces (ankle, knee) / Mouth Guards – Please notify the coach if any guard or brace is to be worn. Mouth guards (bite guards) are recommended and can be a good investment.

Equipment Responsibility

Student-athletes and their parents are responsible for school-issued gear, cleaning and bringing uniforms to each sporting event.  Each sport will have individual personal requirements (ie. shoes, knee pads, etc) At the end of the season, all athletes will be responsible for returning clean intact uniforms to the coach or Athletic Director within two weeks of the last game.  Uniforms that are damaged or lost will be the financial responsibility of the family to replace.


Practice Schedules

Each coach will provide parents and athletes with the practice and game schedule through TeamSnap at the beginning of the season. A posting of game schedules can also be found on the athletics  website.  The coaching staff is responsible for staying at the practice site for the duration of the given practice time or until all the athletes are gone. Therefore, parents need to make the effort to be sure their child is picked up by the end of practice.  Failure to pick up child on time may result in not participating.


Game Schedules

Game schedules will be provided as early as possible and updates will be posted on the school Team Snap and athletics website.  

Locker Room / Road Trip Regulations

  1. The locker rooms are not a place for “horseplay” or anything other than team meetings or changing clothes. Appropriate behavior is expected at all times.
  2. All teams are responsible for cleaning their locker room in away and home environments.
  3. All teams are responsible for maintaining a “clean” environment during a road trip.  This includes picking up after themselves in the visitor’s locker room, restaurants, as well as the cars used for travel to the competition.
  4. The coaches accompanying the student-athletes are responsible for insuring their players are in compliance with #3 above.
  5. Students who fail to comply with 2-5, are subject to disciplinary action which could lead to suspension from road trips.  Even if you did not put trash there, be courteous and pick it up.  A coach will not ask you more than once to clean an area.

Transportation Policies

The coach/sponsor of each team will determine specific guidelines for traveling to/from events.  These general guidelines that pertain to all team travel:

  1. Travel to and from games will be the responsibility of the parent.
  2. If parents carpool, this is between parent arrangements and VCSI is not held responsible for delay of arrival or any injury occurred because of accident in carpooling.
  3. Coaches are not allowed to be alone in a vehicle with an athlete for any reason.

Physical Examination

Every athlete starting in the 6th grade must have a medical examination from a medical doctor before he/she will be allowed to participate on any athletic team.  This exam must be recorded on the form provided by OSAA.  A link is located in this handbook. One exam every other school year is all that is required to play every sport for that school year.  A physical received after May 1 may be used for the upcoming school year.

Risk of Participation

By its nature, participation in athletics includes risk of injury, which may range in severity from minor to disabling to even death.  Although serious injuries are not common in supervised programs, it is impossible to eliminate all risk. Participants have the responsibility to help reduce the chance of injury. Participants must obey all safety rules, stretch properly, report all physical problems, follow proper guidelines for safe play and inspect all their own equipment.

Valor “Knights Club”

Purpose of Athletic Booster Club:

The Valor Christian School International Athletic Booster Club exists for the purpose of broadening the school athletic program and the involvement of the students and their families. The Knights Club works to achieve the following through active participation of parents, working closely with the school administration and athletic director:

  1. To support, promote, and maintain a high degree of values and good sportsmanship in all athletic activities.
  2. To support, promote, and maintain a high standard of priorities within the athletic program.
  3. To promote and encourage attendance at all sporting events by the parents, students, friends and faculty.
  4. To raise funds to assist in the development of the athletic program.
  5. To assist in holding down expenses of the athletic program by providing volunteer services which would include supervision of parking lots, assisting with admission ticket sales and collection of gate monies, working concession stands, and other club projects as may be established.

All family members are included in the “Knights Club” on the general level.  This allows the child’s immediate family admission to the home athletic events. You may wish to increase your level of admission to the games if there are multiple parents.  Please ask the Booster club representative for details.

Letter & PE Credit Requirements

(High School Students Only)

Athletic letters are awarded for all sports. It is also possible for support personnel (managers, statisticians, etc.) to earn letters, which will be determined by the coach. Regular attendance to practice is required for high school student participating in athletics for PE credit.

Lettermen’s Jacket Requirements

Lettermen’s Jackets are available to all students. Contact the Athletics Department for more information on how to order.

Team Captains

Captains can be crucial to team management and success. They may not be the ones who lift the most weight on the bench press or yell the loudest during drills, but most often earn the most respect and show the most dependability.  A captain is one who leads on the playing field, and off the playing field.  They have a solid knowledge of the sport as well as a solid Christian faith foundation. This athlete supports all team fundraisers.  This athlete recognizes that Valor is very important to them and will help in any project for school improvement. This athlete arrives early for practice ready to learn and often stays afterwards to master a technique.  He/She never complains and is excited about competing. Both the coach and the team can count on this person.

Responsibilities of Team Captains

A wise coach seeks out captains in the pre-season to discuss potential responsibilities and team goals.  Keep in mind that these must be meaningful responsibilities.  The coaching staff must be prepared to share leadership of the team with the captain(s) who should have, in fact, opportunities to address teammates (“Captains’ Talks”) either before or after practices.  Choice of team captain is at the sole discretion of the head coach.


Financial Obligations of Equipment

Below is listed the 2017-18 athletic fees broken down by grade. Certain activities require that students provide some of their own equipment and/or clothing.  Each coach or sponsor will provide all the potential participants with a list of required obligations.    

Elementary Sports                        $50 per sport

Middle & High School                $150 per sport

*At the coach’s and parent’s discretion, 5th grader student-athletes can join a middle school team for the same price as the 6th grade fee per sport.

1A-1 The Valley 10 League

Below is a list of schools we will most likely compete against at team events.  This is not an exhaustive list and we may play teams outside this league at times.  This list is subject to change per OSAA guidelines and membership levels of schools.

Country Christian -                 17186 OR-211, Molalla, OR 97038

Damascus Christian-                 14251 SE Rust Way, Damascus, OR 97089

Grand View Christian Acad         14855 S Leland Rd, Beavercreek, OR 97004

Life Christian School

North Clackamas Christian -         19575 Sebastian Way, Oregon City, OR 97045

Open Door Christian Acad. -         27710 SE Strebin Rd, Troutdale, OR 97060

Portland Waldorf  -                 2300 SE Harrison St, Milwaukie, OR 97222

Southwest Christian -                 14605 SW Weir Rd, Beaverton, OR 97007

St. Stephens Acad. -                 7275 SW Hall Blvd, Beaverton, OR 97008


Metro Christian League West (MCLW)

Below is a list of schools we will most likely compete against at team events.  This is not an exhaustive list and we may play teams outside this league at times.  This list is subject to change per MCLW guidelines.

C.S. Lewis Academy                         609 Wynooski St, Newberg, OR 97132

Faith Bible Christian School                 4435 SE Tualatin Valley Hwy, Hillsboro, OR 97123

Forest Hills Lutheran Christian School  4221 SW Golf Course Rd, Cornelius, OR 97113

Gilkey International Middle School         8500 NW Johnson St, Portland, OR 97229

Life Christian School                        5585 SW 209th Ave, Aloha, OR 97007

Pilgrim Lutheran                         5650 SW Hall Blvd, Beaverton, OR 97005

Portland Jewish Academy                 6651 SW Capitol Hwy, Portland, OR 97219

St. Stephens Academy                7275 SW Hall Blvd, Beaverton, OR 97008

Southwest Christian                        14605 SW Weir Rd, Beaverton, OR 97007

Tualatin Valley Junior Academy         21975 SW Baseline Rd, Hillsboro, OR 97123

Oregon Episcopal School                 6300 SW Nicol Rd, Portland, OR 97223

Veritas                                  401 Mission Dr, Newberg, OR 97132

Forms to be returned to Coach / Athletic Director

  1. OSAA Medical Examination & Consent to treat form: 
  2. OSAA Concussion Consent form: 
  3. OSAA Transfer Form (students who enroll in school, after start of the year): 
  4. OSAA Student intent to transfer form 
  5. Consent to Treat & Waiver Form pg16 of this handbook
  6. Parent/Athlete Handbook Consent Form at end of handbook. pg 17

School Directory – Important Phone Numbers & Emails

VCSI Phone                                        503-649-1592

VCSI Fax                                        503-649-8031

Head of School – Angie Taylor      

Dean of Students – Rashell Linenberger        503-260-9568


Athletic Director – Matt Dietrich                503-332-6299                                

        Individual coach’s emails and phone numbers will be printed on the schedules.

*As a courtesy these contacts are provided. The use of these contact points need to keep in mind the chain of command (Coach/AD/Dean/School Head).

*VCSI Athletic Handbook is assembled by the Athletic Department for the purpose of communicating philosophy, purpose, and operational guidelines with approval from the head of school and school board for the 2017-18 academic year.

Content and formatting suggestions were pulled from the following sources:

OSAA Individual Eligibility

8.       Rule 8 – Individual Eligibility                                                                                                                                         

The purpose of Rule 8 is to preserve harmony among member schools and school districts by preventing not only actual proselytization, professionalism and participation by other than regular students in good standing, but conduct or circumstances, which may give rise to the appearance thereof.  Exceptions to the general rules herein will be narrowly construed to serve that purpose.

8.1.        Academic Eligibility.

Rule:  An eligible student must be enrolled full time and making satisfactory progress as defined in this rule.

Rationale.  The objective of the academic eligibility rule is to complement member schools’ curriculum programs in recognition of the fact that interscholastic activity programs are an extension of the classroom.  Academic standards help ensure a balance between activities and academic performance, promote the objective of graduation from high school, ensure that student participants are truly representing the academic mission of the institution and allow the use of interscholastic participation as a motivator for academic excellence.  It is in the interests of the member schools and the students participating in athletics and interscholastic activities that these objectives be promoted during the entire school year.

8.1.1.        Full Time Enrollment.  For purposes of this rule, a full time student is one who is enrolled in high school, attending regularly and passing in courses offered by a high school, college, work experience or other school-approved educational activities (including summer school or night school) equivalent to at least the quantity listed on the appropriate line of the chart below.  In addition, a full time student shall have been enrolled in school, attended regularly and passed subjects equivalent to at least the quantity listed on the appropriate line of the chart below during the immediate preceding transcripted grading period. 

Number of Classes Offered                    Minimum Number Passed

4                                                                              3

5                                                                              4

6                                                                              5

7                                                                              5

8                                                                              5

EXCEPTION:  The requirement for immediately preceding transcripted grading period credit is inapplicable to a student who has not previously enrolled in any high school offering the 10th, 11th or 12th grades.

8.1.2.        Satisfactory Progress Toward Graduation.  In addition to the specific credit requirement identified in Rule 8.1.1., to be scholastically eligible, a student must be making satisfactory progress towards the school's graduation requirements by earning a minimum of the quantity of credits indicated on the chart below prior to the start of the specified year.

Minimum Satisfactory Progress Requirements    (Expanded Chart)

Credits to Graduate








Credits Per Year








Required Prior to Year 2 (75%)








Required Prior to Year 3 (85%)








Required Prior to Year 4 (95%)








Taken from:

Valor Christian School International



PARENTS/GUARDIANS: Please complete this form and have your student athlete return it to the school office. This form must be completed annually! Also current insurance and a sports physical must be returned and on file prior to the first day of practice. A sports physical is required every two years, beginning in the 7th grade. A participation fee will be billed for each season of participation.

Student Name________________________Grade____Address_____________________________________________

Parent(s)/Guardian(s) Name(s)_______________________Phone(H)__________(W)_____________ (C)____________

Person other than you to notify in case of Emergency ___________________________Phone_____________________

Family Doctor_______________________________________Phone_________________________________________

Please check all activities your student plans to participate in:

____Volleyball ____Soccer ____Cross Country _____Basketball _____Track & Field

____Speech & Debate _____Music

STUDENT INSURANCE (Every participant must have insurance – either personal insurance or

purchased school insurance (available from

The undersigned, the parents/legal guardians of ________________________________, request that he/she be released

from the obligation of carrying insurance under the regular school plan of Valor Christian School International, Beaverton, Oregon, for the above marked activities during this school year, including school sponsored summer activities, and in doing so, assume all the responsibility and risk for injuries that may be incurred as a result of his/her participation in the activity. The School is also assured by the undersigned that the above-named student is properly insured against such injuries by this insurance company.

NAME OF INSURANCE COMPANY______________________________DATE_____________



The undersigned, the parent(s)/legal guardian(s) of ______________________________, give our consent for him/her to

participate for Valor Christian School International in OSAA approved activities, and to go with the coach on any trips in

connection with this participation. We agree that in the event of the school’s inability to contact us in an emergency

situation, a licensed physician may take such action as is deemed necessary and proper to treat our child. We are aware

of the standards which our son/daughter is expected to uphold, and we understand that participation in Southwest

Christian School Activities is a privilege which depends on our child’s upholding those physical, moral, personal and

academic standards. I hereby release and hold harmless Valor Christian School International and any staff or volunteers related to this activity from any liability, illness or expenses that may arise from my child’s participation. I acknowledge that I am responsible for any and all medical expenses or other charges in connection with my child’s/ward’s participation in this activity.



Student & Parent Handbook Consent Form

I acknowledge that I have read the VCIS 2018-2019 Student-Athlete Handbook and will abide by its rules and expectations and in doing so I will represent my family, my school, and my Christian faith to the best of my ability.  I will also encourage my family members both immediate and extended to honor these guidelines when cheering at sporting events for VCSI.

One form per athlete per year must be on file please.

_______________________________        ___________________________

Student-Athlete Signature                        Date:        

_______________________________        ___________________________

Parent / Guardian Signature                        Date:        

_______________________________        ___________________________

Parent / Guardian Signature                        Date: