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CSLA Athletics Registration ~ 3rd-12th grade
Student-Athlete First Name *
Your answer
Student-Athlete Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Gender *
Student's Date of Birth *
MM
/
DD
/
YYYY
Grade for 2018-19 *
Please check any sports in which you think your child may participate
Anticipated Sport Participation for 2018-19 (Notification from a parent/guardian that a student wishes to add a sport from this list at a later date, validates this form for that sport) *
Required
School attended LAST year (2017-18) *
Father/Guardian Name *
Your answer
Father/Guardian best phone number *
Your answer
Father/Guardian Email Address *
Your answer
Mother/Guardian Name *
Your answer
Mother/Guardian best phone number *
Your answer
Mother/Guardian Email Address *
Your answer
Emergency Contact (other than Parent/Guardian) *
Your answer
Emergency Contact Relationship to Student *
Your answer
Emergency Contact Phone *
Your answer
Allergies *
Medical conditions *
Current Medications *
Primary Physician *
Your answer
Primary Physician Phone *
Your answer
Insurance
CSLA requires each family to have a current medical/accident insurance policy (see CSLA Parent/Student Handbook). We also require each family to keep CSLA informed of any changes to insurance and emergency contact information. The school’s online RenWeb access should be used for any changes. Home school student insurance changes should be forwarded to the Athletics Director immediately. By signing below you (parent/guardian) confirm that you have up-to-date insurance and that the information noted on Renweb and on this form is current and accurate.

It is understood that C.S. Lewis Academy is not liable for any medical, dental, or hospital bills occurring as a result of athletic injuries by a student while participating in a supervised sport, and that such bills, in excess of insurance benefits, shall be the responsibility of the student-athlete's parents/guardians.

Participants in the CSLA Sports Program who are not daily students at CSLA (Home School) are required to submit a front and back copy of a valid medical insurance card covering your son/daughter and a completed CSLA emergency contact form. .

Medical Insurance Company *
Your answer
Policy Number *
Your answer
Verification *
I verify that the information above is correct and up to date
Required
Participation Agreement
I give my permission for my son/daughter to participate in the C.S. Lewis Academy athletic program, realizing that such activity involves the potential for injury, which is inherent in all sports. I acknowledge that even with the best coaching, use of the most protective equipment, and strict observance of rules, injuries are still a possibility.

I further recognize that medical treatment on an emergency basis may be necessary at a time when I am not available to give my consent in advance of such emergency care, and I give permission to the school to authorize such care as may be deemed necessary under existing circumstances. Consent is also given for an emergency referral to an appropriate physician if, in the opinion of appropriate coaches and representatives of the school, further evaluation is needed.

I hereby give permission for records for my son/daughter of any diagnosis, diagnostic testing, and/or treatment be released to C.S. Lewis Academy and/or its insurance carrier, in order for them to be better informed of his/her medical condition and capabilities while participating in athletics for C.S. Lewis Academy. I understand that the disclosure of protected health information will only be used for the purpose of providing treatment or to conduct healthcare operations of either C.S. Lewis Academy or an emergency care facility.

I acknowledge that participation in the sport or sports described above involves risk to the Participant (and to the Participant’s parents or guardians, if the Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage.

In consideration for the opportunity to participate in the sport or sports described above, the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the Activity. The Participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the sport or sports or during transportation to and from the sport or sports, as well as for any medical treatment rendered to the Participant that is authorized by C.S. Lewis Academy or its agents, employees, volunteers, or any other representatives.

Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless C.S. Lewis Academy or its agents, employees, volunteers, or any other representatives, for any injury arising directly or indirectly out of the described sport or sports or transportation to and from the Activity, whether such injury arises out of the negligence of the Activity Sponsor, the Participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and C.S. Lewis Academy cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.

Student-Athlete Agreement *
I have read the Athletics Guidelines and reviewed it with my parent(s). I accept all conditions associated with becoming a member of the CSLA Athletics program. I am committed to becoming a CSLA student-athlete and will do my best to meet all expectations of membership in the program. By typing your name in the signature box and clicking submit at the end of this document, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions. (type name)
Your answer
Parent/Guardian Agreement *
I acknowledge that I have read and understand this warning. I have also provided information concerning insurance. By typing your name in the signature box and clicking submit at the end of this document, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions.(type name)
Your answer
2018-19 Athletic Guidelines
The CSLA Athletics program is administered utilizing the policy and guidelines as set forth in the CSLA Athletics Program Handbook (available on the CSLA website under PARENT LINKS). By signing below you acknowledge receipt of that handbook and understanding and accepting the school policies regarding Athletics.
Parent/Guardian Agreement *
I have read the Athletics Handbook noted above and reviewed it with my son/daughter. I accept all conditions associated with becoming a member of the CSLA Athletics Program, especially encouraging and supporting the coach and athletic staff. I am committed to becoming a CSLA Team Supporter and will do my best to meet all expectations of membership and help my son/daughter to hold to their responsibilities and commitments for their personal growth, the strength of the team and most importantly to strengthen their walk with the Lord. By typing your name in the signature box and clicking submit at the end of this document, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions. (type name)
Your answer
Student-Athlete Agreement *
I have read the Athletics Handbook and reviewed it with my parent(s). I accept all conditions associated with becoming a member of the CSLA Athletics Program. I am committed to becoming a CSLA student-athlete and will do my best to meet all expectations of membership in the program. By typing your name in the signature box and clicking submit at the end of this document, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions. (type name)
Your answer
Participation Fee
Like most schools, CSLA charges a fee for participation in Athletics. The fee is due no later than the first date of competition for the particular sport. Special arrangements for a payment plan may be made through the Finance Office.

Grade School: 3-5th Soccer/3-4th Basketball: $40
Grade School Volleyball 4-6th/Basketball 4-6th/Track & Field 5th: $80
6th Graders playing both 4-6th and MS volleyball pay $100

Middle School Soccer, Volleyball, Basketball, Track & Field: $130
6th Graders playing both 4-6th and MS basketball pay $100

High School Soccer, Volleyball, Basketball, Track & Field, Golf: $180

Payment can be made by check sent to the FINANCE OFFICE, or online. Payment by credit card does require a small convenience fee.

Any practice or game uniforms or equipment issued to a student-athlete is the responsibility of that student-athlete. Students will be held monetarily accountable and replacement charges added to the student's financial account for unreturned uniforms or equipment.

Participation Fee Verification *
Required
Physical Examinations
Comprehensive physical exams are required for all first-time participants from the 7th grade forward, and every two years thereafter, for example as 7th graders, 9th graders and as 11th graders. Successful results of the physical examination are required for participation. These physicals are the responsibility of the family and the family physician.

The State Board of Education adopts by reference the form entitled "School Sports Pre‐Participation Examination May 2017" that must be used to document the physical examination and sets out the protocol for conducting the physical examination. Medical providers conducting physicals on or after June 30, 2010 must use the form dated May 2017.

Stat. Auth: ORS 326‐051<br>
Stats. Implemented: ORS 336.479<br>
Hist.: ODE 24‐2002, f. & cert. ef. 11‐15‐02; ODE 29‐2004(Temp), f. & cert. ef. 9‐15‐04 thru 2‐25‐05; ODE 4‐2005, f. & cert. ef. 2‐14‐05

If the student-athlete has NOT completed a per-participation physical, they CANNOT participate in practices or contests until the physical is completed, cleared, and submitted to the athletic office.

Link to Physical Examination Form:
http://www.osaa.org/docs/forms/PhysicalExamination-English2017.pdf

Physical Exam Verification *
Required
Transportation
During the course of the sports season, your child will be involved in contests and/or practices held away from the C.S. Lewis campus. The following guidelines relate to transportation of student-athletes for these events.

When teams travel for games/practices away from the C.S. Lewis campus, transportation may be furnished by the school. When school transportation is provided, student-athletes must travel both to and from the location of the contest by school-provided transportation unless exceptions are granted by an official coach of that team, the director of athletics, or a CSLA administrator.

For many activities CSLA will not be providing transportation to and from the event. For those events/activities, CSLA has a private transportation policy. Every family must complete the Private Transportation Release form yearly. That information, including a family's desire to transport independently, will be used for athletics event transportation purposes.

Transportation Verification *
High School Transfers and Foreign Student Information
These additional forms may be required if your student is a transfer from another district, or is a foreign exchange student:

Eligibility Student Transfer Certificate (for 10th-12th grade students transferring in to CSLA from another school at the beginning of the school year or 9th-12th grade students transferring in to CSLA after the school year has started) The Eligible Student Transfer Certificate form linked below must be turned in.

Foreign Student Transfer Certificate -any exchange student wishing to participate for CSLA athletics needs to download and review the Foreign Student Eligibility Certificate linked below.


Eligibility Student Transfer Certificate
http://www.osaa.org/docs/forms/EligibleStudentTransferCertificate.pdf

Foreign Student Transfer Certificate
http://www.osaa.org/docs/forms/ForeignStudentEligibilityChecklist.pdf

Home school students (high school only)
We are excited to welcome new student-athletes to the C.S. Lewis community by way of our home school athlete program. However, it is our duty to protect C.S. Lewis Academy by making sure we are in full compliance with the regulations pertaining to student-athlete eligibility.

Since we are under the governance of the Oregon School Activities Association (OSAA) the requirements are somewhat extensive.

Please note that our association with the Metro Christian League prevents us from allowing home school students to participate at the grade school or middle school levels.

1. For your student-athlete to be considered a “home school” student, you MUST meet all criteria as outlined on the OSAA Parents Checklist (see below).

2. A student who is enrolled full time at another OSAA member or associate member school (recent suggestions have been Estacada Charter and Connections Academy), would not qualify as a home school student and would not be allowed the athletics eligibility provisions of a home school student. In most of these cases the student may be allowed to participate in athletics at his/her local public school, but not CSLA.

The OSAA has emphasized that as a home school parent, you must be diligent in following Oregon State law. You can find the pertinent State laws and statutes linked from the ESD site. (see below)

Home School Student-Athlete Additional Requirement List

1. One time only, you will need to complete the OSAA School Representation Eligibility Certificate.
(see below)

2. Initialed and signed copy of the OSAA Checklist (yearly-see below)

3. Letter of confirmation from ESD. Link to Willamette ESD, serving Yamhill County. (one-time-see below)

4. Copy of the test results noted on checklist showing a proficiency which meets OSAA criteria. (submitted yearly)

5. Copy of a current Insurance Card submitted to the Director of Athletics


OSAA School Representation Eligibility Certificate
http://www.osaa.org/docs/forms/SchoolRepresentationEligibilityCertificate.pdf

OSAA Home School Checklist
http://www.osaa.org/docs/forms/HomeSchoolEligibilityParentChecklist.pdf

Willamette Valley ESD
https://www.wesd.org/homeschool


Concussion – Private School Informed Consent
Excerpt OSAA Handbook, Executive Board Policies - Concussion Management (Revised Fall 2015)

A. “Member Private School’s Responsibilities (Max's Law, ORS 336.485, OAR 581-022-0421) (Jenna’s Law, ORS 417.875)

1) Suspected or Diagnosed Concussion: Any athlete who exhibits signs, symptoms or behaviors consistent with a concussion following an observed or suspected blow to the head or body, or who has been diagnosed with a concussion, shall not be permitted to return to that athletic contest or practice, or any other athletic contest or practice on that same day. In schools which have the service of an athletic trainer registered by the Oregon Board of Athletic Trainers, that athletic trainer may determine that an athlete has not exhibited signs, symptoms or behaviors consistent with a concussion, and has not suffered a concussion, and return the athlete to play. Athletic trainers may also work in consultation with an appropriate Heath Care Professional (see below) in determining when an athlete is able to return to play following a concussion.

2) Return to Participation: Until an athlete who has suffered a concussion is no longer experiencing signs, symptoms, or behaviors consistent with a concussion, and a medical release form signed by an appropriate Health Care Professional (Physician (MD), Physician’s Assistant (PA), Doctor of Osteopathic (DO) licensed by the Oregon State Board of Medicine, nurse practitioner licensed by the Oregon State Board of Nursing, or Psychologist licensed by the Oregon Board of Psychologist Examiners) is obtained,the athlete shall not be permitted to return to athletic activity.

3) Private Schools Only: On an annual basis prior to participation, private schools shall require each student and at least one parent or legal guardian of the student to sign the Concussion -Private School Informed Consent form acknowledging the receipt of information regarding symptoms and warning signs of concussions. Private schools shall maintain a copy of each student's signed form on file for review at any time by the OSAA staff.

See OSAA Executive Board Policies, “Concussion Management” for additional information.

Concussion Information
With a medical focus on concussions, our understanding of these injuries continues to evolve.

In addition, the OSAA has collected several documents outlining the most recent information about diagnosis and returning from concussions: Please take time to review this information.

The links below give you, as a parent, some immediate information on the symptoms and warning signs of concussions.

OSAA~ Parent Guide to Concussion
http://www.osaa.org/docs/health-safety/ParentGuidetoConcussionApril2013.pdf

OSAA~ Health/Safety- Concussions
http://www.osaa.org/health-safety/concussion


Jenna's Law Compliance Statement
I certify that:

1. I have been provided with information on concussions in high school sports in compliance with ORS 417.875.

2. I understand that on an annual basis, the Concussion – Private School Informed Consent form shall be signed and turned into my school’s Athletic Director by myself (or my parent or legal guardian if I am under the age of 18 years old) prior to my participation in a practice or competition.

Student-Athlete Signature *
By typing your name in the signature box and clicking submit, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions. (type name)
Your answer
Parent Guardian Signature *
By typing your name in the signature box and clicking submit, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions. (type name)
Your answer
THANK YOU!
Thank you for completing this form. It is only required once per-year, per-student-athlete.

However, should your student-athlete decide at a later date to add a sport not indicated here, the Athletics Director will need a note/email stating your desire to add that sport to this form.

See you on the field/court!

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