MMS Athletic Permit Form
Athletic Permit Form
Email address *
Student Last Name *
Student First Name *
Sport Participating In: *
Date of Birth *
Year in School *
All Mascoutah student athletes will be required to pay a fee for participation in the MMS Athleic Programs. The fee charged is $30.00 for the first and second sport. The maximum fee per athlete is $60.00. The fee must be paid before the first scheduled practice for the sport in which the athlete is participating. If fee is not paid prior to the first scheduled practice the athlete will be ineligible to compete until the fee has been paid.

A student athlete must pay his/her MMS basic fees before the athlete will be able to participate in athletics.

The athletic fee may be refunded if the athlete is injured before the first scheduled contest. After the first scheduled game there will be absolutely no refunds for any reason.


Students are given the opportunity to participate in the following interscholastic sports: Soccer, Baseball, Softball, Cross Country, Bowling, Wrestling, Basketball, Track, Volleyball, and Cheer.

My son/daughter has my permission to practice and compete in the interscholastic sports listed above. In addition, we realize that such activity involves the potential for injury, which is inherent in all sports. We acknowledge that even with the best coaching, use of the most advanced protective equipment and strict observance of rules, injuries are still a possibility. On rare occasions these injuries can be severe.
PARENT(S) Signature *
Date: *
Every athlete is fully responsible for any uniforms or practice equipment issued to him/her, whether it is lost or stolen. All issued equipment and uniforms must be returned to MMS at the conclusion of the season. Restitution for any lost items will be made at replacement cost and is due immediately at the conclusion of the season.

Athletic awards will be held if equipment is not returned or if restitution is not made for lost equipment.
The extra-curricular code of conduct is cumulative beginning with the student and parents signing and continuing throughout the student's middle school career. The procedures are in effect on and off campus throughout the entire calendar year, including weekends and summer and do not supersede, but are in addition to, District #19 school disciplinary procedures.

We, the athlete and parent(s) have read and had the opportunity to ask any question we may have had, and understand all elements of the Mascoutah Community Unit School District #19 Extra Curricular Code of Conduct. Furthermore, as the parent I agree to support these codes and the above items. As the athlete, I agree to comply with all sections of the code and the above items.
Signature of Parent(s): *
Signature of Athlete: *
Date: *
Athletic Waiver Form/ Mascoutah Community District #19
The Mascoutah School District requires that all athletes have proof of insurance before they can compete in any sport. This can either be in the form of school-time insurance coverage or proof of family insurance coverage. This must be on file before any athlete is allowed to participate in any practices or games.

This form will be good for one calendar year and will cover the athlete for all sports they participate in. The school and the state requires that all athletes have a current physical on file (examination date cannot exceed 13 months.)
We will purchase school insurance *
We will provide our own insurance *
Insurance Company *
We will be using military provided services *
Accident or Injury
We agree that in the case of an accident or injury, we will not hold the Board of Education of Mascoutah Unit District #19 or it's designated representatives responsible. We certify that the above insurance information is accurate to date.
Student: *
School: *
Address: *
Grade: *
Parent/Guardian Signature: *
Date: *
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 concussions may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussions, or if you notice the symptoms or signs of concussions yourself, seek medical attention right away.

Symptoms may include one or more of the following:
“Pressure in the head”
Nausea or vomiting
Neck pain
Balance problems or dizziness
Blurred, double, or fuzzy vision
Sensitivity to light or noise
Feeling sluggish or slow down
Feeling foggy or groggy
Change in sleep patterns
“Don't feel right”
Fatigue or low energy
Nervousness or anxiety
More emotional
Concentration or memory problems
(forgetting gameplays)
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 in coordination
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

Adapted from the CDC and the third International Conference on concussion in sport
Document created 7-1-2011
Concussion Information Sheet
What can happen if my child keeps on playing with a concussion or returns too soon?

Athletes with signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of concussion leaves the young athletes especially vulnerable to greater injury. There is an increase 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 severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that the adolescent or teenage athletes will often fail to report symptoms or injuries. Concussions are no different. As a result, education of administrators coaches parents and students is the key to student-athletes' 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 seemed or how quickly symptoms clear, without medical clearance. Close observation of the athletes should continue for several hours. IHSA policy requires athletes to provide their school with written clearance from either a physician licensed to practice medicine in all its branches or a certified athletic trainer working in conjunction with a physician licensed to practice medicine in all its branches prior to returning to play or practice following a concussion or after being removed from an interscholastic contest due to possible head injury or concussion and not cleared to return to that same contest. In accordance with state laws all IHSA member schools are required to follow this policy.

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

For current and up-to-date information on concussions you can go to:
IHSA Return to Play Policy
Background: With the start of the 2010-11 school term, the National Federation of State High School associations (NFHS) implemented a new National playing rule regarding potential head injuries. The rule requires “any player who exhibits signs symptoms or behaviors consistent with concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) shall be immediately removed from the game and shall not return to play until cleared by an appropriate healthcare professional.” In applying that rule in Illinois it has been determined that only certified athletic trainers and physician's licensed to practice medicine in all it's branches in Illinois can clear an athlete to return to play the day of a contest in which the athlete has been removed from the contest for a possible head injury.

Policy: In cases for an athlete is not cleared to return to play the same day as he she is removed from a contest following a possible head injury or concussion the athlete shall not return to play or practice until the athlete is evaluated by and receives written clearance from a licensed healthcare provider to return to play.

For the purposes of this policy licensed healthcare providers consist of physicians licensed to practice medicine in all its branches in Illinois and certified athletic trainers working in conjunction with physician's licensed to practice medicine in all it's branches in Illinois.
Signature of Athlete: *
Signature of Parent(s): *
Signature of Parent(s): *
Mascoutah Community Unit School District #19 Extra-curricular Code of Conduct
Participation in extra-curricular activities is a privilege and not a right. Furthermore, participation is optional and voluntary and requires the acceptance of additional conditions, which do not necessarily apply to all students. One of these conditions and additional responsibilities is the maintenance of the highest degree of citizenship.

Extra-curricular activities are an extension of and adjunct two formal classroom education. Participants and extracurricular activities are public representatives of their school, school district and community.

Accordingly, the administration of Mascoutah High School and the Mascoutah Middle School, with the consent in approval of the superintendent of schools and the board of education, has officially announce the following rules apply to all high school students enrolled at Illinois high school and middle school extracurricular activities on or after the date of adoption on this document.

Each participant and parent is asked to study these procedures closely and to agree in writing to confirm. Participating students and parents must accept the fact that extra-curricular activities are controlled by the school. Since participation is voluntary, any student who cannot meet the procedures as set forth below shall refrain from participation. The extracurricular code is cumulative beginning with the student and parent signing of this code continuing throughout the students entire high school or middle school career. These procedures are in effect on or off campus throughout the entire calendar year, including weekends and summer, and do not to proceed, but are in addition to, District #19 School disciplinary procedures.

A signature by the participant and indicates they are prepared to meet and accept these provisions.
1. A student may be suspended from participation in any activity according to the following procedure
1a. All reports of violations of the code of conduct are to be made either the administration for the director of Athletics.
1b. The administration or athletic director will contact the student, the parents, the coach or sponsor to inform them of the violation and the penalties. If requested, a meeting is scheduled with the activity Council within three school days. The activity Council includes the assistant principal, the athletic director and the coach or activity sponsor if not Athletics. His/her parents may attend if they desire. The principal may substitute for any of their members.
1c. The athletic director or activity sponsor will notify the student and his/her parents of the decision and penalty, if to be imposed or confirmed, immediately following the discussion the conclusion of the scheduled meeting.
1d.Penalties will be applied in every area of activity in which is didn't participate. Any of the offense constitutes a violation in all activities covered under the guidelines.
The students participating in the following activities will be considered in violation of the extracurricular code of conduct. Under these procedures a student who knowingly uses, attempts to use, possesses, cells or assist any other student in the following:
use of tobacco in any form, whether smokeless or otherwise on school property or in violation of rules or promulgated by the coach or sponsor;
possession, sale, distribution, transporting and or use of beer, wine, whiskey or any other alcoholic beverage;
possession, sale, distribution, and or use of any form of controlled substance, illegal drugs, look-alikes, drug paraphernalia other than those prescribed by a physician.
Violation of the above listed activities will result in the following disciplinary measures.
1st offense
The first violation will result in a suspension of two weeks from all activities. The athletic representative will be suspended for 25% of the contest in their current season or the first scheduled sport in which the individual wishes to participate.
2nd offense
A second violation in the same school year of anyone or more of the rules will result in a penalty of suspension from all activities from the balance of the school year.
3rd offense
A third violation in the same or any prior year of any one or more of the rules shall result in the penalty of suspension from all activities during the balance of the student enrollment in any Mascoutah School with no appeal process.

If the student is in violation of to see above drugs or is driving a vehicle or alcohol contribute to an accident in which a personal injury is involved, the activity Council will invoke a penalty of suspension for a season or the school year and bypass the progressive penalty procedure.

3. Attendance at illegal parties or illegal activities: attendance at illegal parties or other illegal activities including while and an occupant or passenger in a vehicle or alcohol or illegal substances are present, will be suspended for no less than 25% of scheduled contest for each occurrence.
4. Hosting of illegal parties: exclusion from participation. Parental consent to possession and or used shall not be a defense.
5. The Activity Council will review all situations in which a student: engages in vandalism or damages school property; convicted of a non-traffic misdemeanor or a felony. The Activity Council may suspend the student from all activities for the balance of the school year or impose a lesser penalty.
6. Eligibility
6a. Eligibility (High School only): A student must be enrolled in and passing twenty (20) hours of classroom work each week in order to remain eligible. A classroom contact Mark will count as the same as an academic failing mark. A student must have also passed twenty (20) hours of classroom work the previous semester. However the previous semester rule does not apply to first semester entering freshman. A person declared ineligible under the previous semester will May in the consent of the Activity Council and coach or sponsor of the activity in question join a team for the purpose of practice only. This person will not be allowed to participate in any level of competition in any activity during the semester of ineligibility. During the semester of an eligibility if a person is allowed to participate in practice sessions he she must maintain a minimum grade of “C” weekly in each class. Monitoring of the students grades is the responsibility of the athletic director. If a student's grade in any class falls below a “C” at any time, the student must be declared ineligible for participation in as a “C” grade is maintained in all subjects.
6b. Eligibility Middle School only no middle school student grades will be no F grades exist the student becomes eligible once again.
6c. Passing for the purposes of 6 a.m. and 6 p.m. all grades must be D or above.
7. Required forms for participation for athletic activities a current physical exam. A person becomes ineligible on the day the physical date exceed One calendar year. Non-athletic activities such as speech, band and chorus are required only to sign the code of conduct.
8. Absences: If a participant is not in attendance for 5 full periods, he/she will not be eligible to practice or play in a contest with the following exceptions:
8a. absence due to death and family.
8b. absence due to school sponsored field trip.
8c. prior approval by principal or assistant principal.

Absence due to illness is not an exception because if a student is too ill to attend class, he or she should not on the same day, participate in an activity or contest. Being in attendance and spending the majority of the day in the nurse's office will not be considered as being in attendance.

Student suspended from school will not be allowed to participate in activities or Athletics well they are on suspension.

9. Each coach or sponsor has a prerogative to establish additional rules pertaining to the activity supervisor. These rules may include attendance at practice, curfew, dress and general conduct of participants at practice, games or trips, rules set by individual culture sponsor must be in writing and approved by the administration and communicated to student participants before activity begins
10. Personal Appearance: while it's cool in school activities, students and their attire should be neat and clean at all times. Male athletes will follow ihsa standards concerning facial hair.
11. Equipment: participants are responsible for school equipment checked out to them. the participants must return all equipment no later than 1 week after the conclusion of the activity. If this is not done the individual is prohibited from participating in all other activities until the equipment is paid for, or return to the school.
12. Awards: awards are determined and issued at the discretion of each individual sponsor.
13. Appeal Process: question and his or her parents May appeal a decision in writing within three (3) school they said the suspension. A Review Board consisting of Head Coach, Athletic Director is Athletics, Activity Sponsor if not athletics and Administrator will review the appeal within five (5) school days are receiving the appeal.
Signature of Athlete: *
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