PLEASE READ IMPORTANT INFORMATION

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1 CHECKLIST Dear Parents/Guardians: It is important that ALL parts of the eligibility packet are completed before they are returned to the athletic department. Incomplete packets will not be processed. Below are the items included in the eligibility packet, please check to make sure you have each completed: Acknowledgement Page Welcome To Our Program Parent/Guardian Participation Agreement/Scholarship Request Volunteer Form Athletic Parent Consent and Physician s Statement Note: This is different from the general physical form already submitted to school. All students must be cleared by a doctor as physically fit to engage in sports. The form is valid for the entire school year. Athletic Emergency Cards Note: This is a different card than the school emergency card and is kept with the Athletic Directors and in the Main Office. Athletic Insurance Coverage Permission To Ride Slip Registration: ** PLEASE READ IMPORTANT INFORMATION $75 for the first sport and $50 for each additional sport is requested to help support these programs. These programs are dependent on your contributions to cover costs associated with each sport. Uniform use, referee and tournament fees, and other associated expenses will be covered by the above dollar amount. In addition, each team participant will be expected to participate in a fundraiser to pay for coaches, equipment, and sports banquets. Please make checks payable to Panther Partners of CCMS. (If your child does not make one of our teams a full refund will be given). Please mark the sport your child will participate in: Fall Sports: Winter Sports: Spring Sports: Girls Volleyball Girls Basketball Girls Softball Flag Football Boys Basketball Boys Volleyball Cross Country Girls Soccer Boys Lacrosse Boys Soccer The sports season will begin in September. We are excited to have both you and your child involved in the CCMS Athletic Program.

2 WELCOME TO OUR PROGRAM Over the years, locally and nationally, we have observed an ever-increasing trend towards more organized and more competitive sports for children. At the same time, other alarming trends have been occurring. Children are usually burned out on sports by the time they reach high school. The less proficient, as well as the more proficient student athletes, are not enjoying sports for its own sake; children are being rated as good or bad athletes early in their career development for some. Everyone is aware of the poor role models frequently set by parents and coaches. The CCMS After-School Sports Program is designed so that every child feels like a winner and achieves self-esteem through sports. Our emphasis at CCMS is on having fun and learning to enjoy the sports. We emphasize learning life long values of sportsmanship, respect for self, respect for others, and sound attitudes about winning and/or losing. Competition is an important part of the program, but it is kept in its proper perspective. How the team wins or loses and how the members of the team feel about themselves are even more important. CCMS After-School Sports Program does not hope this happens by osmosis. It is all part of the plan that includes orientation of parents and children, special take home materials, and special events designed to bring the message home.

3 Dear Parents/Guardians: CCMS thrives to nurture all students to reach their potentials in academics as well as in athletics. With the upcoming athletic season approaching fast, it is imperative for parents/guardians to note the following statement: All students participating in an after school sport must maintain an overall 2.0 GPA in order to participate. Students, who do not make the special team, can sign-up for intramural games during lunch. Please contact Mr. Azad for more information regarding intramural sports at Please sign below to acknowledge that you have read and understand the above statement. This entire page needs to be returned to school. Student s Name: Parent s/guardian s Name: (Please Print) Parent s/guardian s Signature: The CCMS sports program is dependent on your contributions to cover costs associated with maintaining a quality program, however, scholarships may be requested below. I am requesting a scholarship because I am able to pay the requested uniform donation of $20

4 Participation Agreement At Culver City Middle School we thrive on educating the whole child. One way to achieve this important task is through athletics. Sports allow children to build character by working with adult role models. In order to maintain a positive and productive program at CCMS, we ask the parents of our students/athletes to agree to the following: 1. Support ALL children in the program 2. Respect the decisions of the officials 3. Respect the decision of the coaches 4. Support and respect the staff at CCMS I have read and agree with the terms of parent involvement and participation: Name of Student: (Please Print) Name of Parent/Guardian: Signature of Parent/Guardian:

5 Culver City Middle School VOLUNTEERS Please check the following if you are interested in volunteering in the CCMS After School Sports Program. I would like to participate in the CCMS Panther Partners. I would like to be a team parent for Name of Sport I would like to make a donation (payable to CCMS Panther Partners) in the amount of : $25 $50 $100 $250 other $ Student s Name: Student s Grade: Parent s Name: Home Phone Number: Cell Phone Number: Work Phone Number:

6 Athletics CULVER CITY UNIFIED SCHOOL DISTRICT CULVER CITY MIDDLE SCHOOL - ATHLETIC EMERGENCY CARD Sport: Student s Name Birthdate / / Grade Print (Last) (First) (Middle) Address City Zip Home Phone( ) Pager/Cell Phone ( ) Mother/Guardian Day Phone ( ) Mother/Guardian Name ( ) Father/Guardian Day Phone ( ) Father/Guardian Name ( ) In case of emergency, illness or accident and I cannot be contacted, the school has my permission to contact and release my child to one of the following: Name Relationship Phone( ) Name Relationship Phone( ) Family Physician/Health Plan Provider Phone( ) Policy Number Is student presently taking medication? Explain EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel selected by Culver City Middle School to order X-rays, routine tests and treatment for my child, and in the event I cannot be reached in any emergency, I hereby give permission to the physician selected by Culver City Middle School to hospitalize, secure proper treatment and order an injection and/or anesthesia and/or surgery for my child as named above, if the physician decides such treatment is necessary. Parent/Guardian Signature

7 CULVER CITY MIDDLE SCHOOL ATHLETIC INSURANCE COVERAGE SPORT: M F STUDENT S NAME Please Print (Last) (First) (Middle) This form will be incomplete and returned to student if Insurance Provider s name & Group Policy number are not filled in with a copy of student s insurance card attached. I have my own health or accident insurance for my student, which meets the requirements of California law WRITE IN INSURANCE PROVIDER AND POLICY NUMBER. INSURANCE PROVIDER STUDENT S POLICY NUMBER If you do not have insurance coverage you may purchase Myers/Stevens school insurance please follow instructions below: I am purchasing the Myers/Stevens school insurance. Complete the Myers Stevens Enrollment Form (attached). Enclose payment (check, money order or credit card) made payable to MYERS STEVENS and return enrollment form (please include first class postage on the envelope) with your clearance packet to Mr. Sablan, Co-Athletic Director. Do not mail to Myers Stevens. Please check below the coverage you are purchasing: School time coverage---covers all sports except tackle football 24-hour coverage---covers all sports except tackle football INSURANCE COVERAGE FOR ATHLETES California state law (Education Code section ) requires every member of an athletic team to have accidental bodily injury insurance providing at least $1500 of scheduled medical and hospital benefits, and at least $1500 accidental death benefit. The requirement can be satisfied by purchase of the student accident insurance policy provided by Myers-Stevens and Co., Inc., or by private insurance coverage. RISK WARNING Participating in competitive athletics may result in severe injury, including paralysis or death. Change in rules, improved conditioning programs, better medical coverage and improvements in equipment have reduced these risks. HOWEVER, IT IS IMPOSSIBLE TO TOTALLY ELIMINATE SUCH INCIDENTS FROM OCCURRING. Players may reduce the chance of injury by obeying all safety rules in their sport, reporting all physical problems to their coaches, following a proper conditioning program, and inspecting their own equipment daily. DAMAGED EQUIPMENT MUST BE REPLACED. Even if all of these requirements are met, and even if the athlete is using excellent protective equipment, a serious accident may still occur. I hereby give my consent for the above-named student to compete in sports. I authorize the student to go with and be supervised by a representative of the school on any athletic trips, in case this student becomes ill or is injured, you are authorized to have the student treated and I authorize the medical agency to render treatment. Parent/Guardian Signature Student s Signature 10/09

8 Culver City Middle School Athletic Parent Consent and Physician s Statement SPORT: M F (Please Check) Student s Name: Age: Grade: Please Print (Last) (First) (Middle) THIS SECTION TO BE COMPLETED BY PARENT OR GUARDIAN PRIOR TO EXAMINATION: This information is very important to the physician who will be examining the student. Please fill out this portion of the form as completely and accurately as possible. If you need more space than provided, please use the back of this form. STUDENT S MEDICAL HISTORY: Please list any information regarding the student named above in the following areas: Write None if there is no history in each area listed. HOSPITILIZATIONS: SURGERIES: ALLERGIES: MEDICATIONS: TRAUMA AND INJURIES: Head Elbows Neck Wrists Shoulders Knees Hips Angles I hereby give my consent for the above-named student to compete in athletics and to go with a representative of Culver City Middle School on any trips with the team. In case the above-named student is injured, the school and its representatives are authorized to obtain medical treatment. I certify that the information given above is complete and correct to the best of my knowledge. NOTE: PYYSICALS MUST COVER THE STUDENT THROUGH OUT THE SEASON OF THE SPORT AND ARE GOOD FOR THE CURRENT SCHOOL YEAR ONLY. Parent/Guardian Signature PHYSICAL EXAM (to be completed by Physician): Blood Pressure Pulse Height Weight HEENT Neck Chest Heart Abd. Ext. I hereby certify that the above-named student was examined by me on date:, and he/she IS physically fit to engage in sports. IS NOT physically fit to engage in sports because Signature of Examining Physician Address of Physician: Phone ( ) 10/09

9 TRAVEL PERMISSION FORM Dear Parents/Guardians: We are requesting to allow athletes to ride in the vehicle of a responsible Culver City Middle School teacher, parent or coach to and from an athletic practice or game. No student will be allowed to ride with a teacher, parent or coach without providing this signed document. We are also asking parents to volunteer their time by joining the transportation committee that will help coordinate rides to athletic contests. As a volunteer driver, you are expected to comply with all California DMV Laws, i.e. no talking or texting on a cell phone while driving, drive safely and within the speed limits, and make sure all riders are wearing their seat belts! Please call us if you are interested. In order to make the program successful we need your help and support. PERMISSION TO RIDE My child, may ride (in the vehicle) may not ride (in the vehicle) to and from a practice or game with a Culver City Middle School teacher, parent or coach. Parent/Guardian Signature