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Enter any known drug or food allergies. If none, enter N/A.

If parents cannot be contacted, please call:

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The undersigned certify that they have read the Code of Conduct and understand the eligibility and conduct guidelines contained therein for student and parent. The student hereby makes application for the privilege to participate in the interscholastic programs sponsored by South Bend Community School Corporation and the Indiana High School Athletic Association and NIC Conference. It is understood that in order to be eligible to participate the student must comply with all requirements of the School Behavior-Rights.

The undersigned student, parent/guardian consent to the release of records and/or information indicating law violations or investigations involving the court and/or police. The undersigned recognizes that such records and information may be considered by school officials in determining a student's eligibility to participate in the extra-curricular activities.

The school will only pursue acquisition of legal records in the event that the student is involved in a Code of Conduct violation or there is reasonable suspicion to warrant an investigation. This is not for the purposes of random checks without warranted suspicion.

Student athletes and/or extra-curricular participants may not participate in practices, contests or activities until this form is signed and on file with the schools athletic office/function sponsor.

A. I/we acknowledge that the participant is assuming a certain risk of being injured; that even with the best coaching, use of the most advanced protective equipment and strict observance of rules, injuries are still a possibility in organized athletics and extra-curricular activities. On rare occasions, these injuries can be so severe as to result in total disability, paralysis, or even death.

B. We, as parents, agree to abide by and support the rules established by the coaches, all sanctioning/governing bodies and the school and agree to encourage and assist our child in the same.

C. Parent/guardian and participants are encouraged and expected to read and become familiar with those items of information inlcuded in the Code of Conduct. A signature on this form indicates the following:

-Permission for my son/daughter to participate in any extra-curricular activity listed in the box below.
-An awareness of the school's policies as enumerated in the School Behavior-Rights, responsibilities, Regulations, and Procedures and SBCSC Code of Conduct and in any and all materials distributed by any member of the SBCSC Athletic Department.

I understand that my performance as a participant and the reputation of my school are dependent, in part, on my conduct as an individual. I hereby agree to accept and abide by the standards, rules, and regulations set forth by the South Bend Community School Corporation and the coaches and sponsors for the activity in which I participate.

In order to protect the health, safety, and welfare of the students and employees of the South Bend Community School Corporation, I hereby authorize and consent to the South Bend Community School Corporation conducting a standardized drug/alcohol/steroid test on a sample that I will provide, as determined by SBCSC policy, if there is reasonable suspicion of alcohol/drug usage. Reasonable suspicion will be based on objective, articulable facts (including, but not limited to, a students appearance, behavior, speech, or odor) that warrant conducting a drug test. I also authorize the release of information concerning the results of such a test to the South Bend Community School Corporation and to the parents/guardian(s) of the student.

This shall be deemed a consent pursuant to the Family Educational Rights and Privacy Act for the release of the above information to the parties named above.

I hereby acknowledge my responsibility in caring for any uniforms, equipment, or other gear issued to me for participation in athletics for SBCSC.

Further, in order to participate, I and my parents or guardians, assume financial responsibility for any lost or damaged uniforms, equipment or gear issued to me, other than in the course of normal wear and tear caused by practice and games.

I understand that failure to pay for lost or damaged items will render me ineligible for further sports participation and may subject me (or my parent or guardian) to an appearance in small claims court.

I understand that if legal action is required, we will pay the reasonable attorney fee of SBCSC.

NOTE: Charges for lost or damaged items will reflect the actual replacement or repair costs.

IMPORTANT
South Bend Community School Corporation: Under IHSAA Rule 5-2-E, any athlete failing to return player equipment or uniforms issued by a school or non-school team when the season for that sport concluded, or when the student's continued participation on such team concludes will lose their amateur status in that sport.

Coverage is provided by Guarantee Trust Life Insurance Company and administered by Student Athletic Protection, Inc.

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Please click here to download the Concussion Information Sheet

Due to a new Indiana law "Student Athletes: Concussions and Head Injuries" (Ind. Code 20-34-7 et seq.), all schools are required to distribute information to student athletes and their parents/guardians about the nature and risks of concussions and head injuries, including the risks of continuing to play after suffering a concussion or head injury. The law requires the following:

Each year, before beginning practice for an interscholastic or intramural sport, a student athlete and the student athlete's parents/guardians must be provided an information sheet, and both must sign and return a form acknowledging receipt of the information.

A student athlete who is suspected of suffering a concussion or head injury in a practice or game must be removed from play at the time of injury and may not return to play until he or she has received a written clearance from a licensed health care provider trained in the evaluation and management of concussions and head injuries.

In addition to receiving a written clearance from the licensed care provider referenced above, a high school student athlete who is suspected of suffering a concussion and is removed from play must obtain clearance from the SBCSC's designated medical personnel before returning to play.

Continuing to play with the signs and symptoms of a concussion leaves an athlete vulnerable to greater injury. there is an increased risk of significant damage from a concussion for a period of time after the concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one (second impact syndrome). This can lead to prolonged recovery, or even to severe brain swelling with devastating and even fatal consequences.

I am a student athlete and I have received and read the Heads Up – Concussion in Sports – Fact Sheet for Athletes, as well as the information above. I understand the nature and risk of concussions and head injuries to student athletes, including the risks of continuing to play after suffering a concussion or head injury, and the procedures that will be followed before returning to play.

The previously referenced student participates in extra-curricular athletic activities that require LaSalle Intermediate Academy to transport him/her to and from off-campus locations for practice and/or competition (Athletic Events). I understand that without contrary written authorization from the parent or legal guardian of a student, the School requires the student to be transported to and from Athletic Events either by a family member or by means of school-provided transportation. (For purposes of this form, a “family member” means the student him/herself or a parent, legal guardian, aunt or uncle, grandparent, or sibling of the student. Please note that a student cannot be transported to or from an Athletic Event by any student who is not a family member, and that following an Athletic Event, school-provided transportation will return the student to the School campus. Also, please note that coaches may require students to travel to Athletic Events by school-provided transportation notwithstanding any contrary written authorization from a parent or legal guardian.)

In order that my son/daughter may be transported other than by school-provided transportation, I therefore give my authorization as follows (please check the appropriate boxes):