SJA Cheerleading Tryout Information Packet

Similar documents
SJA Cheerleading Tryout Information Packet

Paperwork checklist Volleyball/Girls Basketball Tryouts (These are the only acceptable forms)

The Louisiana Tigers Youth Organization

Cheers and smiles Ashley Clark

To Potential Cheerleaders and Parents:

To Potential Cheerleaders and Parents:

Westlake High School. Cheerleading Tryout Packet

Cheer tryouts and the cheer clinic are MANDATORY. May 16, 2016

Team Knightro Tryout Checklist

Seminole County s Cheerleading Pledge

UNION MINE HIGH SCHOOL

LSU SPIRIT SQUAD TRYOUT APPLICATION (Please Circle): Male / Female Cheerleading Tiger Girls Mascot

HS CHEERLEADING TRYOUTS APRIL :30-5:00 In Upper Gym. **lmportant parent meeting** Monday. April 6:30. Chapel

NEWBERN MIDDLE SCHOOL PARENT/STUDENT CHEERLEADING AGREEMENT

CHEERLEADER CONSTITUTION

Clay Middle School Cheerleading Information Packet for FOOTBALL and BASKETBALL

Cheerleader Information Packet

BOOTH MIDDLE SCHOOL CHEERLEADING CONSTITUTION. Football, Basketball, and Competition Cheerleading

Oak Creek High School Cheerleading

Congratulations on trying out for the Xavier Cheer team for the school year of !

SIMPSON COUNTY ACADEMY CHEERLEADING HANDBOOK

If you have any questions, please contact B. Forsythe

Congratulations on trying out for the Xavier Cheer team for the school year of !

Congratulations on trying out for the Xavier Cheer team for the school year of !

All appointments and work schedules MUST be made around practices and games NO EXCEPTIONS.

Spirit Squad Handbook/Constitution Expectations

*REQUIRED TRYOUT FORMS AND INSTRUCTIONS*

CHEERLEADER CONSTITUTION

Menendez Cheerleading Guidelines

Cheerleading Tryout Information 2018~2019

Akimel A-al Middle School Cheerleading Tryout Information

KELLER ISD MIDDLE SCHOOL CHEERLEADING CONSTITUTION

JV & Varsity Tryout Packet

Seymour Middle School Cheerleading Tryouts Football Season

WOODLAND HILLS HIGH SCHOOL CHEERLEADING TRYOUTS FOR SCHOOL YEAR Students entering grades 9-12

Northern High School Cheer Tryouts Season

AMS Cheerleading Tryout Packet

Pleasant Prairie Patriots House Hockey

cheerleader TRYOUT PACKET

Oologah High School Cheerleading Requirements & Cod of Conduct

TFS Cheerleading Tryout Document TFScheer.weebly.com

Independent School District. Middle School Drill Team Program Guidelines

Highland School of Technology Cheerleading Tryouts

West Forsyth High School PARENT/STUDENT CHEERLEADING AGREEMENT

IMPACT ELITE is an EVALUATION ONLY program EVERY ATHLETE GETS PLACED. IMPACT - ELITE Team Information - Express All-Stars Prep Cheer Program

Spring Hill College Athletic Training Department

KIRBY SMITH MIDDLE SCHOOL CHEER

Cheerleader Tryouts

Covington High School Lion Drive Covington, La (985) Fax: (985)

Semmes Middle School Golden Girls

Cheerleader/Parent Information

IMPACT - ELITE Team Information - Express All-Stars All-Star Prep Cheer Program

Rocky Mountain High School Cheerleading. Tryout Packet

INFORMATIONAL PACKET

Info Packet

Bridgeland High School Cheerleader & Mascot Rules and Guidelines

Holy Ghost School SPIRIT TEAM HANDBOOK

DOWNINGTOWN MIDDLE SCHOOL CHEERLEADING

CHEER HANDBOOK WINK JUNIOR HIGH/HIGH SCHOOL CHEERLEADERS AND MASCOT

Head Coach: Nicole Masco Assistant Coach: Taylor (Teeg) Kirk JV Coach: Marianne Brown

Greeley Central High School Co-ed Cheerleading Tryout Packet

Strike rs Allstars INC Information Packet

TEXAS HOTSHOTS BASKETBALL CLUB

Summit Academy High School JR. CHEER (1 st -8 th grade) Tryout Packet

Lake Olympia Middle School Cheerleading Tryout Packet You will need to review the following three documents:

Van Hoosen Cheerleading

FJH Viking Cheer. Candidate Forms to be Completed! Turn In To Ms. Harris or Ms. Littlejohn

Independence High School Cheerleading Rules and Regulations

CONSTITUTION OF THE FLORIDA HIGH CHEERLEADERS

Basketball Cheerleaders

2. Each candidate must have a current Physical, Concussion, AHSAA release, Star, and Homewood City Schools release on file.

CHEER TRYOUT

MIDDLE SCHOOL CHEERLEADER CONSTITUTION

Cheerleader/Mascot Tryout Packet

LCHS Competitive and Sideline Cheerleading Tryout Information

CHEER TRYOUT PACKET. If you have any questions, please Ms. McCann at See you on Tuesday August 28 th! GOOD LUCK!

Rules & Guidelines COACHES INFORMATION: Jon McGuire & Francesca Gigg

Murfreesboro City Schools Competition Cheerleading

GRIFFIN HIGH SCHOOL Cheerleading Tryout Information Packet

SWANSON ADMIRALS CHEERLEADING

Segerstrom High School Cheer Tryout Packet

PIERRE POST 8 AMERICAN LEGION AND TEENER BASEBALL 2016 REGISTRATION

Brighton High School Cheerleading Season

2015 OMMS Cheerleader Clinic Information

UCSB Tryout Information

IMPACT Half- Year Team Information - Express All- Stars Cheer Prep Program

BELLEVUE HIGH SCHOOL CHEERLEADING CONTRACT

Saraland High School Cheerleading Tryouts

CHEER FORCE ELITE. Small Gym Big Dreams TEAM PLACEMENT & REGISTRATION PACKET

Pacetti Bay Middle School Cheerleading Team Constitution

Oviedo High School Cheerleading

MISSION VIEJO HIGH SCHOOL Course Syllabus and Policies

NCA Pick-up Team - Explicit Express All-Stars Cheer Program

MBA Varsity Cheerleading Tryout Information Football, Basketball, and Wrestling Squad

Just Hoop Basketball

Oviedo High School Cheerleading

Middle School Cheerleading Constitution and Guidelines

Calera Middle School Cheerleading Constitution

CLEARVIEW CHEERLEADER CONTRACT AND RULES OF CONDUCT

Cheerleading Candidates & Parents/Guardians,

Transcription:

SJA Cheerleading Tryout Information Packet 2019-2020 TRYOUT DATE Wednesday, April 3, 5-7 p.m., SJA Activity Center Ms. Morris will post the team roster on the front doors of the Activity Center by 8 p.m. on Wednesday night. TRYOUT CLINICS Girls MUST attend both of these clinics to be eligible to try out. Monday, April 1, 4:30-6 p.m., SJA Activity Center Tuesday, April 2, 4:30-6 p.m., SJA Activity Center PARENT MEETING Girls trying out must have at least one parent attend this meeting. Tuesday, April 2, 5:30-6 p.m., SJA Activity Center (Health Room) TRYOUT FEE: $20 ($10 tryout fee and $10 choreography/coach/mats fee) CURRENT STUDENTS will pay via ShopSJA. INCOMING STUDENTS will pay with check made payable to SJA. FITTING APPOINTMENT WITH VARSITY In the event that your child makes the squad and cannot be at this fitting, you must let me know by Thursday, April 4. Monday, April 8, 4 p.m., SJA Activity Center (Health Room) CAMP DATES: June 10-12 at LSU DRESS: Each girl should come to the clinics and tryouts dressed neatly in a mostly white t-shirt or tank, black Nike shorts, white socks and cheer shoes. If you do not own cheer shoes, tennis shoes are perfectly fine. Please dress appropriately (no bare midriffs, etc.). You may not wear any item of clothing that indicates prior membership on a cheerleading squad (except shoes). For example, no shirts that say St. Agnes Cheerleader or anything with a competitive team logo will be allowed. Attendance at the clinic, tryout and camp is mandatory. Please complete and return this packet by Friday, March 22, to the SJA main office, or mail to Lauren Morris, Cheerleading Moderator St. Joseph's Academy, 3015 Broussard Street, Baton Rouge, LA 70808 Please direct all questions to SJA Cheerleading Moderator Lauren Morris at MorrisL@sjabr.org.

Checklist of forms/items to be completed and returned by March 22, 2019. SJA Cheer Form Tryout fee ($20) Rules and Regulations (initialed) Signed Demerit Slip Cheerleading Skills Checklist Completed Athletic Packet The physical must be up-to-date and signed by a doctor prior to tryouts! SJA Cheerleader Information Form *Please PRINT on the lines below* Cheerleader s Name: Grade (RISING): Cheerleader s Primary Address: Cheerleader s Phone Number (cell): Cheerleader s Date of Birth: Mother s Name: Father s Name: Mother s Cell: Father s Cell: Mother s Email Address: Father s Email Address: Mother s Address: Father s Address: I have read and understand all of the requirements and costs involved in becoming an SJA cheerleader. I have looked over the tentative calendar and am aware of practice dates and competition dates. I also agree to attend all home volleyball and basketball games that I am assigned to and will provide my own transportation to all events for cheerleading. Student Signature Date I have read and understand all the requirements and costs involved with my daughter being an SJA cheerleader. I also agree to provide my own transportation for my daughter to all events for cheerleading. Parent Signature Date

SJA Cheerleader Responsibilities GRADES o Cheerleaders must maintain a 2.0 or higher grade point average. ATTENDANCE o PRACTICE: Attendance at all practices is required. If you must miss a practice, the moderator must receive either a written note or an email from both the cheerleader and a parent. o SJA EVENTS: Cheerleaders will cheer at all designated SJA volleyball and basketball games or other event deemed necessary by the moderator and/or administration (i.e, pep rallies, incoming freshmen events, etc.). There are no free passes for games. You must find someone to sub for you in advance. o CAMP: Cheerleaders are required to attend cheerleading camp on June 10-12 at LSU. o COMPETITIONS: Cheerleaders will compete in the regional cheer competition in November (Hammond), the Dixie competition in December (Jackson, Mississippi) and the national competition at Disney World in February. o Note: You must provide your own transportation to and from practices and events. Please be aware of drop-off and pick-up times. UNIFORMS o COMPETITION UNIFORM: Cheerleaders will receive one uniform that has been purchased by the school. If lost or damaged, you are responsible for replacing/repairing. It should be clean for every game. o GAMEDAY UNIFORM: Cheerleaders will purchase a uniform that is to be worn for games (unless otherwise specified). It should be clean for every game. o PRACTICE UNIFORM: Cheerleaders will be notified every weekend about what practice uniforms they are to pack for that week s practices. If they are out of uniform, they will receive a demerit. o No jewelry is to be worn while in uniform. This is during practices, games and competition. CONDUCT o BE ON TIME: If you are late for practice or an event without an excuse, you will receive a demerit. o BE RESPECTFUL: Failure to show respect for your coaches, moderator or teammates will result in a demerit. You must remember you are a team.

Annual Events April 2019 May 2019 June 2019 July 2019 August 2019 September 2019 Tryouts Practice in May Practice in June Conditioning Practice Volleyball games Fittings leading up to leading up to camp resumes camp Cheer Camp at LSU: June 10-12 Plan for choreography Conditioning in early August; most likely will be the week before we return for school October 2019 November 2019 December 2019 January 2020 February 2020 March 2020 Volleyball Basketball Basketball National Challenge Day Volleyball games State season begins season Competition Pep Rally Volleyball PINK Championship Basketball continues in Disney (Cheerleaders OUT Game in New PINK OUT Show-off World plan this one) First Pep Rally Orleans Game Seafood Supper Regional Competition Dixie Cheer Competition (benefitting SJA athletics) Financial Responsibilities All prices are approximate and subject to change. Others fees may arise during the year (sweatshirts, t-shirts, Disney trip, posters, competition fees, etc.). April 2019 May 2019 June 2019 July 2019 Sometime in the Fall August 2019 UCA Camp at LSU: $100 Remaining payment Summer workouts: Choreography: $100 Regional Competition 2019 SJA Cheer Uniform + Camp Wear: Approximately $850-950 due for camp: $300 $100 Fee: $40 Dixie Competition Sweatshirt: $40 Fee: $40 Bodyliner for red SJA uniform, competition uniform, 3 practice uniforms, shoes, cheer bookbag (girls previously on the team are not required to purchase this), cheer jacket, white bow, red bow, 3 poms (1 red, 1 white, 1 pink) National Competition Fee: $100 deposit Flight: $50 deposit $35 coaches fee: Chelsea Milazzo $35 coaches fee: Chelsea Milazzo $35 coaches fee: Chelsea Milazzo October 2019 November 2019 December 2019 January 2020 February 2020 National Competition National s t-shirt: 1 st Balance $25 $35 coaches fee: Chelsea Milazzo $35 coaches fee: Chelsea Milazzo National Competition: $1,500 (includes flight, hotel and competition fee) $35 coaches fee: Chelsea Milazzo *Girls who were on the squad previously do not have to purchase items they received last year. $35 coaches fee: Chelsea Milazzo NATIONALS!!

SJA CHEERLEADING RULES AND REGULATIONS Please read carefully to ensure that you fully understand the expectations of St. Joseph s Academy cheerleaders. After reading each item, both the prospective cheerleader and her parent will need to initial. SAFETY is of the utmost importance. In order to provide the safest environment, we must all be working as a team and looking out for each other. While stunting, you should be focused and serious. It is important to be aware of your surroundings when stunting and tumbling. You must follow the coach s instructions at all times. Failure to follow the established safety guidelines will result in possible loss of cheering time, suspensions or dismissal from the team (at the coach s discretion). ATHLETE S INITIALS: PARENT S INITIALS: All athletes are expected to comply with the rules set forth by St. Joseph s Academy. The rules associated with the student code of conduct can be found in the student handbook, and the rules set forth by the LHSAA can be located at www.lhsaa.org. ATHLETE S INITIALS: PARENT S INITIALS: If a cheerleader has more than three unexcused absences or tardies for practices, games or events, she will be expelled from the team. Excused: class trips, makeup tests, sickness. Unexcused: hair appointments, obligations with friends, too much homework (plan ahead). ATHLETE S INITIALS: PARENT S INITIALS: If the athlete is injured or sick and not contagious, she is required to attend practice but not participate. ATHLETE S INITIALS: PARENT S INITIALS: Practices the week before a competition or pep rally are mandatory. Only extremely extenuating circumstances will be excused. ATHLETE S INITIALS: PARENT S INITIALS: Respect yourself, parents, teachers, administrators, coaches, teammates and classmates at all times. ATHLETE S INITIALS: PARENT S INITIALS: You must communicate with your moderator. If you must miss practice, you must notify the moderator 24 hours in advance. If you are asked to pick something up, drop something off or see the moderator for any reason, you are expected to do so. ATHLETE S INITIALS: PARENT S INITIALS: Profanity at school, during practices, games, events or within the community does not represent SJA Cheerleading. Remember you are an ambassador for our school; please conduct yourself in a manner that represents our school in a positive light. ATHLETE S INITIALS: PARENT S INITIALS:

DEMERIT SYSTEM If any of the above rules are broken, demerit penalties will be issued. The number of demerits will be determined by the severity of the infraction and will be issued by the moderator. Serious infractions or continuous violations may result in additional demerits, disciplinary probation or dismissal from squad. The moderator/coach will determine the length of any disciplinary probation. Examples: Improper practice uniform (minor) = conditioning with Chelsea Improper practice uniform (major) = 1 demerit Improper game/competition uniform = 2 demerits 2 Improper uniform violations = 2 demerits and conditioning with Chelsea Tardy to practice = conditioning with Chelsea Missing a practice or conditioning (unexcused) = 5 demerits and 5 workouts with Coach Liz Any practice missed without a doctor s note is unexcused. Missing a function or event = 10 demerits and probation Missed summer workout = 1 demerit Late payments = 1 demerit Accumulation of 12 demerits results in automatic probation. (While on probation, you must attend all events in full uniform, but you will not perform.) If you are on probation and do not attend an event, you will be dismissed from the squad. Accumulation of 15 demerits or at the discretion of the moderator results in dismissal from the squad. Parents will be contacted by email each time demerits are issued. I have read and understand the demerit system set forth for SJA Cheerleading 2019-2020. (Student Signature) (Parent Signature) CONFLICT DECLARATION Please list any conflicts you foresee below: mission trips, vacations, etc., that could interfere with any May/June practices or camp. List all that you know. I have a conflict with on. The moderator will contact you if you complete this line to discuss. Explanation/Comments re: conflict:.

TIME COMMITMENT and COACH PAYMENT Tentative Schedule for SUMMER and SCHOOL-YEAR Practices May: Anticipate three-four practices after school at SJA. The purpose of these practices will be to start looking at stunt groups, prepare for camp and get to know one another. Summer: Anticipate practices May 28-31 and June 3-6 leading up to camp. We will also require conditioning over the summer. Competition choreography will take place in August (usually the week before school starts). School Year: We have a full set of hard mats, so we will be having practice at SJA after school three days a week. Days and times are yet to be determined. There is also a possibility of a tumbling class one day per week (cost and location to be determined). Monthly payments: $35 payment to Chelsea Milazzo and $TBD for gym/tumbling.

Cheerleading Skills Checklist To be completed by the cheerleader. Please note that no skills listed below are required to tryout. Cheerleader s Name: Previous SCHOOL Cheerleading Experience: Previous COMPETITIVE Cheerleading Experience: What other extra-curricular activities do you currently or are you planning to partake in? In your opinion, what qualities does a good cheerleader possess? Why do you feel you would be a good addition to the St. Joseph s Cheerleading Program? Stunting position(s) you are trying out for (check all that apply): Flyer Main base Secondary base Backspot Skills (check all that apply) Tumbling: Standing Back Handspring Standing Back Tuck Round off Back Handspring Round off Double BHS Running Round off Tuck Round off BHS- Back Tuck Layout Full 2 to Full Basing Experience? Please list specific skills you have mastered. Flying Experience? Please list specific skills you have mastered.

LHSAA MEDICAL HISTORY EVALUATION IMPORTANT: This form must be completed annually, kept on file with the school, & is subject to inspection by the Rules Compliance Team. Please Print Name: School: Grade: Date: Sport(s): Sex: M / F Date of Birth: Age: Cell Phone: Home Address: City: State: Zip Code: Home Phone: Parent / Guardian: Employer: Work Phone: FAMILY MEDICAL HISTORY: Has any member of your family under age 50 had these conditions? Yes No Condition Whom Yes No Condition Whom Yes No Condition Whom Heart Attack/Disease Sudden Death Arthritis Stroke High Blood Pressure Kidney Disease Diabetes Sickle Cell Trait/Anemia Epilepsy ATHLETE S ORTHOPAEDIC HISTORY: Has the athlete had any of the following injuries? Yes No Condition Date Yes No Condition Date Yes No Condition Date Head Injury / Concussion Neck Injury / Stinger Shoulder L / R Elbow L / R Arm / Wrist / Hand L / R Back Hip L / R Thigh L / R Knee L / R Lower Leg L / R Chronic Shin Splints Ankle L / R Foot L / R Severe Muscle Strain Pinched Nerve Chest Previous Surgeries: ATHLETE MEDICAL HISTORY: Has the athlete had any of these conditions? Yes No Condition Yes No Condition Yes No Condition Heart Murmur / Chest Pain / Tightness Asthma / Prescribed Inhaler Menstrual irregularities: Last Cycle: Seizures Shortness of breath / Coughing Rapid weight loss / gain Kidney Disease Hernia Take supplements/vitamins Irregular Heartbeat Knocked out / Concussion Heat related problems Single Testicle Heart Disease Recent Mononucleosi High Blood Pressure Diabetes Enlarged Spleen Dizzy / Fainting Liver Disease Sickle Cell Trait/Anemia Organ Loss (kidney, spleen, etc) Tuberculosis Overnight in hospital Surgery Prescribed EPI PEN Allergies (Food, Drugs) Medications List Dates for: Last Tetanus Shot: Measles Immunization: Meningitis Vaccine: PARENTS WAIVER FORM To the best of our knowledge, we have given true & accurate information & hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that if the examination is provided without expectation of payment, there shall be no cause of action pursuant to Louisiana R.S. 9:2798 against the team volunteer healthcare provider and/or employer under Louisiana law. This waiver, executed on the date below by the undersigned medical doctor, osteopathic doctor, nurse practitioner or physician s assistant and parent of the student athlete named above, is done so in compliance with Louisiana law with the full understanding that there shall be no cause of action for any loss or damage caused by any act or omission related to the health care services if rendered voluntarily and without expectation of payment herein unless such loss or damage was caused by gross negligence. Additionally, 1. If, in the judgment of a school representative, the named student-athlete needs care or treatment as a result of an injury or sickness, I do hereby request, consent and authorize for such care as may be deemed necessary...yes No 2. I understand that if the medical status of my child changes in any significant manner after his/her physical examination, I will notify his/her principal of the change immediately..yes No 3. I give my permission for the athletic trainer to release information concerning my child s injuries to the head coach/athletic director/principal of his/her school..yes No 4. By my signature below, I am agreeing to allow my child s medical history/exam form and all eligibility forms to be reviewed by the LHSAA or its Representative(s).. Yes No Date Signed by Parent Signature of Parent Typed or Printed Name of Parent II. COMPLETED ANNUALLY BY MEDICAL DOCTOR (MD), OSTEOPATHIC DR. (DO), NURSE PRACTITIONER (APRN) or PHYSICIAN S ASSISTANT (PA) Height Weight Blood Pressure Pulse GENERAL MEDICAL EXAM : OPTIONAL EXAMS: ORTHOPAEDIC EXAM : Norm Abnl VISION: Norm Abnl ENT L: R: Corrected: I. Spine / Neck Lungs Cervical Heart DENTAL: Thoracic Abdomen 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Lumbar Skin 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 II. Upper Extremity Hernia Shoulder (if Needed) COMMENTS: From this limited screening I see no reason why this student cannot participate in athletics. [ ] Student is cleared Ankle [ ] Cleared after further evaluation and treatment for: [ ] Not cleared for: contact non-contact Elbow Wrist Hand / Fingers III. Lower Extremity Hip Knee Printed Name of MD, DO, APRN or PA Signature of MD, DO, APRN or PA Date of Medical Examination Revised 4/18 This physical expires one year from the date it was signed and dated by the MD, DO, APRN or PA.

Sports seasons are Fall (Cross Country, Swimming and Volleyball); Winter (Basketball and Soccer); and Spring (Bowling, Golf, Gymnastics, Softball, Tennis and Track & Field). St. Joseph s Academy Travel Policy (revised April 2017) Depending on the nature of the event and the location, SJA may or may not provide transportation for students to attend off-campus, school-sponsored events. In those situations in which SJA does not provide student transportation, SJA requests that transportation be provided by the parents or guardians of the students to events at locations in excess of thirty (30) miles from SJA s campus. Because the students are inexperienced drivers, safety is a concern. Therefore, SJA strongly recommends that students not drive to an event that is more than thirty (30) miles from SJA. St. Joseph s Academy Drug Testing Policy The school-wide policy of St. Joseph s Academy has the purpose of acting in the best interest of our students. If there is concern that a student is using or abusing drugs, the person concerned will confer with one of the counselors and/or administrators. If the problem is judged to be of a serious nature, the student s parents will be informed. With the permission and cooperation of her parents, the student will be asked to undergo drug testing. If the school administration believes the problem is serious, drug testing may be required as a condition for remaining at SJA. Should the test reveal a positive result, the student and her parents will work with school officials to outline a plan of action for the student s recovery and for her continued enrollment at SJA. As with all other school policy issues, the final decision rests with the school administration. This policy is in compliance with the Louisiana High School Athletic Association and has been adopted by the SJA Athletic Department retroactive to August 13, 1999. St. Joseph s Academy Athletic Participation Fee (revised May 2018) Each sport will have a $50 participation fee. Payment should be made online at our Shop SJA site. St. Joseph s Academy Uniform, Bags and Equipment Care of the school owned uniforms, bags and equipment is the responsibility of the student-athlete. A replacement charge will be assessed if uniform or equipment is lost or retuned in poor or damaged condition. Student s Name (please print) Student s Signature Parent/Guardian s Signature Date Date Phone (Home) (Work)

Student Name Age DOB Student ID Address (Street, City, ZIP) Student s Cell Mother/Legal Guardian Cell Work Father/Legal Guardian Cell Work Family Physician Physician Phone Health Insurance Provider Policy Number Group Number Hospital Preference in Case of Emergency Other Individuals to be Notified in Case of Emergency: Name Relationship Phone Name Relationship Phone ALLERGIC REACTION Allergy type: Medical History Food [list food(s)] Medications [list medication(s)] Insect bite/sting [list insect(s)] Other [list] Describe reaction to allergen Does your daughter carry an EpiPen? Yes No If yes, you must schedule an appointment with the school nurse prior to the start of school and complete these requirred forms: Required Forms:* 1) Food Allergy and Action Plan 2) Prescription and Over-the-Counter Medication Order (Parts 1-3) DIABETES (TYPE 1) You must schedule an appointment with the school nurse prior to the start of the school year. Required Forms:* 1) Diabetes Medical Management Plan 2) Prescription and Over-the-Counter Medication Order (Parts 1-3) ASTHMA Does your daughter carry an inhaler? Yes No Required Form:* 1) Prescription and Over-the-Counter Medication Order (Parts 1-3) SEIZURE DISORDER Type of seizure: Absence (staring, unresponsive) Complex Partial Health Information 2018-2019 To be completed by parent/legal guardian Please place this completed form in a sealed envelope addressed to School Nurse Marie Vukovics and return it with the other required admissions forms. Or, you may scan and email the form to vukovicsm@sjabr.org. Please note that a picture of the form is not acceptable. Generalized Tonic-Clonic (Grand Mal/Convulsive) Other (explain) You must schedule an appointment with the school nurse prior to the start of the school year. Required Form:* 1) Seizure Action Plan

Additional Medical History Please check all which apply and explain any selected items below. Anemia or other blood disease Anxiety Concussion Depression Dizzy/faint spells Ear disease Frequent headaches Migraines Digestive disorders Glasses/contacts Hay fever Head or spinal injury Heart condition/disease Heat-related illness Kidney disease Liver disease Mononucleosis Nervous or mental disorders Nosebleeds Physical disability Recent surgery Rupture or hernia Sinus issues Skin condition Type II Diabetes/Insulin resistance Vertigo Other Explanation Date of last tetanus shot Home Medications (list all home medications) If the student will need to take any medication (prescription or over-the-counter) while at school, please complete the Prescription and Over-the-Counter Medication Order form, found on the SJA website (www.sjabr.org). Required Form:* 1) Prescription and Over-the-Counter Medication Order form (Parts 1 and 2). A licensed prescriber must fill out Part 2 for prescription and over-the-counter medications. Please circle one I give my permission for health-related information to be released to appropriate YES NO St. Joseph s Academy faculty/staff for the care, safety and welfare of my daughter. Parent/legal guardian signature Printed name of parent Date *All required forms can be found in the online Student Handbook. You will need to log in to the Parents portal at www.sjabr.org. The Handbook is located under Useful Links on the right side of the page. Forms are located in the Personal Growth section under Medication/Health. Please notify the school nurse of any changes to the student s medical history which occur during the school year. Contact Marie Vukovics at 388-2208 or vukovicsm@sjabr.org.