irrigon junior-senior high school - Irrigon High School

IRRIGON JUNIOR-SENIOR HIGH SCHOOL
315 East Wyoming Avenue; Irrigon, Oregon 97844
Telephone (541) 922-5551, Fax (541) 922-5558
Craig Bensen, Principal
Tina Joyce, Vice Principal
Blaine Ganvoa, Athletic Director
28 June, 2013
Dear IJSHS Students and Parents,
Welcome to Irrigon Junior-Senior High School, home of the Knights. We hope you enjoyed your summer and
are looking forward to a great 2013-14 school year. In an effort to streamline the registration process, this year
we will be offering the registration forms on-line. You may access these forms on our school website
(http://ihs.morrow.k12.or.us/home). Please complete the forms, print them out, and bring them with you, along
with any applicable fees, when you register for school. As always, to insure that our information on every
student is as current as possible in case of an emergency, please be sure to answer every question, sign every
signature line, take notice of important dates and times, and be sure that your contact information is correct.
This includes who is allowed to pick your child up from school. Only those people specifically approved by you
will be allowed to collect your child from school. In this mailing you will find:






Morrow County School District 2013-2014 Calendar
Notice of Fees and Costs – Please bring a separate check for meals made out to MCSD and another
check for student body fees made out to Irrigon High School. The student body fee of $15 is mandatory
for every student. Students who have not paid this fee will not be allowed to participate in any
extracurricular clubs, sports, or activities until such fee is paid.
Notice of Documents Required For Athletes
Current Contact Information – Make any changes or updates to your information on this form
OSAA Physical Examination Form – Students who have not had an OSAA sports physical within the
last two (2) years will not be allowed to participate in sports.
Vehicle Registration Form – Any student who will be driving to school and parking a vehicle on school
property must have this form, filled in completely and signed, on record with the office.
Registration: Students must register on August 13th, 14th , or 15th in order to be officially enrolled. Students
will receive their class schedules and lockers upon completion of all paperwork. Each student will be assigned
his/her own locker. Students may not share lockers. Following is a list of dates during which each grade
may register:
August 13th
August 14th
August 15th
8:00 am
8:00 am
1:00 pm
7:30 am
– 12:00 pm and 1:00 pm – 3:00 pm Students new to our District
– 12:00 pm
All Juniors and Seniors
– 5:00 pm
All Freshmen and Sophomores
– 12:00 pm
All 7th and 8th grade students
School Times: Classes will resume on Monday, August 26, 2013 at 7:30 am, and the school day will end at
3:00 pm. Please encourage your child to be punctual. Three (3) consecutive tardies will result in mandatory
detention.
Morrow County School District does not discriminate on the basis of race, religion, color national origin, sexual orientation, disability, marital status, age,
or sex in providing employment, education or access to education services, activities and programs in accordance with T itle I I, T itle VI, T itle IX and other
civil rights and discrimination issues; Section 504 of the Rehabilitation Act of 1973, as amended; and the Americans with Dis abilities Act of 1990.
School Supplies: Teachers will distribute lists of needed supplies and materials on the first day of class.
However, there are some basic supplies that every student will need, such as pencils, pens, at least two (2)
spiral notebooks, one (1) three ring binder, and lined notebook paper. Please send your child to school with
these basic supplies so that he/she is ready to learn from the first day.
Lunches: Irrigon Jr/Sr High School has an “open campus” policy during lunch for high school students only.
Students in 7th and 8th grade will eat their lunches in the cafeteria only.
Dress Code: In order to avoid any misunderstandings about what type of clothing is school appropriate, the
following guidelines must be observed by all students:







Any tops that show cleavage, have an open back, allow undergarments to be seen, or have oversized
armholes are not allowed;
Any clothing that allows the midriff or undergarments to be seen is not allowed;
Dresses, skirts, and shorts must reach the mid-thigh (at the fingertips when arms are held at the sides)
Yoga pants and/or leggings are only allowed when worn with a shirt which reaches the mid-thigh, as is
required for dresses, skirts, and shorts;
Hats, bandanas, or other types of headgear are not allowed during school hours;
Pajamas and slippers are not allowed;
T-shirts showing pictures or messages related to drugs, alcohol, weapons, or other inappropriate
subjects are not allowed.
Each student will receive a Student Handbook that specifies dress code, codes of conduct, and other safety,
sports, and academic rules and guidelines that must be followed by all students. Please make sure your child
reads, signs, and returns the Code of Conduct form at the back of the Student Handbook and encourage your
child to adhere to these policies. Violation of school rules and policies will result in disciplinary action.
Technology: Cell phones, iPhones, Smart Phones, MP3 Players, and iPods are not to be used inside
the school building at any time. Any such devices must be turned off the moment the student enters the
school building and may not be turned on again until after 3:00 pm. If a student is discovered to be using
his/her electronic devices, such devices will be confiscated and held for 24 hours until retrieved by a parent.
Should a student need to contact his/her parents during the school day, he/she may use the telephone in the
office designated for that purpose. If you need to contact your child during the school day, please call the main
office and a message will be delivered to your child promptly.
Evacuation: Your child’s safety is a top priority. In the unlikely event of an emergency situation requiring
evacuation, all students will be escorted to Irrigon Elementary School, where they will be released to a parent
or pre-approved person, who will be required to show ID before the student will be released. Irrigon
Elementary School will, in the event of an evacuation, shelter here at IJSHS and the same protocols for
student retrieval will apply. At no time will students be unsupervised, nor will IJSHS students and IES students
intermingle. Please be aware that, because student safety is our number one priority, we may require up to 90
minutes before we will be prepared to release information regarding the emergent situation to the public. Be
assured that we will operate in concert with law enforcement and emergency services to keep your children
safe and to keep you well informed of any developments. Again, it is critical that your contact information be
up to date and correct.
We are looking forward to a great year. If you have any questions, please feel free to contact the school at
(541) 922-5551.
Sincerely,
Craig Bensen
Principal
Tina Joyce
Vice Principal
Blaine Ganvoa
Athletic Director
Providing a Quality Education for ALL!
Linda Pedro
Head Secretary
IRRIGON JUNIOR-SENIOR HIGH SCHOOL
REGISTRATION FORM
Today’s DATE:
________________________
Student’s LEGAL Name:
___________________________________________________________________ ___________________
Last
Gender:
 - Male
Date of Birth:
First
 - Female
Grade: _____
____________________
Middle
Graduation Year: ___________
Place of Birth:
th
9 Grade Entrance Date _____________
_________________________________________________________
City
State
Country
NEW ARRIVALS: These questions are a federal requirement for schools:
1. Was your child born in another country not the United States or Puerto Rico?
2. Has your child been enrolled in a U.S. school less than 3 full academic years?
Yes 
Yes 
No 
No 
EMERGENCY CONTACT INFORMATION:
PLEASE COMPLETE THE SECTION BELOW ONLY IF THIS INFORMATION HAS CHANGED FROM LAST YEAR.
(Please make the first entry the student’s primary residence with custodial parent or guardian).
1.) _________________________________________________
Name
________________________________
Relationship
__________________________________________________________
Physical Address
 - LEGAL CUSTODY
 - LIVES WITH
_________________________________________________
Mailing Address
__________________________________________________
Place of Employment
_______________________
Home Phone
2.) _________________________________________________
Name
________________________________
Relationship
__________________________________________________________
Physical Address
 - OK TO PICK UP
 - GETS SCHOOL MAIL
_______________________
Work Phone
_______________________
Cell Phone
 - OK TO PICK UP
 - GETS SCHOOL MAIL
 - LEGAL CUSTODY
 - LIVES WITH
_________________________________________________
Mailing Address
__________________________________________________
Place of Employment
_______________________
Home Phone
_______________________
Work Phone
_______________________
Cell Phone
3.) ________________________________________________
Name
________________________________
Relationship
 - OK TO PICK UP
_______________________
Phone
4.) ________________________________________________
Name
________________________________
Relationship
 - OK TO PICK UP
_______________________
Phone
5.) ________________________________________________
Name
________________________________
Relationship
 - OK TO PICK UP
_______________________
Phone
NOTE: In cases of divorce or separation, unless the school receives a legal document or copy of a divorce decree stating that your child’s other
parent does not have access to your child’s records, we are required by state law to extend to the other parent access to your child’s records.
 - White (not Hispanic origin)
 - African American / Black
 - Hispanic / Latino
 - Asian / Pacific Islander
 - American Indian/Alaskan Native
 - Decline to Report
 - Other:
Has your student ever been expelled from
school?
 - No
 - Yes
If you are willing to be contacted via text message by high school
staff, teachers, counselors, or administration, please list a current
cell phone number and carrier.
Cell Phone:
__________________
Carrier:
__________________
Has your student ever qualified for any of the
following programs?
 - Special/Individual Education Plan (IEP)
 - Talented and Gifted Program (TAG)
 - Behavior Support Plan (BSP)
 - Medical/504 Plan
 - Other: ___________________________
If you are willing to be contacted via e-mail by high school staff, teachers, counselors, or
administrators, please list a current e-mail address.
e-mail address:
_________________________
TURN PAGE OVER

Computer Technology Acceptable Use – Student Agreement
I have read the district’s Student Computer Technology Acceptable Use policy (IIBGA-AR(2)) and agree to abide by the provisions. I
understand if I violate acceptable use procedures I may be subject to disciplinary actions up to and including revocation of district
system access with permanent loss of privileges and/or expuls ion.
Student Name
Student Signature
Date
IRRIGON JUNIOR-SENIOR HIGH SCHOOL
REGISTRATION FORM
Home Language Survey
Please help us to determine the language(s) spoken at home for each student by answering the following questions. Please mar k
the appropriate language for each question.
 - Engl ish
 - Engl ish
 - Engl ish
 - Engl ish
 - Engl ish
 - Spa nish
 - Spa nish
 - Spa nish
 - Spa nish
 - Spa nish
 - Other
 - Other
 - Other
 - Other
 - Other
Wha t l anguage did your s on or daughter l earn when he or she first began to ta lk?
Wha t l anguage does your s on or daughter use most frequently a t home?
Wha t l anguage to you use most frequently when speaking with your son or daughter?
Wha t l anguage is most often s poken by a dults in the home?
In wha t language do you want to receive i nformation from the s chool?
Parent Decision on Insurance
Parents, you may provide insurance coverage through your own insurance carrier or choose to purchase low cost, special studen t
coverage with Meyers-Stevens & Toohey & Co., Inc. This company has agreed to provide this type of coverage for Morrow County
School District students. Please check the appropriate statement below for your particular choice.
-
-
This student is covered by our family policy
You must provide the insurance company and policy number
We wish to purchase the coverage from Meyers -Stevens & Toohey & Co., Inc.
We do not have insurance coverage and do not wish to purchase the above plan.
We recognize that under the policy of the district, our child will not be able to
participate in extra-curricular activities until insurance coverage is obtained.
______________________________
Insurance Company
______________________________
Policy Number
Release of Directory Information
The district is periodically asked to supply information for programs or for news stories. The district may comply with requests by
supplying DIRECTORY INFORMATION only. Directory information means those items of personally identifiable information
contained in a student’s educational records which are generally not considered harmful or an invasion of privacy if released,
including:
Student’s name
Schools attended
Date of graduation
Mailing Address
Name of student’s parents
Awards and honors
Grade Level
Dates of attendance
Do you allow your student’s Directory Information to be released to: (for items left blank, we will assume a YES answer)
School-related organizations? (e.g.: PTO, colleges, honor roll list for newspaper)
Non-school related organizations? (e.g.: businesses, graduation supply compa ny, legislators)
Do you allow your student to be photographed for the school yearbook/class pictures?
Do you allow your student to be photographed by the public news media?
Do you allow your student to be interviewed by the public news media?
 - Yes
 - Yes
 - Yes
 - No
 - No
 - No
 - Yes
 - Yes
 - No
 - No
Release of Information to Military Recruiters
Federal public law 107-110, section 9528, of the No Child Left Behind Act requires schools to provide names, addresses, and
telephone numbers of enrolled students 17-years or older to military recruiters upon their request. The law also requires schools to
notify parents of the right to Opt-Out by requesting the school district not release your student’s information to military recruiters.
If you do not want your student’s information disclosed to military recruiters, check the box below. This request is valid for the
current school year only and must be renewed each year.
Do you allow your student’s name, mailing address, and telephone number to be released to
military recruiters? (if left blank, we will assume a “YES” answer)
 - Yes
 - No
Medical Information / Chronic Health Conditions
Family Physician:
Medication:  - Yes  - No
Phone:
If “yes”, please list:
NOTE: Medication must be labeled, kept in original container, and turned in to the IHS office for dispensing.
Has my permission to attend school-sponsored activities, athletic trips, and field trips.
Print student’s name
In the event of a medical emergency, Irrigon Junior/Senior High School has my permission to administer first aid, obtain medical treatment, and/or transport to a
medical facility if necessary. I understand that I will be financially responsible for all expenses incurred.
Signature of Parent and/or Guardian
Relationship
Date
Irrigon Jr/Sr High School
2013-14 SCHOOL CALENDAR
July 2013
M T W TH F
1 2 3
4
5
8 9 10 11 12
15 16 17 18 19
22 23 24 25 26
29 30 31
August 2013
M T W TH F
1
2
5
6
7 8
9
12 13 14 15 16
19 20 21 22 23
26 27 28 29 30
September 2013
M T W TH F
2
3
4 5 6
9 10 11 12 13
16 17 18 19 20
23 24 25 26 27
30
October 2013
M T W TH F
1 2
3
4
7
8 9 10 11
14 15 16 17 18
21 22 23 24 25
28 29 30 31
November 2013
M T W TH F
1
4
5 6
7 8
11 12 13 14 15
18 19 20 21 22
25 26 27 28 29
December 2013
M T W TH F
2
3
4 5 6
9 10 11 12 13
16 17 18 19 20
23 24 25 26 27
30 31
2013
4
July 2013
Independence Day – Holiday
19
20
21
22
23
26
27
28
29
30
August 2013
Bldg Inservice- Mandatory Trainings
Work Day/Inservice
Work Day/Inservice
Work Day
No School for Students/Staff
School Day – Students Begin
School Day
School Day
School Day
No School for Students/Staff
2
3
4
5
6
9
10
11
12
13
16
17
18
19
20
23
24
25
26
27
30
September 2013
Labor Day - Holiday
School Day
School Day
School Day
School Day
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
School Day
INSERVICE – Professional Dev.
School Day
School Day
School Day
School Day
5 th Avenue
School Day
1
2
3
4
7
8
9
10
11
14
15
16
17
18
21
23
23
24
25
28
29
30
31
O ctober 2013
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
School Day
Statewide Inservice Non-contract Day
School Day
School Day
School Day
School Day
4 Hr. Inservice Work Day
School Day
School Day
School Day
School Day – End of 1 st 9 Weeks
4 Hr. Work Day - Grades
School Day
School Day
School Day
School Day
January 2014
T W TH F
1
2 3
6
7 8 9 10
13 14 15 16 17
20 21 22 23 24
27 28 29 30 31
February 2014
M T W TH F
3
4 5
6 7
10 11 12 13 14
17 18 19 20 21
M
24 25
M
3
10
17
24
31
M
7
14
21
28
M
5
12
19
26
M
2
9
16
23
30
26
27
28
March 2014
T W TH F
4 5 6
7
11 12 13 14
18 19 20 21
25 26 27 28
April 2014
T W TH
1 2
3
8 9 10
15 16 17
22 23 24
29 30
May 2014
T W TH
1
6
7 8
13 14 15
20 21 22
27 28 29
June 2014
T W TH
3 4
5
10 11 12
17 18 19
24 25 26
2014
F
4
11
18
25
F
2
9
16
23
30
F
6
13
20
27
1
4
5
6
7
8
11
12
13
14
15
18
19
20
21
22
25
26
27
28
29
Nove mber 2013
Conferences
School Day
School Day
School Day
School Day
4 Hr Inse rvice/Work Day
Ve te ran’s Day - Holiday
School Day
School Day
School Day
School Day
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day – Early Release
Thanksgiving - Holiday
Thanksgiving - Holiday
2
3
4
5
6
9
10
11
12
13
16
17
18
19
20
23
24
25
26
27
30
31
De ce mber 2013
School Day
School Day
School Day
School Day
5 th Ave nue
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day – Finals Week
School Day – Finals Week
School Day – Finals Week
School Day – Finals Week
Christmas Break Begins
Christmas Break
Christmas Eve - Holiday
Christmas Day - Holiday
Christmas Break
Christmas Break
Christmas Break
Ne w Ye ars Eve – Holiday
1
2
3
6
7
8
9
10
13
14
15
16
17
20
21
22
23
24
27
28
29
30
31
January 2014
Ne w Ye ars Day - Holiday
Christmas Break
Christmas Break
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day – End of Semester
8 Hr Work Day - Grades
8.5 Hr Inservice/Work Day
Martin Luther King - Holiday
School Day
School Day
School Day
School Day
School Day
School Day
School Day
School Day
No School for Students/Staff
3
4
5
6
7
10
11
12
13
14
17
18
19
20
21
24
25
26
27
28
February 2014
School Day
School Day
School Day
School Day
5 th Avenue
School Day
School Day
School Day
School Day
No School for Students/Staff
President’s Day - Holiday
School Day
School Day
School Day
School Day
School Day
School Day
School Day
School Day
No School for Students/Staff
3
4
5
6
7
10
11
12
13
14
17
18
19
20
21
24
25
26
27
28
31
March 2014
School Day
School Day
School Day
School Day
INSERVICE – Professional Dev
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
End of 3 rd 9 Wks
4 Hr. Work Day - Grades
Spring Break
Spring Break
Spring Break
Spring Break
Spring Break
School Day
1
2
3
4
7
8
9
10
11
14
15
16
17
18
21
22
23
24
25
28
29
30
April 2014
School Day
School Day
School Day - Conferences
Conferences
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
1
2
5
6
7
8
9
12
13
14
15
16
19
20
21
22
23
26
27
28
29
30
31
2
3
4
5
6
May 2014
School Day
5 th Avenue
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
School Day
No School for Students/Staff
School Day
School Day
School Day
School Day-Last Senior Day
No School for Students/Staff
Memorial Day – Holiday
School Day
School Day
School Day
School Day
IJSH Graduation – 7 pm
RHS Graduation – 10 am
HHS Graduation – 2 pm
June 2014
School Day
School Day
School Day
School Day – Last Student Day
Last Work Day
Calendar Check List
7
Inservice/Work Days - MCEA
8
Paid Holidays – OSEA – 12 mos.
4
Unpaid Holidays – OSEA
4
Paid Holidays – MCEA
150
Student Days
4
8½ Hour Fridays
8
4 Hour Fridays
Note: Days labeled as “Inservice” will be
reserved for administrative and/or site council
planned or approved inservice activities.
Days labeled as “Workday” will have at least
half the hours set aside for staff to work on
grades, lesson plans, etc..
Morrow County School District does not
discriminate on the basis of race, religion,
color, national origin, disability, marital status,
age, gender, sexual orientation or genetic
testing in providing employment, education or
access to education services, activities and
programs in accordance with Title II, Title IV,
Title IX and Section 504 of the Rehabilitation
Act of 1973, as amended and the Americans
with Disabilities Act of 1990.
IRRIGON JUNIOR-SENIOR HIGH SCHOOL
315 East Wyoming Avenue; Irrigon, Oregon 97844
Telephone (541) 922-5551, Fax (541) 922-5558
Craig Bensen, Principal
Tina Joyce, Vice Principal
Blaine Ganvoa, Athletic Director
FEES AND COSTS
Please send check(s) the first week of August or bring them with you to registration. Below is a list of the fees
based upon your student’s enrollment.
The student body fee is for all students, grades 7 – 12. Students who have not paid this fee will not be
allowed to participate in any extracurricular sports or clubs. If you or you student wishes to receive a yearbook,
it must be purchased at this time.
Since we do not allow students to receive breakfast or lunch without sufficient funds available (prices below),
they must have a positive lunch account balance if they wish to eat a school breakfast or lunch. Please make
checks payable to Morrow County School District. Remember, only students in grades 9 – 12 may leave
campus for lunch. Students in grades 7 and 8 will eat their lunches in the cafeteria.
Students who wish to participate in a sport must pay their Pay To Participate fee (prices below) before the first
contest. Students who have not paid this fee prior to the first contest WILL NOT be allowed to
participate until the fee is paid in full.
Student Body Fees:
Grades 7 – 12
Student Body Fee
$15.00
Yearbook
$40.00
Parking Permit
$10.00 (if renewal of previous permit, $5.00)
Please make checks payable to Irrigon High School
Meal Prices:
Breakfast
$1.25
Lunch
$2.40
Please make checks payable to Morrow County School District
Pay To Participate Fees:
Junior High Students (7-8)
$50 per sport
High School Students (9-12)
$75 per sport
Please make checks payable to Irrigon High School – fees must be paid before the first contest.
Note: There is a $150.00 maximum per student per year and a $300 maximum per family per year.
Morrow County School District does not discriminate on the basis of race, religion, color national origin, sexual orientation, disability, marital status, age,
or sex in providing employment, education or access to education services, activities and programs in accordance with T itle I I, T itle VI, T itle IX and other
civil rights and discrimination issues; Section 504 of the Rehabilitation Act of 1973, as amended; and the Americans with Disabilities Act of 1990.
IRRIGON JUNIOR-SENIOR HIGH SCHOOL
315 East Wyoming Avenue; Irrigon, Oregon 97844
Telephone (541) 922-5551, Fax (541) 922-5558
Craig Bensen, Principal
Tina Joyce, Vice Principal
Blaine Ganvoa, Athletic Director
Documents Required For All Athletes





Registration Form – All sections of this form MUST be completed
Insurance – A copy of an insurance card with the student’s name shown as a named insured. If the student’s
name is not shown on the card, we cannot accept that insurance card. It is your responsibility to obtain student’s
proof of insurance.
Sports Physical – All sports physicals are valid for 2 years. If your child has a physical on file that has been
performed in 2012 or 2013, you do not have to provide a copy this year.
Drug Testing Policy – This document MUST be signed and dated by both student and parent. Any student who
does not return this document signed and dated WILL NOT be eligible to participate in any sports activity.
Fees – The student MUST pay the Pay To Participate fee for his/her chosen sport as well as the Student Body
(ASB) Fee before he/she will be allowed to participate in a sports contest. If a student chooses not to pay these
fees at the time of registration, he/she will be required to do so prior to the first scheduled contest of his/her chosen
sport.
Student Body Fee
Pay To Participate Fee
Jr. High Student
High School Student
Family Cap
$15.00
$50.00
$75.00
$300 per family/household
Morrow County School District does not discriminate on the basis of race, religion, color national origin, sexual orientation , disability, marital status, age,
or sex in providing employment, education or access to education services, activities and programs in accordance with T itle II, T itle VI, T itle IX and other
civil rights and discrimination issues; Section 504 of the Rehabilitation Act of 1973, as amended; and the Americans with Dis abilities Act of 1990.
IRRIGON JUNIOR-SENIOR HIGH SCHOOL
315 East Wyoming Avenue; Irrigon, Oregon 97844
Telephone (541) 922-5551, Fax (541) 922-5558
Craig Bensen, Principal
Tina Joyce, Vice Principal
Blaine Ganvoa, Athletic Director
Authorization to Test for Drugs
I understand that my performance in athletic/non-athletic activities 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 Morrow
County School District Board of Directors.
I also authorize Morrow County School District to conduct a test on a urine specimen
which I provide to test for drugs and/or alcohol use. I also authorize the release of
information concerning the results of such test to Morrow County School District and to
my parents and/or guardians. I understand that once this authorization is signed, I am
eligible for drug testing for the remainder of the school year whether or not I am
participating in an athletic/non-athletic activity at the time of the test.
This shall be deemed a consent pursuant to the Family Education Right To Privacy Act
for the release of the above information to the parties named above. In the event that I
am selected for testing and am taking a prescription medication, I give my consent for
any medical provider to release information regarding any prescription drugs to the
testing laboratory for the purpose of complying with this policy.
I have received a copy of this release. I have read and understand the District’s policy
and related procedures for drug testing and consent to such testing (pages 24 - 28 in
the IJSHS Student Handbook).
Student Name:
Student Signature:
Date:
Parent/Guardian Signature:
Date:
Morrow County School District does not discriminate on the basis of race, religion, color national origin, sexual orientation , disability, marital
status, age, or sex in providing employment, education or access to education services, activities and programs in accordance with T itle II, T itle
VI, T itle IX and other civil rights and discrimination issues; Section 504 of the Rehabilitation Act of 1973, as amended; and the Americans with
Disabilities Act of 1990.
School Sports Pre‐Participation Examination – Part 1: Student or Parent Completes Revised May 2010 NAME: BIRTHDATE: / ADDRESS: PHONE: ( ) Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability. Explain any YES answers on back. Medical Provider: Please review with the athlete details of any positive answers. YES NO Don’t Know / 1.
Has anyone in the athlete’s family died suddenly before the age of 50 years? 2.
Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain? 3.
Does the athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen? 4.
Is the athlete allergic to any medications or bee stings? 5.
Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint? 6.
Has the athlete ever had a head injury or concussion? 7.
Has the athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache? 8.
Has the athlete ever suffered a heat‐related illness (heat stroke)? 9.
Does the athlete have a chronic illness or see a physician regularly for any particular problem? 10. Does the athlete take any prescribed medicine, herbs or nutritional supplements? 11. Does the athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)? 12. Has the athlete ever had prior limitation from sports participation? 13. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily? 14. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension? 15. Is there a history of young people in the athlete’s family who have had congenital or other heart disease: cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome? (You may write "I don't understand these terms" and initial this item, if appropriate.) 16. Has the athlete ever been hospitalized overnight or had surgery? 17. Does the athlete lose weight regularly to meet the requirements for your sport? 18. Does the athlete have anything he or she wants to discuss with the physician? 19. Does the athlete cough, wheeze, or have trouble breathing during or after activity? 20. Are you unhappy with your weight? 21. FEMALES ONLY a.
When was your first menstrual period? b.
When was your most recent menstrual period? c.
What was the longest time between menstrual periods in the last year? Parent/Guardian’s Statement: I have reviewed and answered the questions above to the best of my ability. I and my child understand and accept that there are risks of serious injury and death in any sport, including the one(s) in which my child has chosen to participate. I hereby give permission for my child to participate in sports / activities. I hereby authorize emergency medical treatment and/or transportation to a medical facility for any injury or illness deemed urgently necessary by a registered athletic trainer, coach, or medical practitioner. I understand that this sports pre‐participation physical examination is not designed nor intended to substitute for any recommended regular comprehensive health assessment. I hereby authorize release of these examination results to my child's school. Signed: Date: Parent/Guardian ORS 336.479, Section 1 (3) "A school district shall require students who continue to participate in extracurricular sports in grades 7 through 12 to have a physical examination once every two years." Section 1(5) “Any physical examination required by this section shall be conducted by a (a) physician possessing an unrestricted license to practice medicine; (b) licensed naturopathic physician; (c) licensed physician assistant; (d) certified nurse practitioner; or a (e) licensed chiropractic physician who has clinical training and experience in detecting cardiopulmonary diseases and defects.” Oregon School Activities Association Forms – Physical Examination‐2010 Revised: 05/10 ‐ 132 ‐ 2012‐2013 Handbook School Sports Pre‐Participation Examination – Part 2: Medical Provider Completes Revised May 2010 NAME: / Height: Vision: R 20/ Weight: % Body Fat (optional): L 20/ Corrected: Y N MEDICAL Pupils: Equal NORMAL BIRTHDATE: / Pulse: BP: ____/____ (____/____, ____/____) Unequal Rhythm: Regular _____ Irregular _____ ABNORMAL FINDINGS
INITIALS*
Appearance Eyes / Ears / Nose / Throat Lymph Nodes Heart: Pericardial activity 1 & 2 heart sounds Murmurs Pulses: brachial / femoral Lungs Abdomen Skin st
nd
MUSCULOSKELETAL Neck Back Shoulder / arm Elbow / forearm Wrist / hand Hip / thigh Knee Leg / ankle Foot * Station‐based examination only CLEARANCE Cleared Cleared after completing evaluation / rehabilitation for: Not cleared for: Reason: Recommendations: Name of Medical Provider: (print or type) Date: Address: Phone: ( ) Signature of Medical Provider: ORS 336.479, Section 1 (3) "A school district shall require students who continue to participate in extracurricular sports in grades 7 through 12 to have a physical examination once every two years." Section 1(5) “Any physical examination required by this section shall be conducted by a (a) physician possessing an unrestricted license to practice medicine; (b) licensed naturopathic physician; (c) licensed physician assistant; (d) certified nurse practitioner; or a (e) licensed chiropractic physician who has clinical training and experience in detecting cardiopulmonary diseases and defects.” Oregon School Activities Association ‐ 133 ‐ Forms – School Sports Pre‐Participation Examination Revised: 05/10 2012‐2013 Handbook SUGGESTED EXAM PROTOCOL FOR THE PHYSICIAN Revised May 2010 MUSCULOSKELETAL Have patient: 1. Stand facing examiner 2. Look at ceiling, floor, over shoulders, touch ears to shoulders 3. Shrug shoulders (against resistance) 4. Abduct shoulders 90 degrees, hold against resistance 5. Externally rotate arms fully 6. Flex and extend elbows 7. Arms at sides, elbows 90 degrees flexed, pronate/supinate wrists 8. Spread fingers, make fist 9. Contract quadriceps, relax quadriceps 10. “Duck walk” 4 steps away from examiner 11. Stand with back to examiner 12. Knees straight, touch toes 13. Rise up on heels, then toes To check for: AC joints, general habitus Cervical spine motion Trapezius strength Deltoid strength Shoulder motion Elbow motion Elbow and wrist motion Hand and finger motion, deformities Symmetry and knee/ankle effusion Hip, knee and ankle motion Shoulder symmetry, scoliosis Scoliosis, hip motion, hamstrings Calf symmetry, leg strength MURMUR EVALUATION – Auscultation should be performed sitting, supine and squatting in a quiet room using the diaphragm and bell of a stethoscope. Auscultation finding of: 1. S1 heard easily; not holosystolic, soft, low‐pitched 2. Normal S2 3. No ejection or mid‐systolic click 4. Continuous diastolic murmur absent 5. No early diastolic murmur 6. Normal femoral pulses (Equivalent to brachial pulses in strength and arrival) Rules out: VSD and mitral regurgitation Tetralogy, ASD and pulmonary hypertension Aortic stenosis and pulmonary stenosis Patent ductus arteriosus Aortic insufficiency Coarctation MARFAN’S SCREEN – Screen all men over 6’0” and all women over 5’10” in height with echocardiogram and slit lamp exam when any two of the following are found: 1. Family history of Marfan’s syndrome (this finding alone should prompt further investigation) 2. Cardiac murmur or mid‐systolic click 3. Kyphoscoliosis 4. Anterior thoracic deformity 5. Arm span greater than height 6. Upper to lower body ratio more than 1 standard deviation below mean 7. Myopia 8. Ectopic lens CONCUSSION ‐‐ When can an athlete return to play after a concussion? After suffering a concussion, no athlete should return to play or practice on the same day. Previously, athletes were allowed to return to play if their symptoms resolved within 15 minutes of the injury. Studies have shown that the young brain does not recover that quickly, thus the Oregon Legislature has established a rule that no player shall return to play following a concussion on that same day and the athlete must be cleared by an appropriate health care professional before they are allowed to return to play or practice. Once an athlete is cleared to return to play they should proceed with activity in a stepwise fashion to allow their brain to readjust to exertion. The athlete may complete a new step each day. The return to play schedule should proceed as below following medical clearance: Step 1: Light exercise, including walking or riding an exercise bike. No weightlifting. Step 2: Running in the gym or on the field. No helmet or other equipment. Step 3: Non‐contact training drills in full equipment. Weight training can begin. Step 4: Full contact practice or training. Step 5: Game play. If symptoms occur at any step, the athlete should cease activity and be re‐evaluated by a health care provider. 581‐021‐0041 Form and Protocol for Sports Physical Examinations The State Board of Education adopts by reference the form entitled "School Sports Pre‐Participation Examination May 2010" 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 2010. NOTE: The form can be found on the Oregon School Activities Association (OSAA) Website www.osaa.org. Stat. Auth: ORS 326‐051 Stats. Implemented: ORS 336.479 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 Oregon School Activities Association Forms – Physical Examination‐2010 Revised: 05/10 ‐ 134 ‐ 2012‐2013 Handbook IRRIGON JUNIOR/SENIOR HIGH SCHOOL
VEHICLE REGISTRATION FORM Permit #
Name:
Grade: Advisor:
Last (Please Print)
First
Physical Address:
Home Phone:
Student Drivers License Number:
Auto Insurance Company:
M iddle
Parent Work:
Policy Number:
Vehicle #1
Vehicle #2
Make:
Model:
Year:
City/State/Zip:
Parent Cell:
2 Door
Make:
4 Door
Model:
Year:
2 Door
Color:
Color:
License Plate #:
License Plate #:
Vehicle Registration #:
Vehicle Registration #:
Vehicle Owner’s Name:
Vehicle Owner’s Name:
4 Door
Students need to fill out a separate IHS Vehicle Registration Form for all other vehicles they may be driving to school.
Additional forms can be picked up in the IHS office. Revenue generated from the $10.00 parking permit sales will be
used toward parking lot maintenance and repairs. The parking permit can be transferred from vehicle to vehicle or
additional permits may be purchased for $3.00 each. If a student purchased a parking permit last year, he or she may
renew that permit for a fee of $5.00. The parking permit should be displayed on the plastic hanger in the rearview mirror.
In order to receive a parking permit, the following documents must be attached:

Copy of Drivers License
> Copy of current insurance card
> Copy of vehicle registration
DRIVER’S AGREEMENT:
I certify that all the above information is correct. I have read the Morrow County School District Student Vehicle Use
Policy (JHFD) and agree to abide by said policy.
Date:
Student Driver’s Signature
PARENTAL PERMISSION
I give my child/ward permission to drive a car to school. I have read and reviewed the rules for high school parking with
my child and understand that my child (driver) shall abide by all rules established by the State of Oregon and the Morrow
County School District.
Date:
Parent Signature
If any of the above information changes, you must notify the IHS office immediately.