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Filer High School
Athlete
Athletic Forms
IDAHO HIGH SCHOOL ACTIVITIES ASSOCIATION IDAHO HEALTH EXAMINATION AND CONSENT FORM
It is required that all students complete a History and Physical examination prior to his/her first 9th and 11th grade practice in the interscholastic (9-12) athletic program in the State of Idaho. The exam is at the expense of the student and may not be taken prior to May 1 of the 8th and 10th grade years. This examination is to be done by a licensed physician, physician's assistant or nurse practitioner under optimal conditions. Interim history forms are required during the 10th and 12th grade years and must be submitted to the principal prior to the first practice. Name Home Address Phone Grade Sports Personal Physician Physician's phone number Date of Birth Sex School
HISTORY FORM
*Fill in details of “YES” answers in space below: YES NO 1. A. Have you ever been hospitalized? B. Have you ever had surgery? 2. Are you presently taking any medication or pills? 3. Do you have any allergies (medicine, bees, other stinging insects)? 4. A. Have you ever passed out during or after exercise? B. Have you ever been dizzy during or after exercise? C. Have you ever had chest pain during or after exercise? D. Do you tire more quickly than your friends during exercise? E. Have you ever had high blood pressure? F. Have you ever been told you have a heart murmur? G. Have you ever had racing of your heart or skipped beats? H. Has anyone in your family died of heart problems or a sudden death before age 50?
YES NO 5. Do you have any skin problems? (itching, rash, acne) 6. A. Have you ever had a head injury? B. Have you ever been knocked out or unconscious? C. Have you ever had a seizure? D. Have you ever had a stinger, burner, or pinched nerve? 7. A. Have you ever had heat cramps? B. Have you ever been dizzy or passed out in the heat? 8. Do you have trouble breathing or cough during or after exercise? 9. Do you use special equipment, pads, braces, mouth or eyeguards?
10. A. Have you had problems with your eyes or vision? B. Do you wear glasses, contacts or protective eyewear?
11. Have you ever sprained/strained, dislocated, fractured/broken, or had repeated swelling or other injuries of any of your bones or joints? Head Neck Chest Back Hip Shoulder Elbow Forearm Wrist Hand Thigh Knee Shin/Calf Ankle Foot 12. Have you ever had any other medical problems such as: Mononucleosis Diabetes Asthma Hepatitis Headaches (frequent) Tuberculosis Eye injuries Stomach ulcer Other 13. Have you had a medical problem or injury since last exam? 14. When was your last tetanus shot? When was your last measles immunization? 15. When was your first menstrual period? When was your last menstrual period? What was the longest time between periods last year? *Explain “YES” answers here:
CONSENT FORM
(Parent or Guardian and Student Permission and Approval)
I hereby consent to the above named student participating in the interscholastic athletic program at his/her school of attendance. This consent includes travel to and from athletic contests and practice sessions. I further consent to treatment deemed necessary by physicians designated by school authorities for any illness or injury resulting from his/her athletic participation. In the absence of parents, I also consent to the release of any information contained in this form to carry out treatment and health care operations for the above named student.
PARENT OR GUARDIAN SIGNATURE DATE:
This application to compete in interscholastic athletics for the above school is entirely voluntary on my part and is made with the understanding that I have not violated any of the eligibility rules and regulations of the State Association.
SIGNATURE OF STUDENT DATE:
PHYSICAL EXAMINATION FORM
Height Weight BP / T Pulse R Visual acuity R 20 / L 20 / Corrected: Y N Pupils Normal Abnormal Ears, Nose, Throat Cardiopulmonary Pulses Heart Lungs Skin Abdominal Genitalia Musculoskeletal Neck Shoulder Elbow Wrist Hand Back Knee Ankle Foot
CLEARANCE / RECOMMENDATIONS
Clearance: A. Cleared for all sports and other school-sponsored activities. B. Cleared after completing evaluation / rehabilitation for: C. NOT cleared to participate in the following IHSAA sponsored sports: Baseball Cross Country Golf Softball Track Wrestling Basketball Football Soccer Tennis Volleyball Not cleared for other school-sponsored activities: (Example) 1. Swimming 2. 3. D. Student is NOT permitted to participate in high school athletics. Reason:
Recommendation: Examiner's Signature: Date:
(This Physical form must be signed by a licensed physician, physician's assistant or nurse practitioner) Address: Phone: ( )
FILER SCHOOL DISTRICT
DISTRICT 413
Emergency Information/Medical Clearance
NAME: ______________________________ GRADE: _________________________
AGE: ________________________________
ADDRESS: _________________________________________________________________
TELEPHONE: _______________________________________________________________
SOCIAL SECURITY #: ________________________________________________________
PARENT(S)/GUARDIAN(S) NAMES: ___________________________________________
___________________________________________
WORK PHONE #: _____________________ RELATIONSHIP?: _________________
WORK PHONE #: _____________________ RELATIONSHIP?: _________________
CELL PHONE #: ______________________ RELATIONSHIP?: _________________
EMERGENCY PHONE #: _______________ RELATIONSHIP?: _________________
PREFERRED DOCTOR OR CLINIC: ____________________________________________
TELEPHONE: __________________________
INSURANCE COMPANY: ______________ POLICY #: ________________________
Are there any significant conditions the school medical/coaching staff should be aware of:
______ Head/neck/spine injuries ______ Loss of paired organs
______ Previous broken bones ______ Previous joint injury
______ Cardiopulmonary conditions ______ Allergic to medicines, insect bites,
______ Asthma or other _____________________
Explain if you checked any on the above conditions: __________________________________
____________________________________________________________________________
______ Other medical conditions (describe): ________________________________________
____________________________________________________________________________
In the event of serious injury and your family doctor cannot be contacted, and if we are unable to contact one or the other parent, does
the coaching staff/athletic trainer have your permission to seek medical attention from the nearest physician?
______ YES _______ NO If your answer is NO, please state the procedure you wish the coaching staff/athletic trainer to
follow: _____________________
_____________________________________________________________________________
_____________________________________________________________________________
PARENT SIGNATURE: ________________________________________
In order for your son/daughter to receive the best care this form must be filled our properly. Your son/daughter will not be
allowed to practice, participate, or travel unless this form is completed.
CONCUSSION INFORMATION Concussions are a type of brain injury that can range from mild to severe and can disrupt the way the brain
normally works. Concussions can occur in any organized or unorganized sport or recreational activity and can
result from a fall or from players colliding with each other, the ground, or with obstacles. Concussions occur
with or without loss or consciousness but the vast majority occurs without loss of consciousness.
In accordance with House Bill 676 Section 33-1625, Idaho Code the Idaho High School Activities Association has
provided information on its website for coaches, parents, and athletes, concerning the Identification and
Management Strategies regarding concussions. The IHSAA encourages all coaches, parents, and athletes to educate
themselves about the recognition and treatment of concussions. Please take the time to visit our website at
www.idhsaa.org/concussions/default.asp, or www.cdc.gov/concussion/sports/index.html or
www.cdc.gov/concussion/sports/recognize.html. If you have any questions or need of further information, please
contact your school or the IHSAA Office at [email protected].
It is the wish of the IHSAA that you have a safe and enjoyable sport or activity season.
Concussion Protocol. Many students within Filer Joint School District, No. 413 participate in extra-curricular activities of a nature whereby physical injury may result. Though the District takes care to ensure all extra-curricular activities are as safe as practicable, it is not possible to remove all danger from such activities, and the District acknowledges that concussions may result. The purpose of this policy is to address situations in which student concussions have occurred or are suspected to have occurred. This policy only applies to organized athletic league or sport in which any District student participates as an athlete or youth athlete. For the purposes of this policy, athlete or youth athlete means an individual who is eighteen (18) years of age or younger and who is a participant in any middle school, junior high school, or high school athletic league or sport. A school athletic league or sport shall not include participation in a physical education class. Pre-Season Education The Administration and coaches will work to ensure that athletes, youth athletes, parents, volunteers, and assistant coaches are educated about concussions. Prior to being allowed to engage or participate in any school athletic league or sport: 1. Each student desiring to participate in such school athletic league or sport, and the student’s parents or guardians, shall be provided notice of and/or copies of any concussion guidelines or information available from the State Department of Education and the Idaho High School Activities Association, and also this policy. 2. Each student desiring to participate in such school athletic league or sport, and the student’s parents or guardians, shall acknowledge that they have been provided the guidelines or information available from the State Department of Education and the Idaho High School Activities Association, as well as this policy, and have had the opportunity to review and have reviewed such information. Further, each student and the student’s parents or guardians shall sign an applicable waiver for participating in such school athletic league or sport. 3. The signed waiver and acknowledgment of review of the appropriate information shall be returned to the District. Protocol on Suspected Concussion If, during any school athletic league or sport practice, game, or competition, an athlete exhibits signs or symptoms of a concussion, makes any complaint indicative of a possible concussion, or a coach, assistant coach, volunteer coach, or other school District employee has reason to believe a concussion has occurred, such student shall be removed from play or participation in the practice, game, or competition. According to the Centers for Disease Control and Prevention, and for the purposes of this policy, signs observed by coaching staff which could be indicative of a concussion include if the athlete: • Appears dazed or stunned • Is confused about assignment or position • Forgets an instruction • Is unsure of game, score, or opponent • Moves clumsily • Answers questions slowly • Loses consciousness (even briefly) • Shows mood, behavior, or personality changes • Can’t recall events prior to hit or fall • Can’t recall events after hit or fall According to the Centers for Disease Control and Prevention, and for the purposes of this policy, symptoms reported by the athlete which could be indicative of a concussion include: • Headache or “pressure” in head • Nausea or vomiting • Balance problems or dizziness • Double or blurry vision • Sensitivity to light • Sensitivity to noise • Feeling sluggish, hazy, foggy, or groggy • Concentration or memory problems • Confusion • Does not “feel right” or is “feeling down”
Coaches should not try to judge the severity of the injury themselves. Health care professionals have a number of methods that they can use to assess
the severity of concussions. Coaches should record the following information, if possible, to help health care professionals in assessing the athlete
after the injury:
•Cause of the injury and force of the hit or blow to the head or body •Any loss of consciousness (passed out/knocked out) and if so, for how long •Any memory loss immediately following the injury •Any seizures immediately following the injury •Number of previous concussions (if any) Athletes may not be returned to play or participate in any student athletic league or sport (except on an administrative basis, such as team manager), until and unless the athlete has been evaluated and is authorized to return to play or participate by a qualified health care professional who is trained in the evaluation and management of concussions, including a physician or physician’s assistant licensed under chapter 18, title 54, Idaho Code, an advanced practice nurse licensed under Idaho Code 54-1409, or a licensed health care professional trained in the evaluation and management of concussions who is supervised by a directing physician who is licensed under chapter 18, title 54, Idaho Code. Such authorization must be in writing and must be provided to the District prior to the student being returned to play. If the authorization is signed by a licensed health care professional trained in the evaluation and management of concussions, such authorization must also be countersigned by the directing physician.
Filer Joint School District # 413 ACKNOWLEDGMENT OF RECEIPT OF CONCUSSION GUIDELINES
Parent’s/Guardian’s Signature I, (print name)_______________________________, acknowledge that I am the parent or guardian of the student (below), that I have received from the District information related student athlete concussions, including information from the State Department of Education, the Idaho High School Activities Association, and District Policy , and have had the opportunity to review and have reviewed such information. I understand that participation in school athletics leagues or sports is dangerous, and hereby agree to waive all liability against Filer Joint School District, No. 413, its employees, agents, and trustees, related to any injury or damages that my student may experience or incur as a result of participation in such school athletics leagues or sports. ______________________________________ ______________________________ Signature Date Student’s Signature I, (print name)_______________________________, acknowledge that I am a student of Filer Joint School District, No. 413, or otherwise am allowed to participate in school athletics leagues or sports, that I have received from the District information related student athlete concussions, including information from the State Department of Education, the Idaho High School Activities Association, and District Policy , and have had the opportunity to review and have reviewed such information. I understand that participation in school athletics leagues or sports is dangerous, and accept the risk of the potential consequences of such dangers. ______________________________________ ______________________________ Signature Date NOTE: Both signature lines must be filled in and this form must be provided to the District prior to the
student athlete participating in any school athletic leagues or sports.
Student-Parent/Guardian
Drug Testing Consent Form
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 herby agree to accept and abide by the standards, rules, and regulations set forth by the Filer School District Board of
Trustees and the sponsors for the activity in which I participate.
I also authorize Filer High School to conduct tests on saliva, which I provide to test for drugs and/or alcohol use. I also
authorize the release of information concerning the results of such a test to the Filer High School and to my parent or guardian.
This shall be deemed a consent pursuant to the Family Right to Privacy Act for release of the above information to the parties
named above.
__________________________ ___________________________
Athlete Signature Date
___________________________ ___________________________
Parent/Guardian Signature Date
Athletics:
______ I choose to allow my son/daughter to continue to participate in the voluntary drug testing program after the conclusion of the
activity season.
______ I choose to not to allow my son/daughter to participate in the voluntary drug testing program after the conclusion of the
activity season.
___________________________ ___________________________
Parent/Guardian Signature Date
Descriptor term: Descriptor Code: Issue Date:
Extracurricular Activities I.17/J.45 Revised: 3/6/96
EXTRACURRICULAR ACTIVITIES CODE
FILER HIGH SCHOOL WILDCAT PRIDE CODE
MISSION STATEMENT
Filer School District #413 provides opportunities for students to participate in quality extracurricular activities.
(For the purpose of this code, an extracurricular activity is any function which is outside of the scope of regular classroom
activities.) Filer School District #413 firmly believes that extracurricular activities are a privilege, not a right. The
mission of these activities is to provide opportunities and an atmosphere for promoting:
1. Worthy use of leisure time 5. Sportsmanship
2. Healthy competition 6. Teamwork
3. Mental and physical fitness 7. Individual effort
4. Entertainment 8. Enjoyment
A. Conduct
Filer School District #413 promotes the highest code of conduct among its students. The school district expects
the students who participate in extracurricular activities to behave in a manner that will bring credit to the school district
and to themselves. To promote and sustain this high level of conduct the following rules and regulations and the
accompanying consequences have been developed.
B. Rules and Regulations
If the participant violates a rule, the coach or the extracurricular advisor, building principal, and athletic
director will decide and administer the disciplinary action according to the severity of the offense, unless
the rules and policies of the school district provide otherwise.
The following rules and regulations shall apply to the student participating (Participant) in any extracurricular
program or activity, whether or not the student is acting as a representative of school. Participants include, but are not
limited to, players, managers, members of the pep band, drill team, Future Homemakers of America, Future Farmers of
America, statisticians, cheerleaders, trainers and anyone involved in an activity governed by the Idaho High School
Activities Association. Everyone associated with an extracurricular activity is of equal importance.
1. To be eligible to participate in an extracurricular activity the following educational standard will apply:
a. A student must have received passing grades and earn credits in at least five (5) full- credit
subjects, or the equivalency, in the previous semester or grading period for which credit is
granted. Equivalency is determined by the following criteria:
Five classes available - must pass at least five,
Six classes available - must pass at least five.,
b. In addition to these standards, a grade/behavior report will be circulated to the students’
respective teachers twice a month. If a participant receives a negative school report (poor
deportment, lack of scholarship, excessive tardies or absences), the extracurricular
advisor/coach will organize a conference which will include the participant, the advisor/coach, the parents of the participant, teachers of the participant, and/or administrators. The attendees will formulate a plan of assistance to help the participant which may include, but is not limited to, probation, suspension, or retraction of eligibility for any period of time deemed necessary by the conference. Mandatory tutorials, grade/behavioral expectations and other possible assistance may be in order.
c. At semester a no credit grade (withdrawal from class after the initial two-week period) in
any course will disqualify a participant from extracurricular eligibility. However, if a
student receives an incomplete as a result of illness, an extended period of time, at the
discretion of the teacher, will be given to make up the work.
d. Any student in special education who has a current Individual Education Plan (IEP) will be
allowed to participate in extracurricular activities, even if the student does not meet the
academic eligibility standards, if the student’s Child Study Team (CST) makes the
determination that the student is making satisfactory progress (based upon the student’s effort,
attitude, and intellectual ability.)
2. A participant shall not engage in conduct that brings, or reasonably could bring, discredit to the sports program, the participant, or the school. Such conduct may include, but is not limited to, the following:
a. Theft, possession of stolen property, or vandalism
b. Use, consumption, possession or distribution of alcoholic beverages, illicit drugs or tobacco (includes
chewing)
c. Being present or associated with a private event in which underage drinking or illicit drugs are being used.
3. A participant will not engage in conduct that disrupts the discipline, order, safety, or educational environment of the
school.
4. A participant shall attend all scheduled practices, meetings, contests and performances unless it is necessary to miss
such and, if so, prior arrangements for the failure to attend shall be made with the coach or advisor whenever possible.
5. A participant shall follow the instructions of the coach or advisor regarding playing techniques, training, team rules
of conduct, or other matters related to the extracurricular program.
6. The coach or advisor may set additional rules of conduct which the participants will be expected to follow. As
appropriate, these rules will apply on or off school premises, and students will be subject to penalty if they are found to
have broken the rules.
7. A participant shall be responsible for any school-owned equipment checked out to him or her. The loss or misuse of
such equipment shall be the financial obligation of the participant.
8. A participant shall read and abide by the Idaho High School Activities Association rules and guidelines.
9. A participant shall present to school officials a physician’s written release following an illness serious enough to
require a physician’s care.
10. A participant shall attend at least one-half day of school on the day of any practice or contest in order for the
participant to practice or play that day. Exceptions may be made for prearranged appointments.
11. An athletic fee is required of each student-athlete and is used to support the total Filer School
District activities program.
12. All participants, in order to participate, shall ride the transportation provided by the district to and from the event.
If the participant wishes to ride with the parent or guardian, a written request from the parent or guardian must be
presented to the advisor of the event.
Page 3 - Extracurricular Activities Code
C. Disciplinary Action
If the participant is found to have violated any of the subsections under rule #2, the participant will be dismissed
from extracurricular activities for the remainder of the activity year. (The activity year is defined as August 9th through the
last day of school.) But, if the participant is dismissed as a result of violating subsections b or c, the participant has the
opportunity to regain their eligibility status for other extracurricular activities if the participant adheres to the following
steps: (However, the participant will not be allowed to return to the activity from which they were dismissed until
the following year.)
1. The participant must undergo a free drug and/or alcohol assessment program set up by the district.
2. A committee consisting of the school nurse, building principal, school counselor, health teacher, and athletic
director will review the assessment program.
3. After the participant is assessed and if a treatment plan is prescribed, the committee must approve the treatment
plan and will monitor the participant’s progress.
4. When the participant has completed the treatment plan at his/her own expense, the committee will review the case
and determine the eligibility status of the athlete. The committee will have the authority to approve or deny the eligibility
of the participant.
The following disciplinary action applies for rules 3-5:
First violation will result in a 15 day suspension from the extracurricular activity*. The student will still attend class
or practices in the activity but will not participate in any games or events during the suspension. Failure to abide by
this consequence will result in automatic dismissal from the activity.
*Unless the violation breaks a state or national law, at which time the participant is indefinitely suspended from the team until the matter is resolved.
Second violation will automatically result in the student’s being dismissed from the activity for the remainder of
the activity year. The activity year is defined as August 9th through the last day of school.
Third Violation will automatically result in the student’s expulsion from all extracurricular activities for the
Remainder of their high school career.
A participant who violates the third offense may appeal to the school board to have his/her eligibility
Reinstated.
D. Notice of Risk
STUDENT ATHLETES AND THE STUDENT’S PARENTS, GUARDIAN OR CUSTODIAN NEED TO BE
AWARE THAT SPORT ACTIVITIES CAN BE DANGEROUS AND INVOLVE RISK OR INJURY, AND THAT
THEIR PARTICIPATION COULD RESULT IN PERMANANT INJURY AND POSSIBLY DEATH. WHEN A
STUDENT PRACTICES, PLAYS, OR PARTICIPATES IN ANY SPORT OR ATHLETIC ACTIVITY, THE
ATHLETE MUST FOLLOW INSTRUCTIONS GIVEN BY THE COACH OR ADVISOR REGARDING PLAYING
TECHNIQUES, TRAINING, TEAM RULES AND/OR CONDUCT.
E. Parent-Coach Relations (Please review carefully and keep on hand.) The Filer School Board of Trustees recognizes that situations may arise during the day-to-day operations of the District
which are of concern to parents or other community members. The following procedures are established to provide a
recommended method for resolving patron concerns when the District employees are involved.
Patron concerns should be directed in this manner:
1. Questions or concerns affecting the general operation of the District should be brought to the attention of the District’s
superintendent.
2. Questions or concerns affecting the general operation of the individual school buildings should be brought to the attention of
that building’s principal.
3. Parents/guardians with concerns between their student coach/extracurricular advisor should initially attempt to resolve the
difficulty by meeting with the coach/extracurricular advisor. The meeting should be one-on-one and as informal as possible.
If assistance is needed in setting up the meeting, the building’s office staff will help with the arrangements. If either side is
uncomfortable about meeting one-on-one during the initial meeting, they may request the principal, athletic director or dean
of students be present.
a. If the initial meeting does not satisfy the parents/guardians, they may request a meeting the building principal. The
request should include a short written description of the original concern. All parties should be in attendance at the
meeting.
b. When the meeting with the principal does not resolve the concern, the parent/guardian may request a meeting with
the District superintendent. All parties should be in attendance at the meeting.
When the meeting with the superintendent does not resolve the concern, the parent/guardian may request a hearing before the Board
by submitting a request to the superintendent or the chairman of the Board. All parties will be given reasonable notice of time and
place of the hearing and should be in attendance at the meeting. The Board will render a decision within a reasonable time after such
hearing.
Filer High School Athletic Participation Form
Filer School District #413 is not liable nor responsible for any physician, dental, hospital or other medical bills incurred as a result of
injuries sustained by a student while participating in a school sport or athletic activity. All injury related expenses shall be the
responsibility of the student, his/her parents, guardians, or custodians.
A. Interim Questionnaire (IHSAA)
Since his/her athletic physical examination, has this student (please circle)
1. Had surgery Yes No 6. Been rendered unconscious Yes No
2. Been hospitalized Yes No 7. Started taking any new medication Yes No
3. Been under a physician’s care Yes No 8. Developed any new drug allergies Yes No
4. Had a serious illness Yes No 9. Developed any health problems Yes No
5. Had an injury requiring a physician’s care Yes No
Please explain any “Yes” answers below.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________
(Before participating in high school athletics, students are required to have a
physical examination prior to their freshman and junior years.)
Student has a physical examination on file with the school. Yes_____ No_____
Student still needs a physical examination. Yes_____ No_____
School health insurance needed? Yes_____ No_____
Is this student covered by a family health insurance policy? Yes_____ No_____
B. Information 1. Athletic Information Statement
Name _______________________ _____________________ _____________________ (Last) (First) (Middle) Address_________________________ City________________ Phone_______________
Age______ Birth Date__________ Class_____________ Year of Graduation_________ (Month, Day, Year) (Freshman, Senior, etc.)
a. How many semesters have you attended school since you first enrolled? ___________ (8 Maximum) b. How many subjects did you pass in your most recent semester completed? ___________ (5 required)
c. Did you attend school last semester? Yes_____ No_____
What school did you attend? _________________________________
Did you complete that semester? Yes_____ No_____
d. With whom do you presently reside?_______________________________ (natural parents, foster parents, uncle, sister, etc.)
e. Do your parents live within the Filer School District? Yes_____ No_____
2. Emergency Information
a. In the event of an emergency, the following two people could be notified:
1. Name______________________ Relation to athlete______________________
Home Phone_______________ Work Phone________________
2. Name______________________ Relation to athlete______________________
Home Phone_______________ Work Phone________________
b. Physician’s Name__________________ Address________________ Phone_________
C. Consent, Eligibility and Acknowledgment
1. Consent
The undersigned student and his or her parents or guardian hereby consent to the undersigned student participating in the interscholastic athletic program of the Filer School District. This consent includes travel to and from athletic contests and practice sessions. The undersigned do further consent to treatment deemed necessary by physicians designated by school authorities for any illness or injury from his/her athletic participation.
2. Eligibility
The undersigned student’s participation in interscholastic athletics for Filer Schools is entirely voluntary on such student’s
part, and with the understanding that the student has not violated any of the eligibility rules and regulations of the state association.
(IHSAA)
3. Parent - Coach Relations
The Filer School Board of Trustees recognizes that situations may arise during the day-to-day operations of the District
which are of concern to parents or other community members. The following procedures are established to provide a
recommended method for resolving patron concerns when the District employees are involved.
Patron concerns should be directed in this manner:
4. Questions or concerns affecting the general operation of the District should be brought to the attention of the District’s
superintendent.
5. Questions or concerns affecting the general operation of the individual school buildings should be brought to the attention of
that building’s principal.
6. Parents/guardians with concerns between their student coach/extracurricular advisor should initially attempt to resolve the
difficulty by meeting with the coach/extracurricular advisor. The meeting should be one-on-one and as informal as possible.
If assistance is needed in setting up the meeting, the building’s office staff will help with the arrangements. If either side is
uncomfortable about meeting one-on-one during the initial meeting, they may request the principal, athletic director or dean
of students be present.
a. If the initial meeting does not satisfy the parents/guardians, they may request a meeting the building principal. The
request should include a short written description of the original concern. All parties should be in attendance at the
meeting.
b. When the meeting with the principal does not resolve the concern, the parent/guardian may request a meeting with
the District superintendent. All parties should be in attendance at the meeting.
When the meeting with the superintendent does not resolve the concern, the parent/guardian may request a hearing before the Board
by submitting a request to the superintendent or the chairman of the Board. All parties will be given reasonable notice of time and
place of the hearing and should be in attendance at the meeting. The Board will render a decision within a reasonable time after such
hearing.
ACTIVITY AGREEMENT
The undersigned student and his or her undersigned parents or guardian acknowledge reading the rules and regulations of the Filer
Athletic Handbook and do accept and consent to the provisions contained therein.
Student Name (please print)_________________________________
Student Signature_________________________________________ Date____________
Parent/Guardian Signature__________________________________ Date____________
Address__________________________ _________________ ______ ____________ (Street) (City) (State) (Zip)
Descriptor term: Descriptor Code: Issue Date
District Concern Policy G.53/K.7 12/06/95
District Concern Policy
The Filer School Board of Trustees recognizes that situations arise during the day-to-day operations of the District which are of
concern to parents/guardians or other community members. The following procedures are established to provide a method for
resolving patron concerns when District employees are involved. The procedures are for issues that do not involve legal or teacher
code of ethic issues. Those issues will go straight to the superintendent.
Patron concerns shall be directed in this matter:
1. Questions or concerns affecting the general operation of the District shall be brought to the attention of the District’s
superintendent.
2. Questions or concerns affecting the general operation of the individual school buildings shall be brought to the attention of
that building’s principal.
3. Parents/guardians with concerns between their student and a teacher or coach/extracurricular advisor shall initially
attempt to resolve the difficulty by meeting with the teacher or coach/extracurricular advisor. The meeting shall be one-on-one and as
informal as possible. The meetings shall be held in a timely fashion for resolution to occur. Each concerned party shall allow at least
three working days for the other party to respond. If assistance is needed in setting up the meeting, the building’s office staff will help
with the arrangements. If either side is uncomfortable about meeting one-on-one during the initial meeting, they may request the
principal, athletic director or assistant principal/dean of students to be present.
a. If the initial meeting does not satisfy the parent/guardians, they may request a meeting with the building principal or
the athletic director. The request shall include a short written description of the original concern and what the
parents/guardians consider to be a satisfactory resolution to the concern. The teacher/coach/extracurricular advisor will also
write an explanation of the complaint/concern from their point of view. The principal, athletic director, or assistant
principal/dean of students will receive a photo copy of all concerns/complaints filed before the meeting. A written summary
of previous action (including dates, signatures from all parties, and outcome from meeting) will occur throughout this
process. All parties shall be in attendance at the meeting.
b. When the meeting with the principal or athletic director does not resolve the concern, the parent/ guardian may
request a meeting with the District superintendent. The superintendent will request all parties to write their reflection from
the previous meeting and turn into the district before the next meeting takes place. All parties shall be in attendance at the
meeting.
c. When the meeting with the superintendent does not resolve the concern, the parent/guardian may request a hearing
before the Board by submitting a request that includes copies of all previous action taken to the superintendent or the
chairman of the Board. All parties will be given reasonable notice of time and place of the hearing and shall be in attendance
at the meeting. A minimum of three working days shall pass unless all parties agree to an earlier time. The Board will render
a written decision within a reasonable time after the hearing.
d. The principal or athletic director will follow-up on the concern in an administrative capacity to insure the situation is
resolved and satisfactory to all parties. He/she will write a follow-up letter to be given to all parties involved within a
reasonable period of time.
The above policy shall be printed in all student handbooks as well as in the Board of Education Policy Manual.
Edited 07/29/08
The following forms are attached:
Patron/Community Member Form – Page 3 (To be completed after meeting with teacher or coach/extracurricular advisor and no
solution is found.)
Teacher or Coach/Extracurricular Advisor Form – Page 4 (To be completed after meeting with parent/patron and no solution is
found.)
Patron Reflection Form – Page 5-6 (To be completed after each meeting if no solution takes place. The form is then presented to the
next level.)
Teacher or Coach/ Extracurricular Advisor Reflection – Page 7-8 (To be completed after each meeting if no solution takes place.
The form is then presented to the next level.)
District Concern Policy Patron/Community Member Form (To be completed after meeting with teacher or coach/extracurricular
advisor and no solution is found.)
Date__________________________
Name_____________________________________ Phone________________________
Explanation of Concern________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I would like to suggest the following solution_______________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature_____________________________________
District Concern Policy Teacher or Coach/Extracurricular Advisor Form (To be completed after meeting with parent/patron and no
solution is found.)
Date__________________________
Name_____________________________________ Phone________________________
Explanation of Concern________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I would like to suggest the following solution___________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature_____________________________________
District Concern Policy Patron Reflection Form (To be completed after each meeting if no solution takes place. The form is then
presented to the next level.)
Name _______________________________________ Date _____________________
Phone__________________________
Summary of Previous Action (include dates and outcome of meeting):
1. Teacher’s/Coach’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2. Athletic Director’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3. Principal’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
4. Superintendent’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Please summarize why you find decisions made at levels 1, 2, 3 or 4 unacceptable.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature_____________________________________
District Concern Policy Teacher or Coach/ Extracurricular Advisor Reflection (To be completed after each meeting if no solution
takes place. The form is then presented to the next level.)
Name _______________________________________ Date _____________________
Phone__________________________
Summary of Previous Action (include dates and outcome of meeting):
5. Teacher’s/Coaches’/Extracurricular Advisor’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
6. Athletic Director’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
7. Principal’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
8. Superintendent’s level:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Please summarize why you find decisions made at levels 1, 2, 3 or 4 unacceptable.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature_____________________________________
Filer High School 3915 NORTH WILDCAT WAY
FILER, IDAHO 83328
208-326-5944 Office
208-326-3419 Fax
URL: www.filer.k12.id.us
ACADEMIC PROBATION
NAME: DATE: 8-23-10
The student will have their grades checked every week to see that they
do not have any failing grades in any of their classes. If a student has a
failing grade in any class they will now be ineligible to participate in any
extracurricular activity, if they are involved in a sport at the time they
will be dismissed from the team. The athlete understands that they must
maintain a certain standard in their class work and if they fall below
that standard then they forfeit their opportunity to be a participant.
STUDENT SIGNATURE:_____________________________
SUPERVISOR:___Coach Patterson____________________________________
PARENT SIGNATURE:_______________________________
Principal – R. Leon Madsen
Assistant Principal – Shane Hild
Athletic Director – LaRell Patterson
Counselor – Cori Cassity
Business Manager – Connie Gartner
Attendance Clerk – Susan Pospichal
Pride of the Magic valley
Filer High School Dual Sport Participation Form
Name : _____________ Date:___________
Season: Fall, Winter, Spring
Sports to Participate in:
1.___________________ 2.____________________
The 1st sport listed will be the main sport and will have priority
over the 2nd sport if they have a game on that particular day.
The Coaches will get together and work on a practice and
game schedule that will work for both sports. Both Coaches
have to sign the agreement, or it will be void, and the Parents
have to sign the agreement.
Coaches Signatures:
1st Coach: __________________________
2nd Coach: __________________________
Parent Signature: _______________________
