2. Performance Tonal Camo T-shirt
DUE: MARCH 18th
3. Black Jogger Style Sweatpant
LAKE ZURICH NORTH
I’m tired
It’s too cold
It’s too hot
It’s raining
It’s too late
Let’s go
RICH NOR
ZU
20
4. 2 Tone PERFORMANCE Hoodie
(Similar to Underarmour Fabric)
TH
LAK
E
LAK
E
LZMSN TRACK 2016
TH
DUE: MARCH 18th
1. Colorblock Grey/Royal Blue Hoodie
RICH NOR
ZU
16
20
I’m tired
It’s too cold
It’s too hot
It’s raining
It’s too late
Let’s go
2 Tone Cinch Sack
4.
16
ADULT
XS S
M
L
XL XXL 3XL
1. Colorblock Grey/Royal Blue Hoodie
2. Performance Tonal Camo T-shirt
3. Black Jogger Style Sweatpant
4. 2 Tone Cinch Sack
5. 2 Tone PERFORMANCE Hoodie
$22.00
$14.00
$19.00
$8.00
$36.00
Add Personalized Word or Name to Back of T-shirt or Hoodie:
$5.00
TOTAL
: CUSD95
PLEASE RETURN FORM WITH PAYMENT ON: March 18th, 2016
DUE: MARCH 18th
CONTACT INFO
Kerry Conrad (847) 719-3763 Kerry.conrad@lz95.org
DUE: MARCH 18th
T-Shirt Order Form & Payment
**Please see separate PDF for apparel designs and order form**
At a minimum, you MUST purchase a t-shirt as part of the Track & Field uniform.
I have enclosed the order form and a check payable to CUSD 95.
Athletic Fee Payment
I have enclosed cash or separate check payable to CUSD 95.
Note: The option for payment online is no longer available.
Volunteer Sign Up
Please return this sheet with your required forms and fee if you are willing to volunteer for our
home meets. We will let you know which event as the meet gets closer. Thank you! 
Name: ________________________________________________
Email: _______________________________________________
Phone Number: ____________________________________________
Timers – We need at least 8 parents or older siblings at each home meet to help record times/
distances. Sometimes parents/ siblings switch off with someone while their athlete is racing. We
could always use more than 8. Please list your name and availability (times) if interested. You’ll be
contacted after all packets are collected and again the week of the meet to confirm availability.
Thank you in advance for your help!
Meet
4/15/16 @ 4:15pm
vs. BP, FRG, M
4/29/16 @ 4:00pm
vs. LZS, HS, M
5/5/16 @ 4:00pm
vs. LZS, BS, G
5/12/16 @ 4:00pm
vs. LZS, CS
(Conference pending)
Availability?
Permission to run off-campus
In an effort to improve each athlete’s endurance, we would like to increase the length and/ or
difficulty of the practice courses. Unfortunately, we do not have these more difficult courses on
the middle school grounds. As a result, we have located some of the other courses off campus.
Please be aware that the athletes will be under adult supervision.
We need permission allowing your child to practice with the team off-campus. Please complete
the form below and return it to the coaches no later than Thursday, March 18th. If you have any
questions, or concerns please feel free to contact one of the coaches at school at (847) 719-3600.
Thank you,
Kerry Conrad
Maggie Lamb
Cara Obrochta
Terry Nelson
Athlete’s Name
___________________________________________
Please Print
_____ My child has permission to run off campus.
_____ My child does not have permission to run off campus.
Parent Signature:
___________________________________________
Email/ Canvas Updates
Please include your e-mail address(es), as e-mail and Canvas will be the quickest and easiest
ways for the coaches to communicate with parents and students. Weekly e-mails are sent to lay
out the plan for the week, previous meet results, and reminders, and may also be sent to inform
parents of last-minute changes (weather related, etc.) in the practice schedule.
(PLEASE PRINT)
Athlete Name:
____________________________________________
Athlete e-mail:
____________________________________________
Guardian(s) Name:
____________________________________________
Email(s):
____________________________________________
____________________________________________
____________________________________________
Behavior Contract
My parents/guardians and I have read the above contract. I understand that two warnings in any
of the areas will result in removal from the team. I also understand that all absences will require
a note, the day prior to the absence (2 days prior to a meet), unless absent from school or if I go
home due to illness.
Name of athlete:
________________________________________
Please print
Signature of athlete: ______________________________
Date
_______________
Signature of parent:
Date
_______________
______________________________
We understand we’ve asked you to look through and digest a lot of information. Thank you for
taking the time to read through this information and for completing the necessary forms and
payments to help us begin an exciting track season!
~MSN Track & Field coaches
7:300-E1 (2)
Lake Zurich Community Unit School District 95
Participation Packet - Agreement to Participate
Name of Student: __________________________________________________ Grade: ___________
(please print)
Sport/Activity/Club/Organization: _______________________________ School: _________________
TO BE COMPLETED BY THE STUDENT/PARTICIPANT:
In consideration of Lake Zurich Community Unit School District 95 permitting me to participate in the
above sport or activity, I agree as follows:
1. I will abide by the school’s Athletic/Extracurricular Code of Conduct and the District’s Student
Code of Conduct and will behave in a sportsmanlike manner.
2. I will follow the coach/advisor’s instructions, playing techniques, training schedule and safety
rules for the above sport/activity.
3. I acknowledge that I am aware that participation in the above sport or activity may involve
MANY RISKS OF INJURY. A serious injury may result in physical impairment or even death. I
hereby assume all the risks associated with participation and agree to hold Lake Zurich
Community Unit School District 95, its employees, agents, coaches, school board members and
volunteers harmless from any and all liability, actions, causes or actions, debts, claims or
demands of any kind and nature whatsoever which may arise by or in connection with my
participation in the above activity or sport. The terms hereof shall serve as a release and
assumption of risk for my heirs, estate, executor, administrator, assignees, and for all members
of my family.
Date: ______________
Student/Participant Signature: ________________________________
TO BE COMPLETED BY THE PARENT/GUARDIAN:
I, _______________________________, am the parent(s)/guardian(s) of the above named student. I
have read the above Agreement to Participate and understand its terms. I understand that all
sports/activities can involve many RISKS OF INJURY. In consideration of the school district permitting my
child/ward to participate in the above sport or activity, I agree to hold Lake Zurich Community Unit
School District 95, its employees, agents, coaches, school board members and volunteers harmless from
any and all liability, actions, debts, claims or demands of any kind and nature whatsoever which may
arise by or in connection with the participation of my child/ward in the above sport or activity. I assume
all responsibility and certify that my child/ward is in good physical health and is capable of participation
in the above-mentioned sport/activity. I acknowledge that my student is covered under our current
insurance policy or that we have no insurance and understand that I am responsible for all
medical/hospital bills.
Date: _______________
Parent(s)/Guardian(s) Signature: _______________________________
Revised 1/2014
District 95 Administration Center - 400 South Old Rand Road - Lake Zurich IL 60047-2459
Phone: (847) 438-2831
FAX: (847) 438-6702
7:300-E1 (3)
Lake Zurich Community Unit School District 95
Participation Packet - Emergency Information Form
Parents/Guardians: Please note, the District 95 Social Media Procedure (5-125) AP1 requires that:
If a teacher/coach/sponsor plans to use texting for immediate and urgent contact with students/team members, they must be transparent
about such use. He/she must make parents aware at the beginning of the school year or season that he/she may use texting. Texting to the
entire team/group is preferable to texting to an individual student. If a text is sent to an individual student, parents/guardians must be copied
on all texts, in addition to a building administrator and/or athletic/activity director.
Student Name: ____________________________________________
Sex: M F
School: __________________________________________________
Grade: __________________
Address: _________________________________________________
Date of Birth: _____________
_________________________________________________
Home Phone: _____________
Student Cell Phone: ______________________ Carrier: ______________________
Parent/Guardian #1 Name: ___________ Parent/Guardian #1 Cell: ____________ Carrier:___________
Employer: ________________________________________________
Work Phone: ______________
Parent/Guardian #2 Name: ____________ Parent/Guardian #2 Cell: ____________ Carrier: __________
Employer: ________________________________________________
Work Phone: _____________
Emergency contacts if parents/gaurdians are unavailable:
1) ______________________________________________________
Phone: __________________
2) ______________________________________________________
Phone: __________________
Any medical, physical or dietary restrictions we should be aware of? ___________________________
___________________________________________________________________________________
Any allergies? _______________________________________________________________________
Physician: ________________________________________________
Phone: __________________
Address: ____________________________________________________________________________
If a parent or guardian or any of the above-listed people or numbers cannot be contacted in case of
serious injury or illness, I authorize the school district to take such emergency actions as may be deemed
necessary, including the transportation of the student to a hospital, medical center or physician for
treatment. In addition, I authorize the use of our family medical insurance.
_____________________________________________
Parent/Guardian Signature
_______________________
Date
Created 8/2012
7:300-E1 (4)
Lake Zurich Community Unit School District #95
Student Code of Conduct for Middle School Athletics/Extra-Curricular Activities
Introduction:
The goal of the extra-curricular program in District 95 is to assist students in developing a positive attitude toward themselves
and others. It is the student’s responsibility to maintain the highest tradition of competition while maintaining a proper
perspective to the overall educational program in District 95 and adhering to the Student Code of Conduct. Therefore, the
purpose of this Code of Conduct is to clarify the general responsibilities and standards of students participating in
extracurricular activities including athletes within District 95. This document is based upon the middle school eligibility policy
and the District 95 Code of Conduct. The District 95 Code of Conduct can be found on our district website and in the district
calendar/handbook that all parents/guardians receive on an annual basis . Please see those documents for further clarification
and information.
General Responsibilities:
x
x
x
x
x
x
x
x
x
x
Students will understand it is a privilege to represent the school;
Students will adhere to the middle school eligibility policy;
Students will attend practices, meetings, and games. Absences disrupt a student’s progress and may have an impact
on participation;
Students will exhibit good sportsmanship in all situations. Students will respect their opponents, officials, coaches,
spectators, and administration;
Students will work to develop a positive climate. Students will be supportive of all extra-curricular participants in
their field of interest and/or sport;
Students will learn and know the rules and proper conduct of the game;
Students will display modesty in victory and graciousness in defeat;
Students will be in attendance for at least ½ the day (from the start of the day to 11:00 or from 11:00 through the end
of the day) in order to participate in any practice/contest that day;
Students will turn in all necessary forms and pay necessary fees. Those forms include but are not limited to the
following: an up-to-date physical (athletics), concussion information sheet, agreement to participate, and emergency
form;
Students will adhere to the school and District 95 Code of Conduct.
Participation in a sport or extra-curricular is a privilege. Students need to understand that their primary responsibility is
academics and adequate academic progress is a prerequisite for extracurricular/athletic participation. In addition, students
need to understand that while on an athletic/extra-curricular team they are a representation of their family, school, and
community. As a result, they need to adhere to all aspects of District 95’s Code of Conduct. Failure to adhere to the District’s
Code of Conduct can result in disciplinary action, suspension, or removal from the activity/team. The actual consequence will
vary based upon the severity of the infraction and prior disciplinary history. For more information please refer to the middle
school eligibility policy and District 95 Code of Conduct.
Name (Print): ____________________________________
Date: ____________________
Signature: _______________________________________
Parent Signature: _________________________________
District 95 Administration Center - 400 South Old Rand Road - Lake Zurich IL 60047-2459
Phone: (847) 438-2831
FAX: (847) 438-6702
www.lz95.org
7:300-E1 (6)
I have read and received a copy of the Lake Zurich Community Unit School District 95 Concussion Information
Sheet.
_____________________________
Student Name Printed
_____________________________
Student Signature
_____________
Date
_____________________________
Parent or Legal Guardian Printed
______________________________
Parent or Legal Guardian Signature
_____________
Date
District 95 Administration Center - 400 South Old Rand Road - Lake Zurich IL 60047-2459
Phone: (847) 438-2831
FAX: (847) 438-6702
www.lz95.org
7:300-E1 (6)
Concussion Information Sheet & Sign-off Form
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the
head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to
severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions
are potentially serious and may result in complications including prolonged brain damage and death if not
recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You
can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of
concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any
symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention
right away.
Symptoms may include one or more of the following:
x Headaches
x “Pressure in head”
x Nausea or vomiting
x Neck pain
x Balance problems or dizziness
x Blurred, double, or fuzzy vision
x Sensitivity to light or noise
x Feeling sluggish or slowed down
x Feeling foggy or groggy
x Drowsiness
x Change in sleep patterns
x
x
x
x
x
x
x
x
x
x
Amnesia
“Don’t feel right”
Fatigue or low energy
Sadness
Nervousness or anxiety
Irritability
More emotional
Confusion
Concentration or memory problems (forgetting
game plays)
Repeating the same question/comment
Signs observed by teammates, parents and coaches/sponsors include:
x Appears dazed
x Vacant facial expression
x Confused about assignment
x Forgets plays
x Is unsure of game, score, or opponent
x Moves clumsily or displays incoordination
x Answers questions slowly
x Slurred speech
x Shows behavior or personality changes
x Can’t recall events prior to hit
x Can’t recall events after hit
x Seizures or convulsions
x Any change in typical behavior or personality
x Loses consciousness
District 95 Administration Center - 400 South Old Rand Road - Lake Zurich IL 60047-2459
Phone: (847) 438-2831
FAX: (847) 438-6702
www.lz95.org
7:300-E1 (6)
What can happen if my child keeps on playing with a concussion or returns too soon?
Students with the signs and symptoms of concussion should be removed from participation immediately.
Continuing to participate with the signs and symptoms of a concussion leaves the student especially vulnerable to
greater injury. There is an increased risk of significant damage from a concussion for a period of time after that
concussion occurs, particularly if the student suffers another concussion before completely recovering from the
first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with
devastating and even fatal consequences. It is well known that adolescent or teenage students will often fail to
report symptoms of injuries. Concussions are no different. As a result, education of administrators, coaches,
sponsors, parents and students are the key to student’s safety.
If you think your child has suffered a concussion
Any student even suspected of suffering a concussion should be removed from the participation immediately. No
student may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how
quickly symptoms clear, without medical clearance. Close observation of the student should continue for several
hours. IHSA, IESA and CUSD 95 Policies require students to provide their school with written clearance from either
a physician licensed to practice medicine in all its branches or a certified athletic trainer working in conjunction
with a physician licensed to practice medicine in all its branches prior to returning to play, practice or participation
following a concussion or after being removed from an interscholastic contest or activity due to a possible head
injury or concussion and not cleared to return to that same contest/event. In accordance with state law, all IHSA,
IESA and CUSD 95 schools are required to follow this policy.
You should also inform your child’s coach/sponsor if you think that your child may have a concussion. Remember
it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out.
For current and up-to-date information on concussions you can go
to: http://www.cdc.gov/ConcussionInYouthSports/
District 95 Concussion Management Guidelines
The following guidelines will be followed when a student athlete exhibits signs of a concussion. A timeframe will
not be determined as a standard but rather on an individual basis since each concussion is different. Lake Zurich
High School students may take the ImPACT concussion test and the results of it will help to determine the level of
participation.
1.
2.
3.
4.
Removal from contest following signs and symptoms of concussion.
No return to play in current game or practice.
Medical evaluation following injury. Rule out more serious intracranial pathology.
Written clearance from a physician licensed to practice medicine in all of its branches or a certified
athletic trainer. A District 95 Athletic Trainer will have the final say on when a student is cleared to
participate.
District 95 Administration Center - 400 South Old Rand Road - Lake Zurich IL 60047-2459
Phone: (847) 438-2831
FAX: (847) 438-6702
www.lz95.org