octubre 18, 2019

FIESTA DE HALLOWEEN KIWANIS Los niños (desde el nacimiento hasta el quinto grado) están invitados a usar sus disfraces de Halloween y el Concurso de Disfraces el martes 29 de octubre en la escuela primaria y secunda-ria el martes 29, en la escuela primaria y secun-daria de Bremen. Los juegos de carnaval comienzan a las 6:30 p.m. en el gimnasio, seguido de un concurso de disfra-ces a las 6:45, también en el gimnasio. Habrá refrigerios disponible al otro lado de pasillo en la cafetería K-8.

No te pierdas esta forma

GRATUITA Patrocinado el Club KiwaniClub Bremen

LA PROXIMA GENERACION DE BOX TOPS ESTA AQUI

Box Tops esta cambiando. To-davía los estamos recolectando, pero están en proceso de elimi-narlos gradualmente de las ca-jas para para escanear sus reci-bos. Una persona deberá descargar la aplicación de Box Tops para escanear su recibo de la tienda. En la aplicación, ubique la Es-cuela Primaria/Secundaria de Bremen, luego el dinero ira di-

rectamente a nosotros. Box Tops esta cambiando para adaptarse a las fa-milias de hoy. La nueva y mejorada aplicación mó-vil Box Tops utiliza tecnología de punta para esca-near el recibo de su tienda, encontrar productos participantes y agregar instantáneamente Box Tops a las ganancias de su escuela en línea. Final-mente, el programa de Box Tops se convertirá en digital.

BAILE DE HALLOWEEN

PARA LA SECUNDARIA

Viernes, octubre 18

5:00-7:00 p.m.

boletos $10

Disponibles en la librería a partir de 10/14

RECOGER A SU ESTUDIANTE TEMPRANO?

POR FAVOR SIGA ESTAS DIRECTRICES Para reducir las interrupciones en los salones de clase, envíe una nota con su estudiante por la mañana si planea recogerlos temprano de la escuela o si necesita informar al maestro sobre un plan alternativo para el día. El estudiante debe darle la nota al maestro indicado el tiem-po que debe estar en la oficina y a ra-zón por la que ne-cesitaran irse. Mu-chas gracias por su ayuda en este asunto!

Boletí n de Padres

Escuela Primaria Secundaria de Bremen

Respeto Mutuo Comunidad Solidaria Grandes Expectativas

Próximos Eventos

10/21 Concierto de Coro de Secundaria 10/22 Concierto de Banda de Secundaria 10/23 Conferencias de Padres/Maestros 10/24 Conferencias de Padres/Maestros 10/25 DESCANSO DE OTOŇO-NO HAY CLASES 10/28 DESCANSO DE OTOŇO-NO HAY CLASES

REGISTRACION PARA DEPORTES DE INVIERNO YA ESTA ABIERTO!

El registro de deportes de invierno es un requisito para todos los atletas en los grados 5-8.

Visita www.bremenathletics.com y haga clic en el cuadro “REGISTER AN ATHLETE” y haga clic en la esquina superior de-recha de la pagina de inicio si tiene algún problema con el registro, comuníquese con Sra. Fish en la oficina de Atletismo al 546-3511 o stfish@bps.k12.in.us

Recuerde: el examen físico (3 paginas) debe descargarse en el registro del atleta para recibir la aprobación final.

***si no puede descargar el formulario físico, se puede entregar copias impresas a la Sra. Fish en la Oficina de Atletismo de la Preparatoria o a la Sra. Huff en la Oficina de la Secundaria.***

PERDIDO Y ENCONTRADO

AL DESBORDE

La mesa de objetos perdidos jun-

to a la oficina de la enfermera se

esta desbordando! Donaremos

cualquier articulo no reclamado

después de las conferencias de

padres y maestros. Cuando ven-

gas a tu conferencia, mira la me-

sa para encontrar lo que has es-

tado perdiendo!

DESCANSO DE OTOŇO 25 Y 28 DE OCTUBRE

NO SCHOOL! ENJOY!!

Lunch Menu

Bremen Public Schools 2019

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

30 1 2 3 4

L. Chicken Quesadilla L. Pepperoni Pizza Ripper L. Mini Corn Dogs L. Egg & Cheese Omelet L. Chicken Fajita

Tator Tots Steamed Broccoli w/Cheese Sweet Potato Fries Sausage Patty Refried Beans

Apricots Orange Slices Pears Emoticons Potatoes Fresh Lettuce Salad

Peaches Juice Cup Ice Cream Sandwich Mandarin Oranges Apple Crisp

Milk Milk Milk Cinnamon Roll & Milk Mixed Fruit & Milk

7 8 9 10 11

L. Hot Dog w/ Goldfish Crackers L. Walking Taco L. Cheeseburger L. Chicken & Noodles L. Chicken Patty

Sweet Potato Slices Lettuce Salad Fresh Veggies w/Ranch Cup Mashed Potatoes Green Beans

Strawberries Celery w/Peanut Butter Cantaloupe & Pears Mixed Fruit Cole Slaw

Wacky Cake Spanish Rice Pickle Spear Wheat Roll w/ Butter Fresh Sliced Apples w/Carmel Cup

Milk Tortilla Scoops & Milk Milk Milk Milk

WE HAVE LOT'S TO LOVE

https://www.fns.usda.gov/ National School Lunch Week14 15 16 17 18

L. Smoked Sausage Sandwich L. Mini Pizza Calzonette L. Tenderloin Chicken Nuggets L. Pork Ribby Sandwich

Macaroni & Cheese Fresh Red Peppers w/Ranch Cup Kidney Beans Peas French Fries

Broccoli Glazed Carrots Corn Au Gratin Potatoes Sliced Oranges

Mandarin Oranges Peaches & Juice Cup Applesauce Pears Fudge bars

Milk Milk Chocolate Chip Cookie & Milk Blueberry Muffin & Milk Milk

21 22 23 24 25

L. Cheese Pizza L. Grilled Cheese Sandwich L. Chicken Tenders L. Sausage Links Happy Fall Y'all Tomato Soup w/Crackers Baked Beans

Sliced Cucumbers w/Ranch Cup Fresh Carrots w/Ranch Cup Cantaloupe Confetti Pancakes NO SCHOOL

Corn Pears Fruit Juice Hashbrowns Fall Break

Peaches Yogurt Banana Bread Grapes

Fruit Snack & MilK Milk Milk Milk

28 29 30 31 1L. Popcorn Chicken L. Bosco Sticks CHILLING CHICKEN DINNER L. Hamburger

NO SCHOOL Broccoli and Cheese Brussel Sprouts Ghostly Potatoes w/ Goolish Gravy Steamed Carrots

FALL BREAK Mixed Fruit Corn Paranormal Pinto Beans Pickle Slices

Bread w/Butter Peaches Spooky Ice Cream/Hocus Pocus Pineapple Applesauce

Milk Fruit Snacks & Milk Eerie Bread w/Butter & Ghostly Milk Sunchips & Milk

OTHER OPTIONS AVAILABLE:

Peanut Butter & Jelly Uncrustable are available everyday,

along with the sides listed for the day.

Pre-made salads are also another available option daily. THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER

Breakfast Menu

Bremen Public Schools 2019

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

30 1 2 3 4

B. Sausage Gravy Pizza B. Scrambled Eggs B. Cinni Minis B. Chocolate Chip Muffin & Yogurt B. Sausage & Cheese Biscuit

Fruit Fruit Fruit Fruit Fruit

Fruit Juice Fruit Juice Fruit Juice Fruit Juice Fruit Juice

Milk Milk Milk Milk Milk

7 8 9 10 11

B. Mini Maple Waffles B. French Toast Sticks B. Egg & Cheese Bagel B. Dutch Waffle Cake B. Donut

Fruit Fruit Fruit Fruit Fruit

Fruit Juice Fruit Juice Fruit Juice Fruit Juice Fruit Juice

Milk Milk Milk Milk Milk

WE HAVE LOT'S TO LOVE CELEBRATE

https://www.fns.usda.gov/ National School Lunch Week14 15 16 17 18

B. Scrambled Eggs w/Sausage Patty B. Mini Pancakes B. Sausage Gravy Pizza B. Glazed French Toast B. Pancake Sausage Stick

Fruit Fruit Fruit Fruit Fruit

Fruit Juice Fruit Juice Fruit Juice Fruit Juice Fruit Juice

Milk Milk Milk Milk Milk

21 22 23 24 25

B. Bacon & Egg Breakfast Pizza B. Cinnamon Roll w/Yogurt B. French Toast Sticks B. Biscuits & Gravy

NO SCHOOL

Fruit Fruit Fruit Fruit

Fruit Juice Fruit Juice Fruit Juice Fruit Juice Fall Break

Milk Milk Milk Milk

28 29 30 31 1

B. Blueberry Cinnamon Breadstick B. Oatmeal w/ Toast B. Gazed French Toast B. Pancake Bites

NO SCHOOL

FALL BREAK Fruit Fruit Fruit Fruit

Fruit Juice Fruit Juice Fruit Juice Fruit Juice

Milk Milk Milk Milk

Other Breakfast options available are Pop-Tarts, various cereal bowls, yogurt, toast with butter and choice of jam.

SERVING TIMES ARE 7:30 - 8:05 AND THURSDAY'S 7:45 - 8 :20

Breakfast cost $1.40 per day or $7.00 per week. Extra Milk cost .45

THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.

Middle SchoolHalloweenCostume dance

Costume ContestPrizes for Best Duo or group, Most

creative & Funniest

Friday,October 18th

5:00-7:00MS Gym

Tickets: $10 each-Includes pizza, popcorn & popPurchase tickets from Mrs. Fitch @ the bookstore

starting 10/14NO weapons * No gore * NO face masks

Music By All Pro Dj's

$10

No weapons, No gore, No face mask, Nothing too scary!

Complete Dinner or Fish Only*

Drive-thru Carry-Out Only

Tickets $9 each – Free to VeteransTickets available at The Whitlock office or Woodies Service Desk

www.thewhitlock.org 574-546-4765

Prepared by Tyner Odd Fellows #821

* Serves 2-3

2019 Bremen Youth Wrestling Camp

Dear Parents:

The Bremen Wrestling coaching staff will be conducting a wrestling camp for athletes in grades K -6th.

Our goal is to teach the athletes basic fundamentals of wrestling, sportsmanship, and to have fun.

Athletes should wear a t shirt, shorts, and a pair of wrestling/gym shoes. All practices will be conducted

within the Lions Den, located in the High School. Please Enter/Exit through Door 16 by the pool.

We will conduct 4 practices to be held on the following dates:

Tuesday, October 22nd 5:30 -6:45pm Wednesday, October 23rd 5:30 -6:45pm Tuesday, October 29th 5:30- 6:45pm Wednesday, October 30th 5:30 -6:45pm

We encourage parents to get involved in these practices and help teach the athletes proper

technique.

Following our 4 practices, we will host an end of camp tournament on Saturday, November 2nd at

1:00pm. During the tournament, we will conduct a brief practice to demonstrate what the athletes have

learned and then each athlete will wrestle 2 matches against others approximately their own weight and

age. We will not keep score during these matches, and there will be no pins. T -shirts will be passed out

before the tournament.

Cost of the camp is $30.00 and includes a T -Shirt from the tournament. Checks/Cash can be made out

to Bremen Wrestling Club. There will be a Google Form Registration available. It will be posted on all

Social Media accounts and will go live on October 1st! If you don’t have Social Media, please email

BremenWC@Gmail.com for the registration link. We would prefer registration forms be submitted early,

however, you may also bring your registration to the first practice on Tuesday, October 22nd, if you wish

to register then.

Contact Information:

If you have any questions, please contact Anthony Lewis at BremenWC@Gmail.com, or call/text

(574)-229-0941.

Social Media:

Facebook – Bremen Wrestling Twitter - @BremenWC Instagram – @BremenWrestling Yours in Wrestling, High School Wrestling Staff

Bremen Wrestling Camp

It is preferred to register through Google Forms (Posted on Social Media). If you don’t have Social

Media, please email BremenWC@Gmail.com for the registration link. If you wish to register on paper,

please return this form to the Bremen HS Athletic Office by October 18th. Please fill out completely and

return with $30 registration fee.

(Cash/Check payable to Bremen Wrestling Club).

Wrestler Information:

Name: ________________________

Grade: _______ Age: ______ School: ______________

Wrestler T-Shirt Size (Please Circle)

Youth: Small Medium Large

Adult: Small Medium Large X-Large

Parent/Guardian Information:

Name (Please Print):_____________________________

Address: _______________________________________

Phone Number(s):

Home: __________________________________________

Cell: ____________________________________________

Email address: ___________________________________

Please list any Medical Problems:

______________________________________________________

______________________________________________________

By signing, I agree that Bremen High School and the Wrestling Staff are not responsible for any

injuries.

Parent Signature: _____________________________________

© 2018 Jostens, Inc. 181848A

STEP 1: SELECT YOUR PACKAGE

STEP 2: PERSONALIZE YOUR YEARBOOK FOR

STEP 3: ADD ICONS* FOR EACH STEP 4: ENTER YOUR INFORMATION AND TOTAL YOUR ORDER

Choose one personalization option: name, monogram or crest

ORDER BY:

Yearbook

(29 characters max.)

Cre 4Cre 2Cre 1 Cre 3

Mon 1 Mon 2 Mon 3Mon 4

NAME

MONOGRAM

CREST

Year YearYearYearInitials

Initials Initials Initials Initials

Name for Crest 1, 3, 4 (9 characters max)

Crest 3 second line (12 characters max)

Icon 1 Icon 2

Icon 3 Icon 4

*IMPORTANT: To add icons, you must first purchase personalization in Step 2.Enter the 4-digit icon code from the chart below into the boxes provided.

Enter Your Package Price

Price Total

Subtotal

TOTAL

YAY! THANKS FOR ORDERING!

Student Name: Grade: ID#:Homeroom:Contact Phone:Contact Email:

YEARBOOK ORDER FORM

5884

5982

5010

9001

5242

5588

5012

5236 5379 5480 5581 5682 5783

5238 5239 5019 9050 5015 5240 5022

5002 5003 5004 5005 5006 5008 5009

5582 5583 5584 5585 5980 5981 5586

9025 9006 5013 5014 5258 5241 5360

5592 5362 5363 5364 5365 5247 5587

5590 9042 9051 5023 5255 5256 5257

5367 5253 5018 5021 5591 9036 9037

5011

5001

5130

9007

5025

5589

5366

5985

Quantity

To purchase online, go tojostensyearbooks.com.

If you have questions, please call CustomerService at 1-877-767-5217.

Personalization $6.00

Icon(s) ea. $3.00 x QTY

$3.00

14299 / 2020

10/25/2019

Now is the time to purchase your 2020 yearbook at the lowestprice of the year! The price goes up after October 25th!You can order online at www.jostensyearbooks.com or

Call 1-877-767-5217

Don't Miss Out to pre-order your book today!

$18.00

Includes Yearbook, 1 Line of Personalization, Color Autograph Section and 5 Multicolor Signing Markers

SIGNATURE PACKAGE $31.00

$6.00

Bremen Elementary Middle School

The IHSAA Pre-participation Physical Evaluation (PPE) is the fi rst and most important step in providing for the well-being of Indiana’s high school athletes. The form is designed to identify risk factors prior to athletic participation by way of a thorough medical history and physical examination. The IHSAA, under the guidance of the Indiana State Medical Association’s Com-mittee on Sports Medicine, requires that the PPE Form be signed by a physician (MD or DO) holding an unlimited license to practice medicine, a nurse practitioner (NP) or a physician assis-tant (PA). In order to assure that these rigorous standards are met, both organizations endorse the following requirements for completion of the PPE Form:

1. The most current version of the IHSAA PPE Form must be used and may not be altered or modifi ed in any way. (available for download at www.ihsaa.org<http://www.ihsaa.org/>)

2. The PPE Form must be signed by a physician (MD or DO) holding an unlimited license to practice medicine, a nurse practitioner (NP) or a physician assistant (PA) only after the medical history is reviewed, the examination performed, and the PPE Form completed in its entirety. No pre-signed or pre-stamped forms will be accepted.

3. SIGNATURES The signature must be hand-written. No signature stamps will be accepted. The signature and license number must be affi xed on page two (2). The parent signatures must be affi xed to the form on pages one (1) and four (4). The student-athlete signature must be affi xed to pages one (1) and four (4). Your cooperation will help ensure the best medical screening for Indiana’s high school athletes.

PRE-PARTICIPATION PHYSICAL EVALUATION FORM (PPE)

(1 of 4)

Preparticipation Physical Evaluation HISTORY FORM

(Note: This form is to be fi lled out by the patient and parent prior to examination. The examiner should keep a copy of this form in the chart.)

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement. This form has been modifi ed by the Indiana High School Athletic Association, Inc. (IHSAA).

Signature of athlete _____________________ Signature of parent/guardian _________________________________ Date _____________

(2 of 4)

(The physical examination must be performed on or after April 1 by a physician holding an unlimited license to practice medicine, a nurse practitioner or a physician assistant to be valid for the following school year.) – IHSAA By-Law 3-10

Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM

(The physical examination must be performed on or after April 1 by a physician holding an unlimited license to practice medicine, a nurse practitioner or a physician assistant to be valid for the following school year.) – IHSAA By-Law 3-10

License #(MD, DO, NP, or PA)

(MD, DO, NP, or PA)

(Consent & Release Cer fi cate - on back or next page)

INDIVIDUAL ELIGIBILITY RULES (Grades 9 through 12)

ATTENTION ATHLETE: Your school is a member of the IHSAA and follows established rules. To be eligible to represent your school in interschool athle cs, you:

1. must be a regular bona fi de student in good standing in the school you represent; must have enrolled not later than the fi eenth day of the current semester. 2. must have completed 10 separate days of organized prac ce in said sport under the direct supervision of the high school coaching staff preceding date of par cipa on in interschool contests. (Excluding Girls Golf – SeeRule 101) 3. must have received passing grades at the end of their last grading period in school in at least seventy percent (70%) of the

maximum number of full credit subjects (or the equivalent) that a student can take and must be currently enrolled in at least seventy percent (70%) of the maximum number of full credit subjects (or the equivalent) that a student can take. Semester grades take precedence. 4. must not have reached your twen eth birthday prior to or on the scheduled date of the IHSAA State Finals in a sport. 5. must have been enrolled in your present high school last semester or at a junior high school from which your high school

receives its students . . . . . . unless you are entering the ninth grade for the fi rst me. . . . unless you are transferring from a school district or territory with a corresponding bona fi de move on the part of your

parents. . . . unless you are a ward of a court; you are an orphan, you reside with a parent, your former school closed, your former

school is not accredited by the state accredi ng agency in the state where the school is located, your transfer was pursuant to school board mandate, you a ended in error a wrong school, you transferred from a correc onal school, you are emancipated, you are a foreign exchange student under an approved CSIET program. You must have been eligible from the

school from which you transferred. 6. must not have been enrolled in more than eight consecu ve semesters beginning with grade 9. 7. must be an amateur (have not par cipated under an assumed name, have not accepted money or merchandise directly

or indirectly for athle c par cipa on, have not accepted awards, gi s, or honors from colleges or their alumni, have not signed a professional contract).

8. must have had a physical examina on between April 1 and your fi rst prac ce and fi led with your principal your completed Consent and Release Cer fi cate.

9. must not have transferred from one school to another for athle c reasons as a result of undue infl uence or persuasion by any person or group.

10. must not have received in recogni on of your athle c ability, any award not approved by your principal or the IHSAA. 11. must not accept awards in the form of merchandise, meals, cash, etc. 12. must not par cipate in an athle c contest during the IHSAA authorized contest season for that sport as an individual or on

any team other than your school team. (See Rule 15-1a) (Excep on for outstanding student-athlete – See Rule 15-1b) 13. must not refl ect discredit upon your school nor create a disrup ve infl uence on the discipline, good order, moral or educa onal environment in your school. 14. students with remaining eligibility must not par cipate in tryouts or demonstra ons of athle c ability in that sport as a

prospec ve post-secondary school student-athlete. Graduates should refer to college rules and regula ons before par cipa ng. 15. must not par cipate with a student enrolled below grade 9. 16. must not, while on a grade 9 junior high team, par cipate with or against a student enrolled in grade 11 or 12. 17. must, if absent fi ve or more days due to illness or injury, present to your principal a wri en verifi ca on from a physician

licensed to prac ce medicine, sta ng you may par cipate again. (See Rule 3-11 and 9-14.) 18. must not par cipate in camps, clinics or schools during the IHSAA authorized contest season. Consult your high school

principal for regula ons regarding out-of-season and summer. 19. girls shall not be permi ed to par cipate in an IHSAA tournament program for boys where there is an IHSAA tournament

program for girls in that sport in which they can qualify as a girls tournament entrant.

This is only a brief summary of the eligibility rules.

You may access the IHSAA Eligibility Rules (By-Laws) at www.ihsaa.orgPlease contact your school offi cials for further informa on and before par cipa ng outside your school.

(3 of 4)

Preparticipation Physical Evaluation IHSAA ELIGIBILITY RULES

I. STUDENT ACKNOWLEDGMENT AND RELEASE CERTIFICATEA. I have read the IHSAA Eligibility Rules (next page or on back) and know of no reason why I am not eligible to represent my school in athle c com-

pe on. B. If accepted as a representa ve, I agree to follow the rules and abide by the decisions of my school and the IHSAA. C. I know that athle c par cipa on is a privilege. I know of the risks involved in athle c par cipa on, understand that serious injury, and even

death, is possible in such par cipa on, and choose to accept such risks. I voluntarily accept any and all responsibility for my own safety and wel-fare while par cipa ng in athle cs, with full understanding of the risks involved, and agree to release and hold harmless my school, the schools involved and the IHSAA of and from any and all responsibility and liability, including any from their own negligence, for any injury or claim resul ng from such athle c par cipa on and agree to take no legal ac on against my school, the schools involved or the IHSAA because of any accident or mishap involving my athle c par cipa on.

D. I consent to the exclusive jurisdic on and venue of courts in Marion County, Indiana for all claims and disputes between and among the IHSAA and me, including but not limited to any claims or disputes involving injury, eligibility or rule viola on.

E. I give the IHSAA and its assigns, licensees and legal representa ves the irrevocable right to use my picture or image and any sound recording of me, in all forms and media and in all manners, for any lawful purposes.

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE PROVISION. (to be signed by student)

Date: ____________________Student Signature: ____________________________________________________

Printed: _____________________________________________________

II. PARENT/GUARDIAN/EMANCIPATED STUDENT CONSENT, ACKNOWLEDGMENT AND RELEASE CERTIFICATEA. Undersigned, a parent of a student, a guardian of a student or an emancipated student, hereby gives consent for the student to par cipate in

the following interschool sports not marked out: Boys Sports: Baseball, Basketball, Cross Country, Football, Golf, Soccer, Swimming, Tennis, Track, Wrestling. Girls Sports: Basketball, Cross Country, Golf, Gymnas cs, Soccer, So ball, Swimming, Tennis, Track, Volleyball.B. Undersigned understands that par cipa on may necessitate an early dismissal from classes.C. Undersigned consents to the disclosure, by the student’s school, to the IHSAA of all requested, detailed fi nancial (athle c or otherwise), scholas-

c and a endance records of such school concerning the student.D. Undersigned knows of and acknowledges that the student knows of the risks involved in athle c par cipa on, understands that serious injury,

and even death, is possible in such par cipa on and chooses to accept any and all responsibility for the student’s safety and welfare while par- cipa ng in athle cs. With full understanding of the risks involved, undersigned releases and holds harmless the student’s school, the schools

involved and the IHSAA of and from any and all responsibility and liability, including any from their own negligence, for any injury or claim resul ng from such athle c par cipa on and agrees to take no legal ac on against the IHSAA or the schools involved because of any accident or mishap involving the student’s athle c par cipa on.

E. Undersigned consents to the exclusive jurisdic on and venue of courts in Marion County, Indiana for all claims and disputes between and among the IHSAA and me or the student, including but not limited to any claims or disputes involving injury, eligibility, or rule viola on.

F. Undersigned gives the IHSAA and its assigns, licensees and legal representa ves the irrevocable right to use any picture or image or sound re-cording of the student in all forms and media and in all manners, for any lawful purposes.

G. Please check the appropriate space: The student has school student accident insurance. The student has football insurance through school. The student has adequate family insurance coverage. The student does not have insurance.

Company:  Policy Number:

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE PROVISION. (to be completed and signed by all parents/guardians, emancipated students; where divorce or separa on, parent with legal custody must sign)

Date: _______________ Parent/Guardian/Emancipated Student Signature:_________________________________

Printed: ________________________________

Date: _______________ Parent/Guardian Signture:_______________________________

Printed: ________________________________

FORM D - 7/11 DLC: 6/24/2016 g:/prin ng/forms/schools/1617physicalform.indd

CONSENT & RELEASE CERTIFICATEIndiana High School Athle c Associa on, Inc.9150 North Meridian St., P.O. Box 40650Indianapolis, IN 46240-0650

File In Offi ce of the PrincipalSeparate Form Required for Each School Year

(4 of 4)

(X)

(X)

(X)

Preparticipation Physical Evaluation CONSENT & RELEASE CERTIFICATE

S M T W T F S S M T W T F S

1 2 3 1 2 3 4

4 5 6 7 8 9 10 5 6 7 8 9 10 11

11 12 13 14 15 16 17 12 13 14 15 16 17 18

18 19 20 21 22 23 24 19 20 21 22 23 24 25

25 26 27 28 29 30 31 26 27 28 29 30 31

S M T W T F S S M T W T F S

1 2 3 4 5 6 7 1

8 9 10 11 12 13 14 2 3 4 5 6 7 8

15 16 17 18 19 20 21 9 10 11 12 13 14 15

22 23 24 25 26 27 28 16 17 18 19 20 21 22

29 30 23 24 25 26 27 28 29

S M T W T F S S M T W T F S

1 2 3 4 5 6 7

1 2 3 4 5 8 9 10 11 12 13 14

6 7 8 9 10 11 12 15 16 17 18 19 20 21

13 14 15 16 17 18 19 22 23 24 25 26 27 28

20 21 22 23 24 25 26 29 30 31

27 28 29 30 31

S M T W T F S S M T W T F S

1 2 1 2 3 4

3 4 5 6 7 8 9 5 6 7 8 9 10 11

10 11 12 13 14 15 16 12 13 14 15 16 17 18

17 18 19 20 21 22 23 19 20 21 22 23 24 25

24 25 26 27 28 29 30 26 27 28 29 30

S M T W T F S S M T W T F S

1 2 3 4 5 6 7 1 2

8 9 10 11 12 13 14 3 4 5 6 7 8 9

15 16 17 18 19 20 21 10 11 12 13 14 15 16

22 23 24 25 26 27 28 17 18 19 20 21 22 23

29 30 31 24 25 26 27 28 29 30

31

May

1/3 Final Day of

Winter Break

1/20 Virtual Day

(Students Home)

11/4 Staff

Development/

Work Day

(No School)

11/27-11/29

Thanksgiving Break

12/23/18-1/3/19

Winter Break

(No School)

4/3-4/10

Spring Break

5/25

Memorial Day

5/21 Staff

Work Day or

21,22,26,27,28

Snow

Makeup Days

9/2

Labor Day

(No School) 2/17 Staff

Development/

Work Day

10/23 & 10/24

Parent Teacher

Conferences

(BEMS Evening)

10/25-10/28

Fall Break

(No School)

December

20

19

- 20

20

Acad

emic C

alend

ar 20

19

- 20

20

Acad

em

ic Calen

dar

8/5 - 8/6

Staff Work &

Professional

Development Days

(No School)

8/27 Virtual Day

(Students Home)

August

SEPTEMBER

OCTOBER

NOVEMBER

Graduation: May 31, 2020

January

February

March

April

Elementary Quarters:

1st Quarter: 08/07/19-10/10/19

2nd Quarter: 10/11/19-12/20/19

3rd Quarter: 01/06/20-03/10/20

4th Quarter: 03/11/20-05/20/20

1st Trimester: 08/07/19-11/01/19

2nd Trimester: 11/05/19-02/14/20

High School Trimesters:

3rd Trimester: 02/18/20-05/20/20