2017 EAST/WEST ALL-STAR FOOTBALL GAME
August 5th, 2017
Baker City, Oregon
Once a year, Oregon's best and brightest senior football players and cheerleaders from the 1A to 4A
high schools meet in Baker City to participate in an all-star football game that is much more than a
game. These healthy players and cheerleaders are playing for the children who are patients of Shriners
Hospital for Children.
The players and cheerleaders learn why they play/cheer in this important game, when they visit
Portland Shriners Hospital for Children and meet the children for whom they are playing. This meeting
with the children forms bonds between the players and the patients. The players learn how important
their contribution is to these children through interaction and play, leaving the players with a new
understanding of their mission. The players and cheerleaders participate with a common goal and,
although they play on two different teams, they are united in their purpose and are only opponents on
the field.
Shriners Hospitals for Children is the only pediatric health care system in The United States that provides
care and services regardless of the patient’s ability to pay.
Shriners Hospital for Children is one of the largest pediatric sub-specialty health care systems in the
world.
The three Shriners Hospitals for Children specializing in burn care are the only hospitals initially
established for the exclusive treatment of pediatric burns and related conditions. A fourth hospital in
our health care system offering treatment for burns also provides care of orthopedic conditions, spinal
cord injuries and cleft lip and palate.
Since the first Shriners Hospital opened in Shreveport, LA., in 1922, the Shriners health care system has
cared for nearly one million children.
In 2011, Shriners Hospitals for Children cared for 121,713 children including:
-285,154 outpatient, outreach and telemedicine clinic visits
-10,109 prosthetic patient visits (inpatient and outpatient)
-51,288 orthotics patient visits (inpatient and outpatient)
Cheerleaders are selected by an application process. The cheerleaders for this event are sponsored by
the OCCA (Oregon Cheerleading Coaches Association). Coaches must be a member of OCCA to nominate
cheerleaders for the game. Applications may be found on the OCCA website under Special Events,
Shrine Game. Applications are posted by January of each year and are due March 31st, 2017.
The football players who are selected will be 2016 graduates; we encourage your current senior
cheerleaders to apply. The Shrine Cheerleading team is open to all 2016 graduates. If we do not have
enough current graduates to fill the team, the team will be open to Class of 2017 cheerleaders who have
applied.
If you are selected to participate in this extraordinary event you will build friendships, make
unforgettable memories, participate in all game activities, half time performance, game day parade, and
Shriners Hospital visit. You will be provided with a game day t-shirt, practice t-shirt, poms, bow, and
daily meals. Hotel expenses are paid by the Shriners and OCCA. Cheerleaders will need to provide their
own transportation to choreography, hospital visit and Baker City. Cheerleaders who are named to the
team will also be REQUIRED to obtain a $250 sponsorship from local businesses. Sponsors will be
featured in the game day program. Once you have been selected, more information will be sent
regarding this process. To participate in the game, a sponsorship is REQUIRED by all cheerleaders.
We are looking for both female and male athletes who excel at the sport and who are leaders on their
team and school. Tumbling is not required however; we are looking for the most talented athletes. It is
an honor to be named to the Shrine Team. Please only recommend the most deserving athletes and all
around athletes.
The number of applicants continues to grow every year. Please understand that we may not be able to
select all of your applicants. Priority will be given to 2017 graduates. We definitely try to include as many
schools as possible and try to name at least one athlete from each school that has applied.
Required Dates
Cheerleaders must be available for the dates listed below, no exceptions will be allowed. If you are not
available during the dates below, please do not apply for the team.
July 27th-28th - Hospital Visit and Choreography
August 3rd-5th - Game in Baker City
For more information or if you have questions, please visit our “Shrine Cheerleading” Facebook page
and the official game website at www.eastwestshrinefootball.com.
Amber Rosa
OCCA East/West All-Star Football Game Coordinator
541-401-2347
[email protected]
2017 EAST/WEST ALL-STAR FOOTBALL GAME
CHEERLEADER APPLICATION
Name: _______________________________________________________
Age: _________
Mailing Address: ______________________________________________________________
City: __________________________________
Phone Number: (
Zip Code: ____________________________
) ___________________________
Email Address: ________________________________________@________________._____
(please be sure your email address is correct, this will be the primary form of communication)
High School: __________________________________________________
Please circle one:
CLASS OF 2017 GRADUATE
CLASS OF 2018
Please place an “X” if you:
______ 2016 1A-4A All State Team Member.
______ Participant in the 2016 All State Individual Competition.
______ Participant in the 2016 All State Stunt Competition
T-shirt Size: _________
Cheerleading:
(Please list your cheerleading experience)
Tumbling:
(please circle the skills you are comfortable performing on a grass field)
Standing BHS
Standing Tuck
Running Tumbling Pass (Round off BHS/Series)
Other: _______________________________________________________________________
Stunting:
(circle the skill set you are MOST comfortable performing)
Beginning (preps, thigh stands, basic cradles)
Intermediate (one foot stunts at prep level, extensions, toe touch baskets, basic pyramid
sequences)
Advanced (extended one foot stunts with different body positions, inversions, full ups, advanced
pyramid sequences, full down cradles)
Please circle ALL stunting positions you are comfortable performing:
FLYER
BASE
BACK BASE
FRONT BASE
**You may NOT be performing the stunting position you are used to performing. We need
team members that are willing to learn and perform the position asked of them**
Cheerleading Achievements:
Academic Achievements:
***HIGH SCHOOL JUNIORS/COACHES***
MORATORIUM WEEK
Moratoium Week is July 24-30th this year. If you will still be in High School (Junior
applicants) during the Shrine events, you and your school will need to apply through the
OSAA for an exception to be able to participate in the Hospital visit and choreography
portions. It is the responsibility of the athlete, coach and AD of each school to request and
seek approval for this exception. Failure to do so may result in fines or penalties for your
school. The OCCA and Shriner’s Organization’s will not be liable or responsible for any
schools who do not comply. You may contact Kelly Foster with the OSAA for questions
and exception requests.
Kelly Foster
503.682.6722 x233
[email protected]
High School Coach Signature (REQUIRED): _______________________________
Email Address:_________________________________________________________________
Phone Number:______________________ Cellphone Number:__________________________
Application Instructions
Please send completed application and portraits to:
Mail:
Terry Griffith
61246 Ladera Road SE
Bend, Ore 97702
Email:
[email protected]
Applications must be submitted or postmarked by March 31st, 2017 in order to be considered.
All forms MUST be completed in order to be considered for the 2017 Shrine Team. Please use
the checklist below to be sure you have completed all forms due.
Applications must be signed by your current high school coach.
_____ Application
_____ Cheerleader Ethic Form
_____ High Resolution Digital Picture (5x7 Print / Digital 4mg)
_____ Cheerleaders/Parent Consent Form
_____ Cheerleader Information Sheet
_____ Cheerleader Insurance Form
_____ Photo/Information Release Form
_____ Physician’s Form
_____ $250 Sponsorships (Not due until May 1 2017)
**Physician’s Form MUST be completed to cheer at the game. ALL cheerleaders must be
physically able to perform cheers, dance motions, jumps, and stunting. This form can NOT be
replaced with a current sports physical per Shriners.**
All of the above forms must be completed in order to be considered for the team!
Questions? Please contact:
Amber Rosa
541-401-2347 (call or text)
[email protected]
Heidi Lagao
541-977-8899 (call or text)
[email protected]
CHEERLEADERS and PARENT/GUARDIAN CONSENT FORM
Please Print Clearly when completing form
TO SHRINER’S HOSPITAL OREGON EAST-WEST ALL-STAR COMMITTEE
We hereby give our consent for the participation of our son/daughter.
Cheerleaders Name
As a cheerleader in the Annual Shriner’s Hospital Oregon East-West Football
Game to be played at the Baker High School Stadium, Baker City, Oregon on
August 5th, 2017. It is understood that the East-West Shrine Football Game
Organization shall provide supplementary or secondary insurance for medical care
and expenses for your daughter/son in the event of accident/or injury during her/his
participation becoming effective when your personal coverage ceases.
In the event your daughter/son is injured, do we have your consent to take him/her
to a local doctor or hospital for an examination and/or treatment?
YES_________ or NO__________
Family Doctor: ______________________________________________________________
Family Dentist: ______________________________________________________________
Please Print Legibly:
Cheerleader’s Full Legal Name:____________________________________________________
Cheerleader’s Known by:_________________________________________________________
Address:_______________________________________City:________________Zip:________
Mailing Address (if different):_____________________________________________________
Email Address:_________________________________________________________________
Phone Number:______________________ Cellphone Number:__________________________
Birthday: Mo_________ Day__________ Year__________
--------------------------------------------------------------------------------------------------------------------Cheerleader’s Signature
Date
Parent/Guardian Name (please print):_______________________________________________
Parent/Guardian Signature:________________________________________________________
Address:_______________________________________City:________________Zip:________
Mailing Address (if different):_____________________________________________________
Email Address:_________________________________________________________________
Phone Number:______________________ Cellphone Number:__________________________
--------------------------------------------------------------------------------------------------------------------Parent/Guardian Signature
Date
--------------------------------------------------------------------------------------------------------------------Parent/Guardian Signature
Date
When Submitting a Photo for Programs, Websites and Misc. Media:
Please submit your photo in High Resolution Digital Picture (5x7 Print / Digital 4mg).
If we don’t receive a usable image, we will try to contact you. If we don’t hear back you
in a timely matter, you give us permission to search social media for one.
--------------------------------------------------------------------------------------------------------------------Cheerleader Signature
Date
--------------------------------------------------------------------------------------------------------------------Parent/Guardian Signature
Date
East – West All-Star Game
Cheerleader Information Sheet – (All Must be Filled Out For Program)
Name:________________________________________________________________________
School:_______________________________________________________________________
Mascot:_______________________________________________________________________
Cheerleading Highlights / Honors:_________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Other Athletic or Academic Highlights / Honors:______________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Community / Volunteer Activities:_________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
College / Vocational Future Plans: _________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Phone:_______________________________ Email:___________________________________
East- West Shrine All-Star Cheerleader / Coach Insurance Form
The accident insurance policy provided by the Shrine East-West Game Committee is
supplementary or secondary to your personal family insurance policy, becoming effective when
your personal insurance coverages ceases. This policy covers accidents sustained by duly
registered participants in the game or related activities. It does not cover any illnesses, mental
health, diseases or naturally caused ailments unrelated to an accidental injury.
To properly register the cheerleader for insurance coverage, the following information is
required. To expedite and avoid confusion, please complete all the information requested.
Insurance Company:____________________________________________________________
Policy Number:_________________________________________________________________
Name of Policy Holder:__________________________________________________________
Cheerleader’s Full Name:_________________________________________________________
Cheerleader’s Date of Birth:_______________________________________________________
Parent/Guardian Name (please print):_______________________________________________
Address:_______________________________________City:________________Zip:________
Mailing Address (if different):_____________________________________________________
Email Address:_________________________________________________________________
Phone Number:______________________ Cellphone Number:__________________________
--------------------------------------------------------------------------------------------------------------------Cheerleader Signature
Date
--------------------------------------------------------------------------------------------------------------------Parent/Guardian Signature
Date
Cheerleader Ethic Form
The purpose of a code of conduct for our Cheerleaders establish a consistent expectation for
athletes’ behavior. By signing this code of conduct, I agree to the following statements:
❏ I will respect and show courtesy to my teammates and coaches at all times.
❏ I will demonstrate good sportsmanship at all practices and EW games / events.
❏ I will set a good example of behavior to my teammates and others around me.
❏ I will be respectful of my teammates’ feelings and personal space. Athletes who exhibit sexist, racist,
homophobic, or otherwise inappropriate behavior will be faced with consequences.
❏ I will attend all EW cheer team meetings, training sessions and events / game.
❏ I will show respect for all facilities and other property (including hotel rooms) used during practices,
EW events & activities, and overnight stays .
❏ I will refrain from foul language, violence, behavior deemed dishonest, offensive, or illegal.
❏ If I disagree with an official’s call, I will talk with my coach and not approach the official directly.
❏ I will obey all OSSA rules and codes of conduct. I understand that if I violate this code of conduct, I will
be subject to disciplinary action determined by my coaches and The EW Shiner All-Star Committees.
❏ I Refrain from the use of alcohol, tobacco, illegal and non-prescriptive drugs, anabolic steroids or any
substance to increase physical development or performance that is not approved by the United States
Food and Drug Administration, Surgeon General of the United States or American Medical Association.
❏Exhibit fair play, sportsmanship and proper conduct on and off the playing field.
--------------------------------------------------------------------------------------------------------------------Cheerleader Signature
Date
--------------------------------------------------------------------------------------------------------------------Parent/Guardian Signature
Date
Shrine East-West All-Star Football Game
All-Star Cheerleader Physician Form
Signature of a license physician is required to participate in all East-West All-Star Football
Game cheerleading activities.
There is no medical or physical reason indicated to prevent
___________________________________________________
(Please print name of cheerleader)
from participating in cheerleading activities for the East-West All-Star Football Game (including
practices) from July 27th-August 5th , 2017 in Sweet Home and Baker City, Oregon.
The main cheerleading activities will be on August 5h, 2016 at the East-West All-Star Football
Game.
_______________________________________________
Licensed Physician’s Signature
_______________________________________________
Address
____________________________
Date
___________________________
Phone Number
*A current sports physical does NOT take the place of this form*