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Sports Participation Checklist

   EAGLE PEAK SCHOOL 2017-2018

SPORTS PARTICIPATION CHECKLIST

_______________________     ______        __________         _____

Student’s Name                           Grade             Sports                    I.D. #

 

I have read and understand the following documents that are available on the (PLEASE INITIAL NEXT TO EACH DOCUMENT):

Athlete                 Parent/Guardian             

________           ________           Health Examination and Parent Consent

________           ________           CIF Code of Conduct

________           ________           UUSD Extra-Curricular Rules & Regs/Student Contract

________           ________           Acknowledgement/Assumption of Potential Risk

________           ________           NCS Ejection Policy

Signature of Parent         ____________________________  Date   __________________

Signature of Athlete       ____________________________  Date  __________________

-----------------------------------------------------------------------------------------------------------

PARTICIPATION RECOMMENDATIONS

_____ 1. There were no history or physical findings on this exam which would prohibit this student from participating in competitive athletics.

_____ 2.  This student should have the following health problems evaluated or treated prior to participating in competitive athletics.

_____ 3.  This student has health problems which would prohibit him or her from participating in competitive athletics.

PHYSICIAN’S STATEMENT CERTIFICATION

Are there apparent cavities in teeth?    _____ Yes       _____ No

Is there a bridge or false teeth?            _____  Yes        _____ No

Has the above had any injury or physical condition that should be watched? _____ If yes, please list.

I hereby certify that ____________________________ was examined by me on ____________  20______

and found physically fit to participate in sports in the school year 2017 – 2018.

Physician’s Signature __________________________________  Date ____________________

Please Print Name ______________________________________________________________

 

RETURN THE PHYSICIAN’S CERTIFICATION & PAGES 1-3, PARENT ASSURANCE OF INSURANCE COVERAGE, & CONCUSSION PARENT ATHLETE FORM TO THE

EAGLE PEAK MIDDLE SCHOOL OFFICE

 

1

 

PARENT ASSURANCE OF INSURANCE COVERAGE

 

 

Students taking part in the school athletic program must be fully insured against injury and death. You must have insurance covering sports including contact football, for your child. If you do not have insurance, you may obtain it through your own agent or purchase (student) insurance available to all students.  See the Athletic Director for information.

 

 

       NAME OF INSURANCE COMPANY                             POLICY NO.

 

  1. Ten (10 days written notice to the Principal of Eagle Peak School, Ukiah Unified School District,

8601 West Rd, Redwood Valley, California, must be given prior to cancellation.

  1. Deductible insurance does not fulfill the legal requirements for participation.

 

I will maintain this coverage during the current school year or will immediately notify the school if the coverage terminates or does not meet the stated requirements.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                

 

 

 

 

 

 

 

 

 2   

                                                                       Eagle Peak School

Concussion Information Sheet

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:

 


  • Headaches
  • “Pressure in head”
  • Nausea or vomiting
  • Neck pain
  • Balance problems or dizziness
  • Blurred, double, or fuzzy vision
  • Sensitivity to light or noise
  • Feeling sluggish or slowed down
  • Feeling foggy or groggy
  • Drowsiness
  • Change in sleep patterns


  • 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 include:

 

  • Appears dazed
  • Vacant facial expression
  • Confused about assignment
  • Forgets plays
  • Is unsure of game, score, or opponent
  • Moves clumsily or displays incoordination
  • Answers questions slowly
  • Slurred speech
  • Shows behavior or personality changes
  • Can’t recall events prior to hit
  • Can’t recall events after hit
  • Seizures or convulsions
  • Any change in typical behavior or personality
  • Loses consciousness

 

 

Adapted from the CDC and the 3rd International Conference on Concussion in Sport

Document created 5/20/2010


                                          3                 

                                               Eagle Peak School

Concussion Information Sheet

 

What can happen if my child keeps on playing with a concussion or returns to soon?

 

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to  play with the signs and symptoms of a concussion leaves the young athlete 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 athlete 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 athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.

 

If you think your child has suffered a concussion

 

Any athlete even suspected of suffering a concussion should be removed from the game or practice  immediately.  No  athlete  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 athlete  should continue for several hours. The new CIF Bylaw 313 now requires implementation of long and well-established return to play concussion guidelines that have been recommended for several years:

 

“A student-athlete  who  is  suspected  of  sustaining  a  concussion  or  head  injury  in  a practice or game shall be removed from competition at that time and for the remainder of the day.”

and

“A student-athlete who has been removed may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion  and  received  written  clearance  to  return  to  play  from  that  health  care provider”.

 

You should also inform your child’s coach if you think that your child may have a concussion Remember its  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/

 

 

 

 

            Student-athlete Name Printed                  Student-athlete Signature                        Date

 

 

 

 

 

            Parent or Legal Guardian Printed                                                                                    Parent or Legal Guardian Signature                                       Date

 

Adapted from the CDC and the 3rd International Conference on Concussion in Sport

Document created 5/20/2010

 

 

 

 

 

 

4

To  b e  c ompl et ed  b y  st udent  and  parent s  pri or  t o  examination

PR EPA R TI C I PA TI ON H EALTH  EXAMINATION R EC OR D

                    

                      Last Name   First Name                                                                Middle School


Grade                                       Sex:           


Male            


Female         


Student No.                     


HE AL T H  HI S T O RY

 

Yes

No

Ha s t h i s S t u d e n t h a d a n y :

Yes

No

Do e s t h i s St u d e n t :

 

     

Chronic or recurrent illness?

 

     

Wear eyeglasses

 

     

Illness lasting over one week?

 

     

Wear dental bridges, braces, plates?

 

     

Hospitalizations?

 

     

Take any medication?

            Surgery other than tonsillectomy? ____         ___       Is  there  any  H istory  of:


            Missing organ (eye, kidney, testicle)?

            Allergy to any medication?

            Problems with heart or blood pressure?     


            Injuries requiring MD treatment?

            Neck injury?

            Knee injury?


            Chest pain with exercise?

            Dizziness or fainting with exercise?

            Concussion or unconsciousness?     

            Heat exhaustion, heat stroke?

            Cortisone taken in last year?


            Knee surgery?

            Ankle injury?

            Other serious joint injury?

            Broken bones (fractures)?

            Any reason why this student should


            Health concerns/questions you wish                                    not participate in sports?


to discuss with an MD?


            Has any family member died


            Anyone tell you not to participate                         suddenly younger than 40 years old


in a sport?

            Habits that might affect your athletic performance?


of causes other than an accident?


 

Date of last known Tetanus (lockjaw) shot:                                                                                                  

 

Use this space to explain any of the above numbered YES answers or to provide additional information:

 

 

 

PA R EN T C ON SEN T

 

I h av e read th e G eneral Inform ation B u lletin of th e C .I.F .P .F . and agree to th e p rov isions contained th erein I

he r e by g i ve m y  con s e n t f or t he a bove n a m e d (s on, daughter , or w ar d) to com pete i n s por ts and go w i th a

rep resen tativ e o f  th e sc h o o l o n an y  ath letic trip s.  In c ase th is p u p il is in ju red , y o u are au th o riz ed to h av e h im treated .

 

PA R EN T S  O R  G U A R D I A N ’ S  PER M I SSI O N  A N D  R ELEA SE

 

I  h ereb y  giv e  m y  consent  for  th e  ab ov e  nam ed  stu d ent  to  rep resent  h is  or  h er  sch ool  in  th e  ath letic  activ ities

excep t th os e ind icated on th is f orm b y  th e exam ining p h ys ician p rovid ed th at s uch ath letic activitie s a re a p p ro v e d by t he St a t e A s s o c i a t i o n .  I a l s o g i v e m y  c o n s e n t f o r t he s t u de n t t o a c c o m pa n y  t he s c ho o l t e a m o n a n y  o f  i t s l o c a l or  out - of - tow n  trip s.

The  U k i a h  Sc ho o l  Bo a r d  o f  Edu c a t i o n  ha s  n o  r e s po n s i bi l i t y  t o  pr o v i de  f i r s t  a i d  a t  a n y  o f  t he  g a m e s  a n d  p arents

under s tand that r i s k of i nj ur y  i s as s um ed b y  s tudent and par ents w hen they ar e executi ng thi s f or m .  H ow ever , i n th e  event  p h ysicians,  p h ysical  th erap ists,  p h ysician’s  assistants,  nurses  or  oth er  p ersons  trained  in  th e  rend ering

of f i r s t ai d ar e ava ilab le as v o lu nteers o r o th erw ise, and rend er aid to any stu d ent inju red d u ring th e c o u rse o f any  s uch  activities  or  travel,  th e  p arents  d o  h ereb y  releas e  and  f orever  d is ch arge  s uch  p ers ons  and  th e  U kiah

Sc ho o l  Bo a r d  o f  Educ a t i o n  f r o m  a n y  l i a bi l i t y  a r i s i n g  o u t  o f  a n y  first  a id  o r  tre a tm e n t  o f  in ju rie s.

 

 

 

5

PHYSICIAN   R ET AIN  T H IS  PAG E  AND  NEXT  PAG E FOR  Y OU R  RECORDS


 

PHYSICAL EXAM INAT ION


Height                                       Weigh                                 Pulse                                       Blood press.            


Vision Right

 

Left


                Normal        w/o glasses

      with glasses

                Abnorm.       w/o glasses

      with glasses


 


 

Eyes


NORMAL               ABNORMAL                          COMMENTS                         EXAMINER


 

Ears/Nose/Throat

 

Mouth/Teeth

 

Neck (Soft Tissue)

 

Cardiovascular

 

Chest/Lungs

 

Abdomen

 

Genitalia-Hernia

Sexual Maturity                                                                                                                                                                                     

Skin and Lymphatics

 

Neck

 

Spine

 

Shoulders

 

Arms and Hands

 

Hips

 

Thighs

 

Knees

 

Ankles

 

Feet

 

Neurological

 

Based on this history and physical exam, the following abnormalities were found and may need treatment:

 

 

 

 

 

STUDENT NAME                                                                                                 DATE

 

 

PHYSICIAN   R ET AIN  T H IS  PAG E  AND  PR EVIOUS PAGE  FOR  YOUR  RECORDS

 

4

 

CIF – Eagle Peak School

Code of Conduct for Interscholastic Student-Athletes

 

Interscholastic athletic competition should demonstrate high standards of ethics and sportsmanship and promote the development of good character and other important life skills. The highest potential of sports is achieved when participants are committed to pursuing victory with honor according to six core principles: trustworthiness, respect, responsibility, fairness, caring, and good citizenship (the Six Pillars of Character). This Code applies to all student- athletes involved in interscholastic sports in California. I understand that, in order to participate in high school athletics, I must act in accord with the following:


  TRUSTWORTHINESS

Ø     Trustworthiness be worthy of trust in all I do.

Ø     Integrity – live up to high ideals of ethics and sportsmanship and always pursue victory with honor; do what’s right even when it’s unpopular or personally costly.

Ø     Honesty – live and compete honorably; don’t lie, cheat, steal or engage in any other dishonest or unsportsmanlike conduct.

Ø     Reliability – fulfill commitments; do what I say I

will do; be on time to practices and games.

Ø     Loyalty – be loyal to my school and team; put the team above personal glory.

 

RESPONSIBILITY

Ø     Importance of Education – be a student first and commit to getting the best education I can. Be honest with myself about the likelihood of getting an athletic scholarship or playing on a professional level and remember that many universities will not recruit student-athletes that do not have a serious commitment to their education, the ability to succeed academically or the character to represent their institution honorably.

Ø     Role Modeling Remember, participation in sports is a privilege, not a right and that I am expected to represent my school, coach and teammates with honor, on and off the field. Consistently exhibit good character and conduct yourself as a positive role model. Suspension or termination of the participation privilege is within the sole discretion of the school administration.

Ø     Self Control – exercise self-control; don’t fight or show excessive displays of anger or frustration; have the strength to overcome the temptation to retaliate.

Ø     Healthy Lifestyle – safeguard your health; don’t use any illegal or unhealthy substances including alcohol, tobacco and drugs or engage in any unhealthy techniques to gain, lose or maintain weight.

 

 

 

 

                                                                                      

 

 

                                                                                           7
Ø      Integrity of the Game – protect the integrity of the game; don’t gamble. Play the game according to the rules.

 

 

FAIRNESS

Ø      Be Fair – live up to high standards of fair play; be open-minded; always be willing to listen and learn.

 

 

CARING

Ø      Concern for Others – demonstrate concern for others; never intentionally injure any player or engage in reckless behavior that might cause injury to myself or others.

Ø      Teammates – help promote the well being of teammates by positive counseling and encouragement or by reporting any unhealthy or

dangerous conduct to coaches.

 

 

CITIZENSHIP

Ø      Play by the Rules – maintain a thorough knowledge of and abide by all applicable game and competition rules.

Ø      Spirit of Rules – honor the spirit and the letter of rules; avoid temptations to gain competitive advantage through improper gamesmanship techniques that violate the highest traditions of sportsmanship.

 

I have read and understand the requirements of this Code of Conduct. I understand that I’m expected to perform according to this code and I understand that there may be sanctions or penalties if I do not.


5

PARTICIPATION AGREEMENT FOR CALIFORNIA INTERSCHOLASTIC FEDERATION (CIF) VOLUNTARY ACTIVITIES

 

 

ACKNOWLEDGEMENT AND ASSUMPTION OF POTENTIAL RISK

 

 

I authorize my son/daughter to participate in the District-sponsored activities.

 

I understand and acknowledge that these activities, by their very nature, pose the potential risk of serious injury/illness to individuals who participate in such activities.

 

I understand and acknowledge that some of the injuries/illnesses, which may result from participating in these activities, include, but are not limited to the following:

 

  1. Sprains/strains
  2. Fractured bones
  3. Unconsciousness
  4. Head and/or back injuries
  5. Paralysis
  6. Loss of eyesight
  7. Communicable diseases
  8. Death

 

I understand and acknowledge that participation in these activities is completely

voluntary and as such is not required by the District for course credit or for completion of graduation requirements.

 

I understand and acknowledge that in order to participate in these activities, my son/daughter and I agree to assume liability and responsibility for any and all potential risks, which may be associated with participation in these activities.

 

I understand, acknowledge and agree that the District, its employees, officers, agent, or volunteers shall not be liable for any injury/illness suffered by my son/daughter which is incident to and/or associated with preparing for and/or participating in this activity.

 

I acknowledge that I have carefully read this PARTICIPATION AGREEMENT FOR CIF VOLUNTARY ACTIVITIES and that I understand and agree to its terms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

                                                            Ukiah Unified Schools

EXTRA-CURRICULAR ACTIVITIES -- RULES AND REGULATIONS

 

 

Students who participate in extra-curricular activities serve in the capacity of role models, ambassadors of good will, and assume a posture of high expectations as representatives of Ukiah High School, Pomolita Middle School, or Eagle Peak Middle School.

 

Students who participate in extra-curricular activities are representatives of Ukiah High School, Pomolita Middle School, or Eagle Peak Middle School and are subject to the rules and  regulations outlined below Participation in extra-curricular activities is a privilege given to students, not a right of students.  Extra-curricular activities are defined as athletics, after- school band, after-school drama, and other activities in which the student represents the school.  Violation of the rules and regulations outlined below will result in exclusions from such activities as specified:

 

31.1.        Students are expected to perform well in the classroom, attend class regularly and comply with all school policies and regulations.

 

31.2.        Good citizenship, defined generally as behavior expected of a student who is also a representative of Ukiah Unified School District, Pomolita Middle School, or Eagle Peak Middle School, must be practiced at all times even when not under the direct supervision of school authorities.  Anyone involved in acts detrimental to the best interests of the school or activity group will be excluded from the activity for times specified (first offense, four weeks; second offense, sixteen weeks; third offense, the entire year).

 

31.3.        Students who participate in extra-curricular activities as defined may not be involved in possession and/or using drugs or alcohol during the school term which is defined as during school hours, after school hours, weekends, or vacations during the school term (including Christmas, Easter vacations, and other holidays).

 

31.4.        Students suspended or iced for being under the influence of drugs or alcohol will be excluded from extracurricular activities for four weeks of competition which may span two (2) seasons; a second offense will result in exclusion for the remainder of the semester or 45 days, whichever is greater.  Any exclusion will also include the student being enrolled in a prevention program, including attendance at substance abuse classes and/or participation in a peer-counseling program, when appropriate.

Note: Students expelled for sales, possession, or use of drugs or alcohol, whose expulsion is suspended, will be excluded by the Board of Education from all extracurricular activities for the entire term of their suspended expulsion.

 

31.5         Students placed on a behavior contract for first time possession of marijuana and/or alcohol will be suspended from extra-curricular activities for the remainder of the  present season and the term of the contract School administration may develop criteria which allows participation in the following sports season (fall, winter, spring) if student(s) successfully meets criteria delineated in the behavioral contract, including  completion of increased community service hours and substance abuse counseling.

 

31.6.        Use of either smoking or chewing tobacco will result in exclusion from extra-curricular activities for a period of one week; a second offense will result in an eight-week exclusion; a third offense will result in elimination from extra- curricular activities for the remainder of the school term. .

 

31.7.        If a coach determines that a player has been involved in a gratuitous act of violence during or after a game or if a player is red-carded or ejected from a game, the coach must  report the incident to the principal The player involved will be removed from the next game.  If that student is involved in a second act or if the coach thinks that the initial act  was extreme, the student will be removed from that sport for the remainder of the  season No rewards or recognition will be given that player for the season.

 

31.8.        All school rules are in effect during travel to and from as well as during extra-curricular activities

 

31.9.      Please note that eighteen-year old students or older are obligated to follow the listed  rles and regulations applicable to participation in extra-curricular activities.

 

 31.10.   A student who is suspended from school is also suspended from all extra-curricular activities during the period of suspension.

 

 

 

 

7


31.11.      All students must travel to and from activities in school-provided transportation.    (EXCEPTION With prior arrangement,  a  student may  return from  an  out-of-town  activity  with  his/her parent/guardian,  providing  the parent/guardian makes such a request in person to the coach while at the out-of-town site.

Additional rules:

 

31.12.      In accordance with District Board Policy 610.2(d) and 610.4 participation in an  extracurricular activity includes "preparation for performance".  This means that students are expected to participate in events or activities which support or promote the  extracurricular activity.   Preparatory activities provide important educational and social training and are considered integral to the extracurricular experience These activities  may include:   planning, developing or advertising the program; organizing performances or transportation; assisting with fundraising; and creating or obtaining costumes, equipment, uniforms or other props.

 

(a)           Students whparticipate in  an  extracurriculaactivity must contribute to  all  facets of  the  activity including preparation Certificated staff supervising the extracurricular  activity are responsible for equitably allocating preparation duties and assignments for students.

(b)          Certificated staff supervising an extracurricular activity may establish to the preparatory  stages of an activity.

However, a student may not be denied participation in an extracurricular activity solely on the basis of failing to meet an individual target, standard, or goal, if the student can show he/she has put forth the expected effort is provided by sponsors and other participants to assist each student.

 

31.13.      When a student makes a commitment to participate within a given activity, he/she has made this commitment for the entire season of the activity A great deal of time,  planning and effort is provided by sponsors and other participants to assist each student.

 

31.14.      A student must be in attendance at all practices unless he/she is excused by the  activity sponsor prior to the practice by a telephone message or previous arrangement.  In case of illness, please have your parent telephone the activity sponsor and indicate the participant will not be at practice on that particular day.

 

31.15.      If practices are to be meaningful, instructional and well planned, it is essential that each participant be on time and in attendance at each practice.  Tardiness and absenteeism cause delays in practice and will result in exclusion from the following event and/or dismissal from the activity.

 

31.16.      Since  activities  entail  a  great  deal  of  time  involving practicing  with  specific  personnel,  and  since  detailed preparation is given to each event, a student who misses an event for an unexcused reason may be dismissed from the activity.

 

31.17.      A student may not participate in another activity if either he/she quits or is dropped from an activity, for cause, until that activity is completed.

 

31.18.      Any student who is officially dropped from or quits an activity, forfeits his/her right for any award.

 

31.19.      A student must be in attendance all day on event days and practice days.  Waivers may be given for unusual causes by principal or designee.

 

31.20.      All participants are responsible for uniforms and equipment issued to them.  Uniforms are not to be worn for any purpose other than scheduled events. Students will be billed for lost or damaged uniforms or equipment.

 

31.21.      Continued or persistent violation of any of these procedures will result in disciplinary action, including conferences with parents, suspension, and/or dismissal from an activity.

 

31.22.    All activity sponsors shall have the final authority for setting criteria for selection, participation, and activity rules other than listed. A written copy of these rules will be given to each participant.

 

31.23.    When one or more players leave the bench to begin or to participate in an altercation, the player(s) will be ejected from that game and will become ineligible for the next contest.

 

 

 

          

 

 

     8

EJECTION POLICY NCS NORTH BAY LEAGUE

EAGLE PEAK SCHOOL

 

 

 

 

The following rules and minimum penalties are applicable to players (and coaches as adopted by the NCS Board of Managers on April 21, 1995, in accordance with national Federation Rules).  This policy was in effect at the beginning of the 1995-96 school year (and will include non-league, league, invitational tournaments/events, post-season; league, section or state playoffs, etc.)

 

 

 

  1. Ejection of a player from a contest for unsportsmanlike or dangerous conduct.

Penalty:  The player shall be ineligible for the next contest (non-league, league, invitational tournament/event, post season play whether it is league, section or state).

 

  1. Illegal participation in the next contest by a player ejected in a previous contest.

Penalty:  The contest shall be forfeited and the player shall be ineligible for the next contest.

 

  1. Second ejection of a player for unsportsmanlike or dangerous conduct from a contest during one season.

Penalty:  The player shall be ineligible for the remainder of the season.

 

  1. When one or more players leave the bench (or dugout, etc.) to begin or participate in an altercation.

Penalty:  The player(s) shall be ejected from the contest-in-question and become ineligible for the next contest, non-league, league, invitational tournament/event, post-season play including league, section, state playoffs (matches/events).

 

 

 

I have read and understand the rules and regulations of the Ejection Policy.  Athletes may not participate in any contest until this document is acknowledged.