SAYREVILLE WAR MEMORIAL HIGH SCHOOL PERMISSION TO PARTICIPATE IN ATHLETICS (PLEASE PRINT (NEATLY) EXCEPT WHERE SIGNATURES ARE REQUIRED)

Transcription

1 1 PERMISSION TO PARTICIPATE IN ATHLETICS (PLEASE PRINT (NEATLY) EXCEPT WHERE SIGNATURES ARE REQUIRED) NAME: Gender: M F HOME PHONE: ADDRESS: CITY: GRADE AS OF SEPTEMBER 2016: (CURRENT SCHOOL YEAR) YEAR ENTERED 9 TH GRADE: DATE OF BIRTH: AGE AS OF SEPTEMBER 1 st 2016: Has your address changed in the past year? YES NO If yes, prior address: Have you handed in paperwork for another sport within the last 365 days? YES NO Sport(s) ARE YOU A TRANSFER STUDENT? : YES NO If yes, previous school: IF YES, DATE ENROLLED IN : I hereby request to enroll as a candidate for a place on the (sport) team during the season. I understand that in order to participate, I must: 1. Have on file in the athletic office, for each sport season, a copy of this form signed by myself and my parent/guardian giving his/her approval for my participation. In addition, the Emergency Card, Acknowledgement/Consent Form, Student Conduct Agreement, Notice of Impact Testing and Health History Update must also be completed by myself and my parent/guardian and submitted. 2. Have a current physical examination reviewed by the school doctor and on file in the nurse s office. This must be documented on the NJDOE Pre-Participation Physical Evaluation forms. When the yellow clearance letter is mailed home as verification of my physical s approval, I will keep it for my records. 3. Be eligible according to the New Jersey State Interscholastic Athletic Association and Sayreville Public School rules, including, but not limited to, verification of my academic eligibility as defined on the sayrevillehigh.net website. 4. Agree to obey all regulations, including those pertaining to practice and squad rules as established by the coaches, and to conduct myself as a gentleman/lady on or off the fields and/or courts at all times. 5. Not use or possess drugs, alcohol, tobacco or any controlled or dangerous substances. Failure to comply when participating as a member of a team may result in my suspension from any or all sports. The principal will be notified immediately for disciplinary purposes as appropriate. 6. Be responsible for the care and safe return of all school equipment issued to me and assume financial responsibility for lost or stolen equipment. I have read the rules listed above and fully understand my responsibilities to my school, my team, and myself. STUDENT SIGNATURE DATE I hereby consent for my child/ward to compete in (SPORT, only one per form) for the 2016/2017 season and for him/her to travel as a member of the team to scheduled games and events. I will assume financial responsibility for the return of all school equipment and uniforms issued to him/her. I have read all pertinent links on the sayrevillehigh.net website under Athletics. PARENT SIGNATURE DATE

2 2 EMERGENCY INFORMATION CARD The information on this form will be utilized in the event of an emergency. Please be sure to fill out each section completely and as neatly as possible. Student s Full Name: Gender: M F Home Address: City: Home Telephone Number: Sport: Date of Birth (MM/DD/YY): Age as of Sept. 1 st, 2016: Grade for 2016/2017 year: Mother s Name: Cell/Work Phone Number: Father s Name: Cell/Work Phone Number: * In the event that the parents cannot be reached, please list an alternate contact person below: Name: Contact Number: Relationship to Student: Please list any allergies or notable medical conditions for your child:

3 3 ACKNOWLEDGEMENT/CONSENT SIGN-OFF FORM Student s Name (print): Grade: Gender: M F Sport: Parent s Name (print): Please return this sheet with the rest of your completed medical forms, indicating that you have read and agree to the following policies and informative brochures. All of these policies and brochures can be found on the high school website ( under the Athletics tab. Be sure to read each one completely. ELIGIBILITY AND PARTICIPATION CONSENTS We have read this form and understand all eligibility requirements for athletic participation. In addition, we are aware of the acknowledgement of risk, consent to skin checks and medical assessments and treatments, and notice of insurance. We agree to abide by all of these notices and consents. CONCUSSION AND HEAD INJURY FACT SHEET We have read this form and understand the facts, signs and symptoms of a concussion, as well as the guidelines for concussion management and the procedure for return-to-play following a concussive injury. NJSIAA STEROID TESTING POLICY We have read this policy, as well as the NJSIAA Banned Drug Classes sheet, and consent to random testing in accordance with the NJSIAA steroid testing policy. We understand that, if the student or student s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances. SPORTS RELATED EYE INJURY FACT SHEET & SUDDEN CARDIAC DEATH BROCHURE We have read both the fact sheet and brochure and understand the basic facts and risks of eye injuries and sudden cardiac death in young athletes. We are aware of additional resources available on these subjects from the National Eye Institute ( the American Heart Association ( and the Hypertrophic Cardiomyopathy Association (

4 4 STUDENT CONDUCT AGREEMENT I, [print student s name], wish to participate in an extra-curricular club/activity/athletic team for the Sayreville Public School district. I voluntarily agree to abide by the following conditions of my participation in any and all clubs, activities and/or athletics: 1. As a participant in an extra-curricular activity, I am a representative of the Sayreville Public School District to other school districts and the public at large. I understand that due to my participation in such an activity, I am held to heightened standards for my behavior. Because extra-curricular activities are a reflection of our school program, my fellow participants and I must conduct ourselves in an appropriate manner at all times and in all settings. 2. My participation in extra-curricular activities is a privilege. As such, school administration has the right to revoke this privilege and terminate my participation if I do not conduct myself in an acceptable manner. 3. In exchange for the opportunity to represent my school and my District and to take part in one or more extracurricular activities, I agree not to engage in any conduct, on or off school property, which may tarnish my reputation or that of the District. 4. I will comply with all Board Policies governing student conduct, including but not limited to, Policy Nos Pupil Attendance; 5131-Conduct/Discipline; Harrassment, Intimidation or Bullying; Pupil Conduct on School Bus; Vandalism/Arson/Violence; Substance Abuse; Weapons; and Dating Violence; and all regulations related thereto. 5. I will not engage in any acts of harassment, intimidation or bullying (HIB) against any other student, nor will I tolerate others to engage in such acts. I will report any acts of HIB that I personally witness or am otherwise made aware of to school administration immediately. 6. I will comply with all requirements of the NJSIAA and the directives of my coach/advisor. 7. I understand that my use of any illicit or illegal substance, including but not limited to drugs, tobacco or alcohol, poses a threat to the safety of myself, other players and other students, and I hereby agree not to use any such substances on or off school grounds. 8. I also agree to conduct myself in an appropriate and acceptable manner according to the laws of this State, and any other rules and requirements of my school as a member of an interscholastic, extra-curricular and/or intramural team or activity. 9. I understand that any violations of the above conditions will be handled in accordance with Board Policy and may result in my suspension or dismissal from any activity and/or from school. WE ACKNOWLEDGE THAT WE HAVE READ AND UNDERSTAND THIS DOCUMENT AND AGREE TO BE BOUND BY ITS TERMS. Student s Name (print) Grade Parent/Guardian Signature Date Student Signature Date

5 5 NOTICE OF IMPACT TESTING The IMPACT Test must be taken by all high school student-athletes for the 2016/2017 school year, regardless of prior sports participation or test completion. This test must be taken after May 1, Please check one of the following: I certify that my son/daughter has recently taken the IMPACT Test online under my supervision. I have attached a copy of the IMPACT Test receipt to this clearance packet. A test type of Baseline ++ on the receipt is unreliable and may result in the test having to be re-taken. A test type of just Baseline is desirable. Date taken: My son/daughter has already taken the IMPACT test for a prior sport for the 2016/2017 school year, after May 1, Reminder: all students must take the IMPACT test after May 1, 2016 regardless of prior test completion. ONLINE IMPACT TEST PROCEDURES In addition to checking one of the above, I also certify that I ve read the IMPACT test procedures on the sayrevillehigh.net website. I understand that it is important for my child to take the baseline IMPACT test seriously, since scores from a re-test following a concussion injury will be compared to the baseline scores to assist in the return-to-play decision. Compromised baseline scores can result in a longer wait before returning to play, and baseline IMPACT test results that are rejected by the program for being too unreliable will require a re-take before my child is cleared to begin participation in athletics. Therefore, every effort must be made to ensure that the student gives their best effort to take the test, with no outside aid. Student s Name (print clearly) Sport: Student s signature: Date: Parent s signature: Date:

6 6 HEALTH HISTORY UPDATE Nurse s Office : Athletic Training Room : Denise Brown RN, Ginny Kania RN School Nurses Thomas Law ATC Athletic Trainer Athlete s Name (Print) Grade: Gender: M F Date of Birth: Age: Sport: Season (circle one) Fall Winter Spring Date of most recent Submitted Physical Examination: Today s Date: Since your son/daughter s last physical examination (that was submitted for athletic participation): Has your child broken a bone or sprained/strained/dislocated any muscle or joints? YES / NO If yes, please explain: Has your child sustained a concussion, been unconscious, or lost memory from a blow to the head? YES / NO If yes, please explain: Has your child fainted or blacked out? YES / NO If yes, was this during or immediately after exercise? Has your child gone to the emergency room or been hospitalized? YES / NO If yes, please explain: Has your child experienced chest pains, shortness of breath, or a racing heart? YES / NO If yes, please explain: Has there been a sudden death in the family or has any family member under age 50 had a heart attack or heart trouble? YES / NO Has your child had a recent history of fatigue and/or unusual tiredness? YES / NO Has your child started or stopped taking any over-the-counter or prescribed medications? YES / NO If yes, names of medication(s): Has your child been medically advised not to participate in a sport? YES / NO If yes, please explain: _ Do you have any concerns about your child s health which may affect their sports participation? YES / NO If yes, please explain: Athlete s Signature: Date: Parent/Guardian Signature: Date: ** This form must be dated within 90 days of the start of the first practice. **