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Table of Contents
Welcome from the Administration
………………………………………………………………………………………………. 3
Sport Programs Offered
………………………………………………………………………………………………………………..
4
Athletic Code of Conduct
……………………………………………………………………………………………………………... 5
Bullying, Harassment
……………………………………………………………………………………………………………………. 5
Hazing
………………………………………………………………………………………………………………………………………….. 6
Application of Behavioral Expectations
………………………………………………………………………………………... 7
Playing Time and Practice Time
……………………………………………………………………………………………………. 8
Transportation
……………………………………………………………………………....................................................
8
Parent Involvement
……………………………………………………………………………………………………………………... 8
Communication Procedures
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Athletic Fee
………………………………………………………………………………………………………………………………... 10
Academic Eligibility Requirements
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Try-Out Checklist
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Appendix
…………………………………………………………………………………………………………………………………….. 13
Concussion, Heat, Heart, and Opioid Health Issues
…………………………………………………………………….. 14
Documents to be Turned in
…………………………………………………………………………………………………………. 17
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WELCOME FROM THE ADMINISTRATION
MADISON ELEMENTARY SCHOOL DISTRICT #38
Congratulations on choosing to participate in a Madison Elementary School District Athletic Program.
The relationships you form with coaches and other student athletes will provide experiences and
memories that will stay with you forever. Additionally, the ability to work as part of a team toward a
common goal will be relevant to nearly every aspect of your life. We wish you success on the playing
field or court, as well as in the classroom. Let the games begin!
Due to the pandmeic, Madison Elementary School District has not offered sports for over a year. At this
time, we are looking forward to offering athletic programs this year, however, COVID-19 is still a concern
and student and staff safety and health is our number one priority. As noted in the District’s mitigation
plan, extracurricular activities may be modified, canceled, or postponed depending on local transmission
rates or other COVID-19 related health concerns. Safety protocols may be put in place by the athletic
conference, this may include limiting spectators, mask requirements for indoor spectators, and other
safety measures.
Madison School District Administration
On behalf of the staff and coaches here at Madison, we would like to take this opportunity to welcome
you to our school and our athletic program. We are very proud of the athletic tradition at Madison and
everything that our program represents. We hope you have an enriching and memorable athletic
experience. Your commitment and dedication on the playing field is an investment in your future. With
the proper attitude, you will develop values that will accompany you throughout your life.
Madison Athletic Directors
Mission Statement: The Madison athlete not only learns about his sport, but also about dedication,
responsibility, and good sportsmanship. Madison strives to motivate its athletes to practice, play, and
achieve athletic excellence, while coaches and parents ensure every athlete considers academics a high
priority.
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SPORTS PROGRAMS OFFERED
FALL SPORTS (AUGUST THROUGH OCTOBER)
Boys and Girls Cross Country
Boys Soccer
Girls Soccer
Girls Varsity Volleyball
Girls Jr. Varsity Volleyball
Boys Volleyball (Not available at Park Middle School)
WINTER SPORTS (NOVEMBER THROUGH FEBRUARY)
Boys Varsity Basketball
Girls Varsity Basketball
Boys Jr. Varsity Basketball
Girls Jr. Varsity Basketball
Cheer
Flag Football
Wrestling (Meadows Only)
SPRING SPORTS (FEBRUARY THROUGH MAY)
Boys Varsity Baseball
Boys Jr. Varsity Baseball (Not available at Park Middle School)
Girls Varsity Softball
Girls Jr. Varsity Softball (Not available at Park Middle School)
Track (Not available at MTA)
*Sports are subject to change. Please check with your school’s Athletic Director.
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ATHLETIC CODE OF CONDUCT
All expectation in the Student Handbook apply to athletes
ETHICAL EXPECTATION
Madison Elementary School District believes strongly in the value of extracurricular activities. One of the
most valuable outcomes is the mental, physical, and social development of the students who represent
Madison Elementary School District through participation in athletics and activities.
Being a student in the Madison School District is a right. Participation in extracurricular activities,
however, is a privilege. It is important to have good representatives who are leaders both on campus and
in the community.
As an athlete, I understand it is my responsibility to:
1. Place academic achievement as the highest priority.
2. Show respect for teammates, opponents, officials, and coaches.
3. Respect the integrity and judgment of game officials.
4. Be a positive representation of the school and district at all times.
5. Exhibit fair play, sportsmanship, and proper conduct on and off the playing field. This includes,
but is not limited to:
a. Treat officials, opponents, teammates, and coaches with courtesy and respect in all
situations.
b. Respect the rules of the game without seeking to evade or break the spirit or letter of
the rules.
c. Consider visiting teams and their spectators as honored guests.
d. Behave courteously as a responsible guest at other schools.
e. Be gracious in victory and defeat.
6. Refrain from the use of profanity, vulgarity, and other offensive language and gestures.
7. Adhere to the established rules and standards of the game to be played.
8. Respect all equipment and use it safely and appropriately.
9. 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.
10. Know and follow all state, conference, and school athletic rules and regulations as they pertain
to eligibility and sports participation.
11. Bullying/Harassment: Bullying and or harassment of students is prohibited. Bullying and
harassment mean physical or psychological abuse of another student by means of verbal or
physical threats, intimidation, insults, or other aggressive behavior and includes abuse based
upon race, ethnicity, gender, religion, or disability. If a student believes he or she has been
harassed or bullied, the student should report the behavior to a teacher, coach, school nurse, or
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school administrator. Students who engage in harassment or bullying will be subject to
disciplinary and criminal sanctions.
12. Hazing (A.R.S. 15-2301): Hazing means forcing a student to risk or suffer physical or mental harm
or degradation to join, participate, or remain on a school affiliated organization. This includes
any intentional or reckless act committed by an individual or group of students, against other
students where both the following apply: (1) The act was in connection with an initiation into, an
affiliation with or membership of a school sponsored athletic team or group; (2) the act causes,
contributes to, or poses a substantial risk of physical or mental injury or degradation. There shall
be no hazing, solicitation to engage in hazing, or aiding and abetting another who is engaged in
hazing of any person enrolled, accepted for or promoted to enrollment, or intending to enroll or
be promoted to schools within twelve (12) calendar months. For purpose of this policy a person
as specified above shall be considered a “student” until graduation, transfer, promotion, or
withdrawal from the school. “Hazing” means any intentional, knowing or reckless act committed
by a student, whether individually or in concert with other persons, against another student and
in which both of the following apply:
a. The act was committed in connection with an initiation into, an affiliation with, or the
maintenance of membership in any organization that is affiliated with an educational
institution.
b. The act contributes to a substantial risk of potential physical injury, mental harm or
degradation, or causes physical injury, mental harm, or personal degradation.
13. WIN WITH CHARACTER, LOSE WITH DIGNITY
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CODE OF CONDUCT (continued)
APPLICATION OF BEHAVIORAL EXPECTATIONS
As members of an athletic team, students accept the responsibility of serving as representatives ofMadison School District and its community. Such participation carries increased expectations beyondthose applicable in the daily classroom situation. Once signed, the Code of Conduct is considered to bein effect 24 hours per day and 12 months a year. Each season, students participating in athletics will berequired to sign a form agreeing to adhere to this code of conduct. (Form included in handbook.)
Additionally, Madison athletes are expected to adhere to all behavior guidelines as listed in yourschool’s handbook.
This Code shall apply to all students who participate in Madison School District athletics. The followingwill apply to all athletes:
● This Code shall apply to all students who participate in extracurricular activities involvingcompetition.
● A record of a student athlete’s violations will be kept throughout his or her attendance in
Madison School District.
● Students who violate the Code must serve penalties or consequences prior to re-entry intoathletic program.
● When suspended from a team due to academic eligibility, students are still expected to follow
all rules and regulations for the sport/activity. Students are encouraged to still attend practices
and games until eligible.
● Students who are serving a Code of Conduct penalty must begin and complete their suspension
during the entire season. This means the student must finish the sport/activity season in good
standing and meet all of the requirements of the head coach.
● If a student is dismissed from the team/activity or quits the team/activity during the period of
their suspension for a Code violation, the suspension for the Code violation will continue to the
next sport/activity season in which the student participates.
● Failure to sign the Code of Conduct does not exclude a student from being held accountable for
the rules and regulations of this policy.
● Those not signing the Code shall not be allowed to compete.
EQUIPMENT CARE AND RESPONSIBILITY
The athlete’s family is fully responsible for the return of all equipment and uniforms in satisfactorycondition. Failure to meet this expectation will result in parents having to reimburse the athleticdepartment a minimum of $50. An athlete will be denied further participation in sports and/or access toschool records if equipment is not returned and fees go unpaid.
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PLAYING TIME AND PRACTICE TIME
Playing TimeThe athlete’s effort, attendance, attitude, physical conditioning, skill, and the number of students oneach team are some of the factors considered by a coach when determining playing time. Everyreasonable effort will be made to give each athlete a fair share of playing time. THERE IS NOGUARANTEED PLAYING TIME.
Practice Time
Practices are held at the discretion of the coach. Practices may be scheduled on Saturdays or schoolbreaks at the coach’s discretion. Athletes are required to be at each practice and to be on time, unlessexcused by the coach in advance. Excessive absences (excused or not) can adversely affect the team andmay limit the athlete from participation or playing time.
AttendanceIn order for a student to play in a game, the student must have attended half the academic day.Exceptions to this include family emergencies such as funeral or religious observances.
TRANSPORTATION
Transportation will be provided by Madison School District Transportation Department to all athleticcontests and back to the school. Athletes must provide their own transportation home from the school.All athletes are required to use school transportation and may not participate in away contests if theyuse alternate transportation unless prior written permission is received from the athletic director oradministration in advance. If using alternate transportation, parents must sign out their child with thecoach at the end of away games.
District provided transportation, including school buses, is a privilege, not a right. Athletes must followall directions of the bus driver and comply with all rules regarding the bus. Any athlete that does notfollow directions or that violates bus rules may lose their bus riding privileges.
PARENT INVOLVEMENT
Meeting(s) may be held for parent(s)/legal guardian(s) of the student athlete. If the parent(s)/legalguardian(s) are not able to attend, they must speak to the head coach directly to review the expectationsand conduct of the parent(s)/legal guardian(s) and student athlete. Parent(s)/legal guardian(s)cooperation, communication, and support between school personnel, coaches, athletes, and parents areessential to the success of an intermural athletic program and to ensure students have a positive andenriching experience.
Should there be a concern, call and make an appointment with the coach to discuss any issues.Approaching the coach before, during, and/or after a game is not the proper time to talk. Coaches haveother responsibilities before, during, and/or after the game. The parent(s)/legal guardian(s) will beallowed to arrange a meeting with the coach and/or principal to discuss any concerns. Concerns that arenot appropriate to discuss with a coach include: playing time of the student athlete, team strategy orplay calling, and other student athletes. Parents are encouraged to accompany their child to as manyorientation meetings, athletic contests, and special events their schedule will permit.
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Parents are expected to:
● Try their best to assure that their child attends all scheduled practices, athletic contests, and
team meetings.
● Refrain from the use of negative statements about the coach or the team in front of their child,
and give the coach the opportunity to resolve any concerns.
● Help their child handle adversity with dignity, be gracious in defeat, humble in victory, and treat
others with respect and consideration.
● Be an exemplary role model by displaying good sportsmanship at all times and respecting fans,
coaches, officials, directors, and participants.
● Remember their involvement and support is vital to their child’s overall academic, athletic, and
personal success.
● Pick up their child within 15 minutes of the end of practices or games. Habitual tardiness may
result in the student athlete being removed from the team.
● Model behavior consistent with Madison’s policy: KFA K-1700 Public Conduct on School
Property and A.R.S. 13-2911
COMMUNICATION PROCEDURE
The following is the chain of communication for questions or concerns that may occur before, during, orafter a sports season:
1. The student/athlete addresses concerns with the coach.2. If not satisfied with the outcome, the parent/guardian addresses concerns with the coach.3. If not satisfied with the outcome, the parent/guardian addresses concerns with the athletic
director.4. If not satisfied with the outcome, the parent/guardian addresses concerns with the principal.
Next School Day Communication PolicyCoaches will not address questions or concerns before, during, or immediately after a competition.Please allow 24 hours after a competition before addressing a question or concern.
CONSEQUENCES FOR VIOLATING BEHAVIORAL EXPECTATIONS
The consequences may vary but are not limited to the following:
● Discussion to refocus behavior● Discussion with parent to inform and assist in correcting behavior● Short term suspension from the team● Removal from the team
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ATHLETIC FEE
Madison School District requires all students that participate on an athletic team pay an athletic fee of$100.00 per student-athlete per sport to offset the cost of operating our athletic program. The fee paysfor coaches, referees, conference dues, transportation, uniforms, and equipment. The fee may be “givenback” in the way of a Tax Credit for the same amount. The Athletic Fee is payable after the tryouts areconcluded and the student has made the team. Once feeds are paid the fees are non-refundable. Pleasepay your $100.00 athletic fee online through your child’s PowerSchool portal or the school office. Pleasenote Athletic Directors nor coaches can accept fees.
We can also accept credit card payments in the office.
Madison School District has not turned away a student who meets the academic and behavioral criteriafrom playing a sport due to financial circumstances. If a student/family is in need of a financialconsideration, volunteer assistance to our school and/or athletic program may be considered instead ofthe $100.00 payment. If the student meets all of the academic and behavioral requirements, then awaiver will be considered that will enable him/her to participate. Please contact your athletic director ifyou are in need of a waiver.
Thank you for supporting your child by encouraging him/her to participate in our athletic program. Wetruly believe the investment will enrich their lives from the experience they have in practice andgames.
ACADEMIC VIOLATIONS
Any of the following acts shall be a violation of this code, including those directly from the studenthandbook, but are not limited to:
1. Be a student in good standing, this means maintaining a “D” or above in every subject.
2. If a Student Athlete receives an “F” on his or her Grade Check, that student will not be eligible to
participate in any extracurricular activities for that entire week and until his or her academic
eligibility is reinstated by raising the grade to passing. Passing grades must be confirmed the
week prior to be considered eligible.
3. Administration or the Coach has the right to remove a student-athlete from a team if there are
two cycles of non-compliance in a season.
4. A student may be placed on behavioral probation upon receiving a Severe Discipline Report. The
length of the probation and/or conditions for reinstatement will be at the discretion of the
administration.
5. A student may be suspended or removed from the extracurricular activity for conduct
considered detrimental to the school, after consultation with parents, and school administration
or the school’s designee.
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ACADEMIC ELIGIBILITY REQUIREMENTS
● In order to participate for a team/sport, a student-athlete must maintain an overall grade of a
“D” or higher in each individual subject. Students not meeting this criterion will not have the
privilege of participating in games, sitting on the bench with the team, or riding the bus to games
or events.
● Grade checks will occur minimally on the dates listed below. Coaches, parents, athletic directors,
or teachers reserve the right to request more frequent grade checks.
● Grades will be checked Monday mornings of game weeks. A student with a failing grade will not
be eligible for that week even if they bring up their grade that week.
● Grades will be checked mid-quarter and at the end of each quarter. Any student earning an “F”
for the previous quarter will sit out a week for the last failing grade.
ACADEMIC INELIGIBILITY
If a student-athlete has an overall grade that is lower than a “D,” he or she will be ineligible forparticipating in any games until the overall grade in each subject is a “D” or higher. If a student-athleteraises his or her overall grade to a “D” or higher after the week of being ineligible but before the nextgame week grade check, he or she must have a teacher sign a grade sheet showing they are now eligibleto participate.
*Administration and athletic directors reserve the right to determine any student-athlete ineligible oreligible at any time based on behavior or academic grades.
ACADEMIC HONESTY
Power School print-outs must be current and unaltered. Student-athletes found to be acting dishonestlyin the grade check process will be dismissed from the current team and ineligible to participate inathletics for the remainder of that sport season.
GOING OUT FOR THE TEAM
1. A completed physical/AIA form with clearance by a physician is required within the last 12months of each sport. This must be turned in to the coach for the student to participate prior tothe start of the season.
2. Complete and return emergency information/consent to participate form and concussion formsto your coach on the first day of practice.
3. Keep a copy of these forms for your own records. You may use them for the remainder of theschool year. The athletic department will try, but is not responsible for keeping information onfile from one sport’s season to the next.
4. The $100.00 athletic fee (eligible tax credit) for each sport in which a student participates ispayable after the tryouts are concluded and the student has made the team. A jersey will not beissued during the season unless payment has been made or arrangements have been made withthe Athletic Director.
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5. Please pay the athletic fee/tax credit online at www.madisonaz.org:
● Click where it says “Families” on the top center.
● Scroll down and click where it says “Pay a Fee.”
● Scroll down to the “School activity Fee, Athletic Fee, Student Club Fee.”
● Click on the “online” link.
● Complete and submit the form.
● Forward the tax credit confirmation email to your school’s athletic director.
● Please include the player’s name and sport.
● We can also accept credit card payments in the office. Receipt will be mailed to you.
Please refer to the following checklist to ensure you have all required forms and fees completed:
Checklist
□ Activity Fee Paid
□ Filled out Emergency Contact/Consent to Participate Form
□ AIA Physical Form completed by Guardian and Physician
□ Parent and Student Contract
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APPENDIX
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HEAT
41.4 HEAT ACCLIMATIZATION & EXERTIONAL HEAT ILLNESS MANAGEMENT POLICY
41.4.1 It is the position of the AIA that prevention is the best way to avoid exertional heat stroke.Prevention includes educating athletes and coaches about:
1. Recognition and management of exertional heat illness;2. The risks associated with exercising in hot, humid environmental conditions;3. The need for gradual acclimatization over a 14 day period;4. Guidelines for proper hydration;5. Implementing practice/competition modifications according to local temperature and relativehumidity readings.
41.4.2 DefinitionsExertional heat illness includes the following conditions, ordered from the least to the mostdangerous:
1. Exercise associated muscle cramps: an acute, painful, involuntary muscle contraction usually occurringduring or after intense exercise, often in the heat, lasting approximately 1-3 minutes.2. Heat syncope: also known as orthostatic dizziness, it refers to a fainting episode that can occur in highenvironmental temperatures, usually during the initial days of heat exposure.3. Exercise (heat) exhaustion: the inability to continue exercise due to cardiovascular insufficiency andenergy depletion that may or may not be associated with physical collapse.4. Exertional heat stroke: a severe condition characterized by core body temperature > 40°C (104°F),central nervous system (CNS) dysfunction, and multiple organ system failure induced by strenuousexercise, often occurring in the hot environments.
Heat Acclimatization Protocol(A team may not choose to train in a less severe climate)
Days 1 - 5:
• Days 1 through 5 of the heat-acclimatization period consist of the first 5 days of formal practice. Duringthis time, athletes may not participate in more than 1 practice per day.• If a practice is interrupted by inclement weather or heat restrictions, the practice should recommenceonce conditions are deemed safe. Total practice time should not exceed 3 hours in any 1 day. In additionto practice, a 1-hour maximum walk-through is permitted during days 1-5 of the heat acclimatizationperiod. However, a 3-hour recovery period should be inserted between the practice and walk-through(or vice versa). (Note: A walk-through is defined as no contact with other individuals, dummies, sleds, orshields).• During days 1-3 of the heat-acclimatization period, in sports requiring helmets or shoulder pads, ahelmet is the only protective equipment permitted. The use of shields and dummies during this time ispermissible as a non-contact teaching tool.
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Days 6 - 14:
• Beginnings no earlier than day 6 and continuing through day 14, double-practice days must be followedby a single-practice day.• On single-practice days, 1 walk-through is permitted, separated from the practice by at least 3 hours ofcontinuous rest. When a double-practice day is followed by a rest day, another double-practice day ispermitted after the rest day.• On a double-practice day, neither practice should exceed 3 hours in duration, nor should studentathletes participate in more than 5 total hours of practice. Warm-up, stretching, cool-down,walkthrough, conditioning and weight-room activities are included as part of practice time. The 2practices should be separated by at least 3 continuous hours in a cool environment.• Beginning on day 7, all protective equipment may be worn and full contact may begin.• Full-contact sports may begin 100% live contact drills no earlier than day 7.• Because the risk of exertional heat illnesses during the preseason heat- acclimatization period is high,we strongly recommend that an athletic trainer be on site before, during and after all practices.
41.4.3 Hydration Strategies
• Sufficient, sanitary and appropriate fluid should be readily accessible and consumed at regular intervalsbefore, during and after all sports participation and other physical activities to offset sweat loss andmaintain adequate hydration while avoiding overdrinking.• Generally, 100 to 250 mL (approximately 3- 8 oz) every 20 minutes for 9- to 12- year-olds and up to 1.0to 1.5 L (approximately 34 -50 oz) per hour for adolescent boys and girls is enough to sufficientlyminimize sweating-induced body-water deficits during exercise and other physical activity as long astheir pre-activity hydration status is good.• Pre-activity to post-activity body-weight changes can provide more specific insight to a person’shydration status and rehydration needs. Athletes should be well- hydrated before commencing allactivities• (see guideline box format)
• The following guidelines are suggested:
Condition % Body Weight Change
Well Hydrated +1 to -1
Minimal Dehydration -1 to -3
Significant Dehydration -3 to -5
Serious Dehydration > -5
% Body weight change = [(pre-exercise body weight - post-exercise body weight) / pre-exercise bodyweight] x 100
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41.4.4 Return to Play Following Exertional Heat StrokeThe following is the protocol for return to play following heat stroke:1. Refrain from exercise for at least 7 days following the acute event2.3. When cleared for activity by a licensed physician, begin exercise in a cool environment and graduallyincrease the duration, intensity, and heat exposure for 2 weeks to acclimatize and demonstrate heattolerance under the direction of a licensed healthcare professional.4. If return to activity is difficult, consider a laboratory exercise-heat tolerance test about one monthpost incident.5. Athlete may be cleared for full competition if heat tolerance exists after 2-4 weeks of training.
The AIA also recommends any athlete suspected of having suffered exertional heat exhaustion bereferred to a licensed physician for follow-up medical examination and clearance.
HEART
HEART ISSUES (NFHS)
In 2015, the NFHS provided the “Anyone Can Save a Life” emergency action plan toolkit originallydeveloped by the Minnesota State High School League to member state associations for distribution tothe nation’s schools. Activation of schools’ Emergency Action Plans, including the use of AutomatedExternal Defibrillators (AEDs), is in order as the new school year begins. More information on the“Anyone Can Save a Life” program is available at http://www.anyonecansavealife.org/.
The NFHS also offers its free course on Sudden Cardiac Arrest(https://nfhslearn.com/courses/61032/sudden-cardiac-arrest) which was developed with its partner,Simon’s Fund.
Opioid AbuseWhy does this matter for young athletes? As athletic participation among the nation’s youth hasincreased, so have injuries, surgeries and prescriptions for opioid medications. A study conducted usingthe data from High School Reporting Information Online (supported by the NFHS) found that 20 percentof athletic injuries required a physician’s attention (1). Between 2006 and 2013, surgeries forsport-related injuries in youth increased by 55 percent (2). In another study, opioid prescriptions foradolescents doubled between 1996 and 2007 (3).
To view a Powerpoint on opioid abuse please go to:
http://aiaonline.org/files/16347/high-school-athletes-and-the-risks-associated-with-opioid-use.pdf
Additional information is on AIA’s website: http://aiaonline.org/about/meetings-agendas/medicine
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Arizona Interscholastic Association, Inc.Mild Traumatic Brain Injury (MTBI) / ConcussionAnnual Statement and Acknowledgement Form
I, _________________________ (student), acknowledge that I have to be an active participant in my own healthand have the direct responsibility for reporting all of my injuries and illnesses to the school staff (e.g., coaches,team physicians, athletic training staff). I further recognize that my physical condition is dependent upon providingan accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilitiesexperienced before, during or after athletic activities.By signing below, I acknowledge:
● My institution has provided me with specific educational materials including the CDC Concussion factsheet (http://www.cdc.gov/concussion/HeadsUp/youth.html) on what a concussion is and has given mean opportunity to ask questions.
● I have fully disclosed to the staff any prior medical conditions and will also disclose any future conditions.● There is a possibility that participation in my sport may result in a head injury and/or concussion. In rare
cases, these concussions can cause permanent brain damage, and even death.● A concussion is a brain injury, which I am responsible for reporting to the team physician or athletic
trainer.● A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance,
sleep, and classroom performance.● Some of the symptoms of concussion may be noticed right away while other symptoms can show up hours
or days after the injury.● If I suspect a teammate has a concussion, I am responsible for reporting the injury to the school staff.● I will not return to play in a game or practice if I have received a blow to the head or body that results in
concussion related symptoms.● I will not return to play in a game or practice until my symptoms have resolved AND I have written
clearance to do so by a qualified healthcare professional.● Following concussion the brain needs time to heal and you are much more likely to have a repeat
concussion or further damage if you return to play before your symptoms resolve.
Based on the incidence of concussion as published by the CDC the following sports have been identified as high riskfor concussion; baseball, basketball, diving, football, pole vaulting, soccer, softball, spiritline and wrestling.
I represent and certify that I and my parent/guardian have read the entirety of this document and fully understandthe contents, consequences and implications of signing this document and that I agree to be bound by thisdocument.Student Athlete:
Print Name: _________________________ Signature: __________________________
Date: ___________
Parent or legal guardian must print and sign name below and indicate date signed.
Print Name: _________________________ Signature: __________________________
Date: ___________
FORM 15.7-C 06/15
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