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4/29/2016 Name: UID # Name: UID# Athletic Activity Clearance Packet Kern High School District The following forms must be filled out neatly and completely. Students will not be allowed to participate until ALL forms have been completed and turned in to __________________________________________High School Athletic office, verified and issued a clearance card. Check List: Academic Eligibility 2.0. GPA, Passed 4 courses, 20 units, but must be enrolled in 5 courses, 25 units Physical Examination Form Completed by MD or DO per A.R. 6145.5 Emergency Cards (2 pages) Please fill out each section and list Preferred Hospital. All 3 cards must have parent signatures Steroid Use Policy Agreement Student and Parent Signatures Athletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline Code Summary Student and Parent Signatures Concussion Acknowledgment Form Student and Parent Signatures Ethics in Sport Student and Parent Signatures Sudden Cardiac Arrest Parent Review Form Student and Parent Signatures Physician Letter to School/ACE Form Student and Parent Signatures Parent/Guardian keeps: Ethics in sports description; concussion fact sheet; Physician Letter/ACE evaluation form; SCA parent review Form Sport GPA/Money Owed Clearance Date Fall / Fall Winter / Winter Spring / Spring

Athletic Activity Clearance Packet Kern High School District · PDF fileAthletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline

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Page 1: Athletic Activity Clearance Packet Kern High School District · PDF fileAthletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline

4/29/2016

Nam

e: U

ID #

Name: UID#

Athletic Activity Clearance Packet Kern High School District

The following forms must be filled out neatly and completely. Students will not

be allowed to participate until ALL forms have been completed and turned in to

__________________________________________High School Athletic office,

verified and issued a clearance card.

Check List: Academic Eligibility

2.0. GPA, Passed 4 courses, 20 units, but must be enrolled in 5 courses, 25 units

Physical Examination Form Completed by MD or DO per A.R. 6145.5

Emergency Cards (2 pages) Please fill out each section and list Preferred Hospital. All 3 cards must have parent signatures

Steroid Use Policy Agreement Student and Parent Signatures

Athletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures

Discipline Code Summary Student and Parent Signatures

Concussion Acknowledgment Form Student and Parent Signatures

Ethics in Sport Student and Parent Signatures

Sudden Cardiac Arrest Parent Review Form Student and Parent Signatures

Physician Letter to School/ACE Form Student and Parent Signatures

Parent/Guardian keeps: Ethics in sports description; concussion fact sheet; Physician Letter/ACE evaluation form; SCA parent review Form

Sport GPA/Money Owed Clearance Date

Fall / Fall

Winter / Winter

Spring / Spring

Page 2: Athletic Activity Clearance Packet Kern High School District · PDF fileAthletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline

Revised: 7/11/16

PHYSICAL EXAMINATION FORM FOR STUDENTS

Name: UID#

Grade: School Site: Birth Date: Sex:

Father: Mother:

Address:

Parent Consent: Date:

Medical history to include: rheumatic fever, tuberculosis, epilepsy, allergies, operations, serious illnesses,

congenital defects and menstrual disturbances

Has your son/daughter had a concussion? Yes No

If so, how many? Date of Last concussion:

Immunization Recommendations:

Physical Examination

Check

Additional Remarks

Normal, Abnormal, Not Examined N A NE General Weight & Nutrition General Appearance Skin (Acne, Tinea, Dermatitis) Eyes (Conjunctivae, Cornea, EOM) Ears (Perforations, Deafness) Nose (Allergy, Deformities) Teeth (Cavities, Gingivitis, Occlusion) Tonsils Lymph Nodes Chest (Deformities) Lungs Heart (Size, Murmur, Rhythm) Breast Abdomen Hernias Genitalia Back (Kyphosis, Lordosis, Scoliosis) Skelton (Limited Motion, Deformities) Feet (Flat, Pronated, Tinea)

Blood Pressure: Height: Weight:

This student may participate in:

Competitive Sports Yes No

Regular Physical Education Yes No

Limited P.E. Only Yes Duration

Physician’s Signature Date

Type or print physician’s name License Number

PHYSICALS FROM A CHIROPRACTOR ARE NOT VALID FOR ATHLETIC CLEARANCE

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KERN HIGH SCHOOL DISTRICT

PARENT MEDICAL CONSENT/ATHLETIC PARTICIPATION (Allows your student athlete to compete in sports and receive medical attention if needed.)

Previous Sport

Student Name:_ UID # Grade: 9 10 11 12 Sport:

Parent’s Name:_ Address: Home Phone:_

Student’s Date of Birth:_ Male/Female Work Phone:_

Month Day Year (Circle One)

In the events the parents cannot be contacted, please list another person to call:

Name: Relationship: Phone:

Name: Relationship: Phone:

Family Physician: Phone:_

Preferred Hospital: Phone:_

Insurance Company:_ POLICY #

LIST ANY MEDICATIONS/ALLERGIES:_

I HEREBY GIVE MY CONSENT FOR THE ABOVE NAMED STUDENT TO RECEIVE NECESSARY EMERGENCY MEDICAL

TREATMENT IF HE/SHE IS INJURED OR ILL WHILE PARTICIPATING ON A KHSD ATHLETIC TEAM.

PARENT SIGNATURE DATE

KERN HIGH SCHOOL DISTRICT

PARENT MEDICAL CONSENT/ATHLETIC PARTICIPATION (Allows your student athlete to compete in sports and receive medical attention if needed.)

Previous Sport

Student Name:_ UID # Grade: 9 10 11 12 Sport:

Parent’s Name:_ Address:_ Home Phone:_

Student’s Date of Birth:_ Male/Female Work Phone:_

Month Day Year (Circle One)

In the events the parents cannot be contacted, please list another person to call:

Name: Relationship: Phone:

Name: Relationship: Phone:

Family Physician: Phone:_

Preferred Hospital: Phone:_

Insurance Company:_ POLICY #

LIST ANY MEDICATIONS/ALLERGIES:_

I HEREBY GIVE MY CONSENT FOR THE ABOVE NAMED STUDENT TO RECEIVE NECESSARY EMERGENCY MEDICAL

TREATMENT IF HE/SHE IS INJURED OR ILL WHILE PARTICIPATING ON A KHSD ATHLETIC TEAM.

PARENT SIGNATURE DATE

Page 4: Athletic Activity Clearance Packet Kern High School District · PDF fileAthletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline

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KERN HIGH SCHOOL DISTRICT

Previous Sport

PARENT MEDICAL CONSENT/ATHLETIC PARTICIPATION (Allows your student athlete to compete in sports and receive medical attention if needed.)

Student Name:_ UID # Grade: 9 10 11 12 Sport:

Parent’s Name:_ Address:_ Home Phone:_

Student’s Date of Birth:_ Male/Female Work Phone:_

Month Day Year (Circle One)

In the events the parents cannot be contacted, please list another person to call:

Name: Relationship: Phone:

Name: Relationship: Phone:

Family Physician: Phone:_

Preferred Hospital: Phone:_

Insurance Company:_ POLICY #

LIST ANY MEDICATIONS/ALLERGIES:_

I HEREBY GIVE MY CONSENT FOR THE ABOVE NAMED STUDENT TO RECEIVE NECESSARY EMERGENCY MEDICAL

TREATMENT IF HE/SHE IS INJURED OR ILL WHILE PARTICIPATING ON A KHSD ATHLETIC TEAM.

PARENT SIGNATURE DATE

KERN HIGH SCHOOL DISTRICT

PARENT MEDICAL CONSENT/ATHLETIC PARTICIPATION (Allows your student athlete to compete in sports and receive medical attention if needed.)

Previous Sport

Student Name:_ UID # Grade: 9 10 11 12 Sport:

Parent’s Name:_ Address:_ Home Phone:_

Student’s Date of Birth:_ Male/Female Work Phone:_

Month Day Year (Circle One)

In the events the parents cannot be contacted, please list another person to call:

Name: Relationship: Phone:

Name: Relationship: Phone:

Family Physician: Phone:_

Preferred Hospital: Phone:_

Insurance Company:_ POLICY #

LIST ANY MEDICATIONS/ALLERGIES:_

I HEREBY GIVE MY CONSENT FOR THE ABOVE NAMED STUDENT TO RECEIVE NECESSARY EMERGENCY MEDICAL

TREATMENT IF HE/SHE IS INJURED OR ILL WHILE PARTICIPATING ON A KHSD ATHLETIC TEAM.

PARENT SIGNATURE DATE

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Print Name of Student-Athlete:

As a condition of membership in the CIF, all schools shall adopt policies prohibiting the use and

abuse of androgenic/anabolic steroids. All member schools shall have participating students and

their parents, legal guardian/caregiver agree that the athlete will not use steroids without the

written prescription of a fully licensed physician (as recognized by the AMA) to treat a medical

condition (Bylaw 524).

By signing below, both the participating student-athlete and the parents, legal guardian/caregiver

hereby agree that the student shall not use androgenic/anabolic steroids without the written

prescription of a fully licensed physician (as recognized by the AMA) to treat a medical

condition. We also recognize that that under CIF Bylaw 200.D., there could be penalties for

false or fraudulent information. We also understand that the Kern High School District policy

regarding the use of illegal drugs will be enforced for any violations of these rules.

Signature of Student Date

Signature of Parent Date

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ATHLETIC RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

Student’s Name: __________________________________________Date of Birth: __________________

Sport/Activity: ____________________________________________School Year: ___________________

WARNING: Participation in athletics may result in severe injury which can range from minor to

catastrophic injuries. Both the student and parent/guardian must understand that the dangers and risks of

playing or practicing include but are not limited to: death, complete or partial paralysis, brain damage,

serious injury to virtually all internal organs, bones, joints, ligaments, muscles, tendons and other aspects of

the skeletal system and potential impairment to other aspects of the body, general health and well-being.

Injuries can occur as a result of negligent conduct of the Student, other participants in the sport, coaches,

instructors, trainers and volunteers. Even with protective equipment and safety rules, serious and even fatal

injuries may still occur.

AS A CONDITION OF PARTICIPATION IN ATHLETICS, THE UNDERSIGNED ACKNOWLEDGE

THAT THEY HAVE READ AND UNDERSTAND THIS WARNING STATEMENT AND THAT THEY

VOLUNARILY AGREE TO ASSUME ALL RISKS ASSOCIATED WITH PARTICIPATION IN

ATHLETICS.

IN CONSIDERATION FOR YOUR PARTICIPATION IN ATHLETICS, THE UNDERSIGNED

HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE THE KERN HIGH

SCHOOL DISTRICT, ITS EMPLOYEES, REPRESENTATIVES, BOARD, MEDICAL

PERSONNEL, OFFICERS, COACHES, TRAINERS, STAFF, VOLUNTEERS AND ANY OTHER

AGENTS (HEREINAFTER “RELEASEES”), FROM ANY AND ALL LIABILITY, ACTIONS,

DEBTS, CLAIMS AND DEMANDS FOR ANY LOSS OR DAMAGE TO STUDENT RESULTING

IN INJURY OR DEATH OF THE STUDENT, INCLUDING FOR NEGLIGENCE OR OTHER

WRONGFUL ACTS OF THE RELEASEES AND THIRD PARTIES, WHICH MAY ARISE OUT

OF OR IN CONNECTION WITH THE STUDENT’S PARTICIPATION IN ATHLETICS.

The undersigned further agree to indemnify, defend, save and hold Releasees harmless from any and all

liability, actions, debts, claims and demands of every kind which may arise out of or in connection with the

Student’s participation in athletics.

The undersigned agree that this release, waiver and indemnity agreement is intended to be as broad and

inclusive as is permitted by the laws of the State of California, and that if any portion is held invalid, the

balance shall continue in full legal force and effect. The undersigned further agree that no oral

representations, statements or inducements apart from the foregoing written agreement have been made.

The undersigned agree that this release shall extend to Student’s heirs, personal representatives, assigns, and

next of kin.

I (we) have read and understand the information above and consent to participate in the athletic activity.

____________________________________________ ___________________________

Student Signature Date

____________________________________________ ____________________________

Parent/Guardian Signature Date

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KERN HIGH SCHOOL DISTRICT DISCIPLINE CODE SUMMARY

OFFICE OF ACTIVITIES/ATHLETICS

The Board of Trustees of the Kern High School District, in association with the CIF, supports a strong, wholesome

interscholastic program as an integral part of the educational process for students attending high schools. Each

student athlete is required to adhere to the rules and regulations of the California Interscholastic Federation and to

the Kern High School District Athletic Control Code.

Each parent/guardian and student athlete must sign and return this letter to the finance office, indicating that each

has read the summarized regulations. A COMPLETE COPY OF THE ATHLETIC AND ACTIVITY CONTROL

CODE IS AVAILABLE AT YOUR S ON’ S/DAUGHTER’S HIGH SCHOOL UPON REQUEST.

SCHOLASTIC ELIGIBILITY

1. The student is currently enrolled in at least 25 semester periods of work.

2. The student has maintained during the previous grading period a minimum of 2.0 G.P.A. in all

enrolled courses.

a. No more than one (1) service type class with no more than five (5) semester periods of credit can be included in the classes counted for eligibility in any one grading period.

REGULATIONS GOVERNING STUDENTS ON AND OFF SCHOOL CAMPUSES

1. ALCOHOLIC BEVERAGES

Use or possession of alcoholic beverages by a student is prohibited at any time during the school

year.

2. TOBACCO

Use or possession of tobacco in any form by a student is prohibited at any time during the school

year. 3. DRUGS, NARCOTICS

Use, possession, sale, or distribution of any illegal drugs (marijuana, cocaine, etc.), drug

paraphernalia, or controlled substance (steroids, etc.) (unless prescribed by a licensed physician) is

prohibited during the calendar year.

4. CIVIL OR CRIMINAL OFFENSE

Involvement in an offense classified as a felony or misdemeanor that threatens the discipline of the

team, the welfare of or the educational functions of the school is prohibited during the calendar

year.

5. WILLFUL OR RECKLESS CONDUCT

Willful or reckless conduct which results in, or is likely to result in bodily injury or damage to

person or real property is forbidden during the calendar year insofar as such conduct threatens the

discipline and welfare of the school.

A student found guilty of violating regulations 1 & 2, as outlined above, will forfeit all athletic privileges for a

period of nine (9) regular athletic school weeks. If a student is found in violation of 4 or 5, as outlined above, he/she

will forfeit all athletic privileges for a period of not less than nine (9) nor more than eighteen (18) regular athletic

school weeks. If a student is found in violation of 3, above, he/she will automatically forfeit the privilege of

participating in athletics for a period of eighteen (18) regular athletic school weeks. Second and third violations of

the regulations will result in period of ineligibility of up to one year. First time offenders of tobacco and alcohol

have an alternative program available. Selection of the alternative program could shorten the suspension period.

See your athletic director for information.

Warning: Football players are NOT to use helmets to butt, ram or spear an opposing player. This is in violation of

the football rules, and such use can result in severe head or neck injuries, paralysis or death to you and possible

injury to your opponent. No helmet can prevent all head or neck injuries a player might receive while participating

in football.

NAME OF STUDENT (PRINT) STUDENT ID#

PARENT/GUARDIAN SIGNATURE DATE STUDENT’S SIGNATURE DATE

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4/29/16

AB 25 (Concussion Information Form)

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 CIF Bylaw 503H 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”.

A student diagnosed with a concussion cannot return to activity for a minimum of seven (7) days as

determined by the doctor. See CIF bylaw 503H.

You should also inform your child’s coach if you think that your child may have a concussion, remember it’s 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

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California Interscholastic Federation

Central Section

P.O. Box 1567 Porterville, CA 93258

Phone (559)781-7586 Fax (559)781-7033

ETHICS IN SPORTS

I have read and I understand the Policy Statement, the Code of Ethics and the violations and Minimum

Penalties of the “Ethics in Sports” policy. I agree to abide by the policy and related consequences while

participating in interscholastic athletics, regardless of context, site or jurisdiction. I further agree not to

use drugs, alcohol, steroids or other performance enhancing drugs while in high school.

ATHLETE

Student Signature Printed Name Date

Parent Signature High School

********************************************************************************************

COACHING STAFF

Coach Site Administrator

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Page 11: Athletic Activity Clearance Packet Kern High School District · PDF fileAthletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline

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California Interscholastic Federation

Central Section

P.O. Box 1567 Porterville, CA 93258

Phone (559)781-7586 Fax (559)781-7033

ETHICS IN SPORTS

I. Policy Statement

The Central Section, CIF is committed to the exhibition of sportsmanlike and ethical behaviors in and

around all athletic contests. All contests must be safe, courteous, fair, controlled and orderly for all

athletes and fans alike.

It is the intent of the CIF that violence, in any form, not be tolerated. In order to enforce this policy, the

Central Section has established rules and regulations which set forth the manner of enforcement and of

this policy and the penalties incurred when violation of the policy occurs. The rules and regulations shall

focus upon the responsibility of the coach to teach and demand high standards of conduct and to enforce

the rules and regulations set forth by CIF.

The Central Section requires the following Code of Ethics be issued each year and requires signing by

student athletes, parent/guardian and coaches prior to participation as a guide to govern their behavior.

II. Code of Ethics To emphasize the proper ideas of sportsmanship, ethical conduct and fair play.

To eliminate all possibilities which tend to destroy the best values of the game.

To stress the values derived from playing the game fairly.

To show cordial courtesy to visiting teams and officials.

To establish a happy relationship between visitors and host.

To respect the integrity and judgment of sports officials. To achieve a thorough understanding and acceptance of the rules of the game and the standards of eligibility.

To encourage leadership, use of initiative and good judgment by the players on a team.

To recognize that the purpose of athletics to promote the physical, mental, moral, social and

emotional well-being of the individual players. To remember that an athletic contest is only a game, not a matter of life and death for player, coach, school, official, fan or nation.

III. Violations and Minimum Penalties Act First ejection of player or coach from a contest or SCRIMMAGE for unsportsmanlike conduct.

Second ejection of a player or coach from a contest during the same season of sport for

unsportsmanlike conduct.

Third ejection of a player or coach from a contest during the same season of sport for

unsportsmanlike conduct.

Any players that leave the “bench” area to begin a confrontation or leave these areas during an

altercation.

When players leave the bench area to begin a confrontation or leave the bench area during an

altercation and in the opinion of the officials, the situation is out of control.

Illegal participation in next contest by player ejected in previous contest.

Illegal placement of ejected player or illegal participation by coach ejected in previous contest.

Any acts of a more serious nature by individuals or teams or situations not specifically covered by

this policy or the Constitution or Governing Rules.

If act occurs in CIF Section Finals and both teams are charged with a forfeit.

Page 12: Athletic Activity Clearance Packet Kern High School District · PDF fileAthletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline

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ETHICS IN SPORTS pg 2

IV. Penalties Ineligible for the next CIF contest (league, non-league, tournament, invitational, playoff, etc.,

scrimmage excluded). The next contest could be the second game of a doubleheader or even the

next season of sport. Athletes competing in concurrent sports would be ineligible for both sports.

Ineligibility for next two CIF contests as above will carry over the next season of sport

Ineligibility for all CIF contests for one calendar year (365 days). Any appeal must go through

the CIF Eligibility Committee

Ejection from the contest for those players designated by officials. The contest may be

terminated by the officials. One or both teams may forfeit the contest.

Contest stopped, ejection from the contest for those players designated by the officials. The

team(s) that left the bench area must forfeit contest, record a loss, and the team(s) and players will

be put on probationary status for the balance of the season. A second similar infraction during the

season of sport will result in cessation of the sport for the team(s) and/or players. If the act occurs

at the end of the season, the probationary period will extend to the next year’s season of sport.

Any appeal would have to be made to the CIF Executive Board.

Ineligibility for remainder of season for player. Forfeiture of contest.

Constitution and sport governing rules and procedures for a coach who knowingly violates CIF or

Section Rules.

Area Commissioner may determine and implement penalties for individuals and teams not

otherwise specified by CIF Central Section Constitution and Bylaws.

After deliberation by the CIF and a double forfeit is in order, there will be no champion.

An ejected coach must leave the site of the contest. The coach may have no contact with his/her

team from that point on. If there is no certified replacement for the coach, the contest is halted

and the game is forfeited. The coach must also sit out the next contest and cannot attend the

contest or have any contact with the team during the contest. The coach may be allowed to

participate in practices on days other than the day of the contest.

An ejected player may stay on the bench for the remainder of the contest for supervision reasons.

Further disruption by ejected players may force them to be removed from the site. This could

lead to a forfeit. Players ejected must sit out the next contest, but may sit on the bench in street

clothes.

Appeals Procedure — First and Second Ejection Unless otherwise specified, an appeal of the ineligibility of a player or coach may be made , in writing, to

the player or coach’s site administrator. The site administrator or hi s/ her designee ’ s decision on

his/ her athlete or coach shall be final and shall be conveyed to the site administrator of the school(s)

involved, to the president of the league(s) involved and the CIF Area and Section Commissioner.

V. Physical Assault CIF State Constitution, Article 5, Section 522. Any student who physically assaults the person of a

game or event official shall be banned from interscholastic athletics for the remainder of the student's

eligibility. A game or event official is defined as a referee, umpire or any other official assigned to

interpret or enforce rules competition at an event. A student may, after a lapse of 18 calendar months

from the date of the incident, apply for reinstatement of eligibility to the State CIF Commissioner. For this document, the Central Section also includes coaches, administrators or other school personnel

assigned to the contest or games as a game official.

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4/26/16

PARENT KEEPS

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CIFSTATE.ORG Revised, 03/2016 CIF

Physician Letter to School

To Whom It May Concern:

Patient Name: ____________________________________________________________________ DOB: ___________________

INJURY STATUS Date of Concussion Diagnosis by MD/DO: ________________

__ Has been diagnosed by a MD/DO with a concussion and is currently under our care.

Medical follow-up evaluation is scheduled for (date): ___________________________________________________________

__ Was evaluated and did not have a concussion injury. There are no limitations on school and physical activity.

ACADEMIC ACTIVITY STATUS (Please mark all that apply)

__ This student is not to return to school.

__ This student may begin a return to school based on successful progression through the CIF Concussion Return to Learn Protocol. This student requires the necessary school accommodations set forth on the Physician (MD/DO) Recommended School Accommodations Following Concussion form.

__ This student is no longer experiencing any signs or symptoms of concussion and may be released to full academic participation.

Comments: _____________________________________________________________________________________________

PHYSICAL ACTIVITY STATUS (Please mark all that apply) __ This student is not to participate in physical activity of any kind.

__ This student is not to participate in recess or other physical activities except for untimed, voluntary walking.

__ This student may begin a graduated return to play progression (see CIF Concussion RTP Protocol form).

__ This student has medical clearance for unrestricted athletic participation (Has completed the CIF Concussion RTP Protocol).

Comments: _____________________________________________________________________________________________

Physician (MD/DO) Signature: ______________________________________________ Exam Date: _____________________ Physician Stamp and Contact Info:

Parent/Guardian Acknowledgement Signature: ______________________________ Date: __________________________

Page 16: Athletic Activity Clearance Packet Kern High School District · PDF fileAthletic Release/Consent to Participate Form (Risk Acknowledgement) Student and Parent Signatures Discipline

CIF Concussion Return to Play (RTP) Protocol

Athlete’s Name: ___________________________________________ Date of Concussion Diagnosis: ________________

CIFSTATE.ORG Revised, 03/2016 CIF

CA STATE LAW AB 2127 STATES THAT RETURN TO PLAY (I.E., COMPETITION) CANNOT BE SOONER THAN 7 DAYS AFTER EVALUATION BY A PHYSICIAN (MD/DO) WHO HAS MADE THE DIAGNOSIS OF CONCUSSION, AND ONLY AFTER COMPLETING A

GRADUATED RETURN TO PLAY PROTOCOL.

Instructions:

This is an example of a graduated return to play protocol that MUST be completed before you can return to FULL COMPETITION. o A certified athletic trainer (AT), physician, or identified concussion monitor (e.g., athletic director, coach), must initial each stage after

you successfully pass it. o You should be back to normal academic activities before beginning Stage II, unless otherwise instructed by your physician.

After Stage I, you cannot progress more than one stage per day (or longer if instructed by your physician).

If symptoms return at any stage in the progression, IMMEDIATELY STOP any physical activity and follow up with your school’s AT, other identified concussion monitor, or your physician. In general, if you are symptom-free the next day, return to the previous stage where symptoms had not occurred.

Seek further medical attention if you cannot pass a stage after 3 attempts due to concussion symptoms, or if you feel uncomfortable at anytime during the progression.

You must have written physician (MD/DO) clearance to begin and progress through the following Stages

as outlined below, or as otherwise directed by your physician. Minimum of 6 days to pass Stages I and II.

Date &

Initials Stage Activity Exercise Example Objective of the Stage

I

No physical activity for at least 2 full symptom-free days

No activities requiring exertion (weight lifting, jogging, P.E. classes)

Recovery and elimination of symptoms

II-A Light aerobic activity

10-15 minutes (min) of walking or stationary biking.

Must be performed under direct supervision by designated individual

Increase heart rate to no more than 50% of perceived maximum (max) exertion (e.g.,< 100 beats per min)

Monitor for symptom return

II-B Moderate aerobic activity

(Light resistance training)

20-30 min jogging or stationary biking

Body weight exercises (squats, planks, push-ups), max 1 set of 10, no more than 10 min total

Increase heart rate to 50-75% max exertion (e.g.,100-150 bpm)

Monitor for symptom return

II-C Strenuous aerobic activity

(Moderate resistance training) 30-45 min running or stationary biking

Weight lifting ≤ 50% of max weight

Increase heart rate to > 75% max exertion

Monitor for symptom return

II-D

Non-contact training with sport-specific drills

(No restrictions for weightlifting)

Non-contact drills, sport-specific activities (cutting, jumping, sprinting)

No contact with people, padding or the floor/mat

Add total body movement

Monitor for symptom return

Prior to beginning Stage III, please make sure that written physician (MD/DO) clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor.

III

Limited contact practice Controlled contact drills allowed (no scrimmaging)

Increase acceleration, deceleration and rotational forces

Restore confidence, assess readiness for return to play

Monitor for symptom return Full contact practice

Full unrestricted practice

Return to normal training, with contact

Return to normal unrestricted training

MANDATORY: You must complete at least ONE contact practice before return to competition, or if non-contact sport, ONE unrestricted practice

(If contact sport, highly recommend that Stage III be divided into 2 contact practice days as outlined above)

IV Return to play (competition) Normal game play (competitive event)

Return to full sports activity without restrictions