West Valley High School Revised July 2017 Athletics Eligibility Packet

AUTHORIZATION TO CONSENT TREATMENT OF A MINOR

Student Name Emergency Phone #

Street Address Family Doctor

City, State, Zip Code

MEDICAL INFORMATION

Please select a preferred hospital:

MercyShasta Regional St. ElizabethName of Preferred Physician

List any Drug Allergies List any Regularly Taken Medications

List any Physical Disabilities List any Medical Problems

INSURANCE INFORMATION Is your health care insurance provided through Medi-Cal?

YesNo Insurance Provider

Policy Number

EMERGENCY CONTACTS

Emergency Contact Name Phone Number Relationship to Student

Emergency Contact Name Phone Number Relationship to Student

AUTHORIZATION I/We, the undersigned parent/guardian of the above mentioned minor student do hereby authorize the faculty member of the Anderson Union High School District supervising the activity concerned, as agent for the undersigned, to consent to an x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under general or special supervision of any physician and surgeon licensed under the provision of the Medical Practice Act on the medical staff of any licensed hospital whether such diagnosis or treatment is rendered at the office of said physician or at the said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care required but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his best judgment may deem advisable. This authorization is given pursuant to the provision of Section 25.8 of the Civil Code of California. This authorization shall remain effective until the end of the school year in which it was signed.

Parent/Guardian Signature Date

NCSIG 10/2012

NON-SPONSORED TRANSPORTATION NOTICE

The undersigned hereby acknowledges and understands that the Anderson Union High School

District is NOT providing transportation to the school-sponsored activities shown below and that it is

the responsibility of the undersigned to arrange for transportation.

Events(s): Location(s):

Date(s): Time(s):

As parent/legal guardian, I hereby authorize and give permission for my child,

_____________________________________________, to drive himself/herself or to ride as a passenger in a

vehicle driven by another parent.

The undersigned acknowledges and understands that the driver is not driving on behalf of or as an

agent of the Anderson Union High School. Further, the undersigned understands that the Anderson

Union High School District has not verified the driving record of the driver or the mechanical

condition of the vehicle.

IT IS FULLY UNDERSTOOD THAT THE ANDERSON UNION HIGH SCHOOL DISTRICT IS IN NO WAY

RESPONSIBLE, NOR DOES THE ANDERSON UNION HIGH SCHOOL DISTRICT ASSUME LIABILITY,

FOR ANY INJURIES OR LOSSES RESULTING FROM THIS NON-DISTRICT SPONSORED

TRANSPORTATION. ALTHOUGH THE ANDERSON UNION HIGH SCHOOL DISTRICT MAY ASSIST IN

COORDINATING THE TRANSPORTATION AND/OR RECOMMEND TRAVEL TIME, ROUTES, OR

CARAVANNING TO OR FROM THIS EVENT, I FULLY UNDERSTAND THAT SUCH

RECOMMENDATIONS ARE NOT MANDATORY.

Parent/Guardian Signature Date

Student Signature Date

PARENT & ATHLETE CONCUSSION INFORMATION SHEET

WHAT IS A CONCUSSION? A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION? Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury. The athlete should only return to play with permission from a health care professional experienced in evaluating for concussion.

DID YOU KNOW?

• Most concussions occur without loss of consciousness.

• Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.

• Young children and teens are more likely to get a concussion and take longer to recover than adults.

SYMPTOMS REPORTED BY ATHLETE: • Headache or “pressure” in head • Nausea or vomiting • Balance problems or dizziness • Double or blurry vision • Sensitivity to light • Sensitivity to noise • Feeling sluggish, hazy, foggy, or groggy • Concentration or memory problems • Confusion • Just not “feeling right” or is “feeling down”

SIGNS OBSERVED BY COACHING STAFF: • Appears dazed or stunned • Is confused about assignment or position • Forgets an instruction • Is unsure of game, score, or opponent • Moves clumsily • Answers questions slowly • Loses consciousness (even briefly) • Shows mood, behavior, or personality changes • Can’t recall events prior to hit or fall • Can’t recall events after hit or fall

“IT’S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON”

[ INSERT YOUR LOGO ]

CONCUSSION DANGER SIGNS In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

• One pupil larger than the other • Is drowsy or cannot be awakened • A headache that gets worse • Weakness, numbness, or decreased coordination • Repeated vomiting or nausea • Slurred speech • Convulsions or seizures • Cannot recognize people or places • Becomes increasingly confused, restless, or agitated • Has unusual behavior • Loses consciousness (even a brief loss of consciousness

should be taken seriously)

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION? 1. If you suspect that an athlete has a concussion, remove

the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.

2. Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, and playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

3. Remember: Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS? If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

STUDENT-ATHLETE NAME PRINTED

STUDENT-ATHLETE NAME SIGNED

DATE

PARENT OR GUARDIAN NAME PRINTED

PARENT OR GUARDIAN NAME SIGNED

DATE

JOIN THE CONVERSATION www.facebook.com/CDCHeadsUp

TO LEARN MORE GO TO >> WWW.CDC.GOV/CONCUSSION

Content Source: CDC’s Heads Up Program. Created through a grant to the CDC Foundation from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

A Sudden Cardiac Arrest Information Sheet for Athletes and Parents/Guardians

What is sudden cardiac arrest? Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly.When this happens blood stops flowing to the brain and other vital organs. SCA is NOT aheart attack. A heart attack is caused by a blockage that stops the flow of blood to theheart. SCA is a malfunction in the heart’s electrical system, causing the victim to collapse.The malfunction is caused by a congenital or genetic defect in the heart’s structure.How common is sudden cardiac arrest in the United States? As the leading cause of death in the U.S., there are more than 300,000 cardiac arrestsoutside hospitals each year, with nine out of 10 resulting in death. Thousands ofsudden cardiac arrests occur among youth, as it is the #2 cause of death under 25and the #1 killer of student athletes during exercise.

Who is at risk for sudden cardiac arrest?SCA is more likely to occur during exercise or physicalactivity, so student-athletes are at greater risk. Whilea heart condition may have no warning signs, studiesshow that many young people do have symptoms butneglect to tell an adult. This may be because they areembarrassed, they do not want to jeopardize their play-ing time, they mistakenly think they’re out of shape and need to train harder, orthey simply ignore the symptoms, assuming they will “just go away.” Additionally,some health history factors increase the risk of SCA.

What should you do if your student-athlete is experiencing any of thesesymptoms? We need to let student-athletes know that if they experience any SCA-relatedsymptoms it is crucial to alert an adult and get follow-up care as soon as possiblewith a primary care physician. If the athlete has any of the SCA risk factors, theseshould also be discussed with a doctor to determine if further testing is needed.Wait for your doctor’s feedback before returning to play, and alert your coach,trainer and school nurse about any diagnosed conditions.

The Cardiac Chain of SurvivalOn average it takes EMS teams up to 12 minutes to arrive

to a cardiac emergency. Every minute delay in attending

to a sudden cardiac arrest victim decreases the chance

of survival by 10%. Everyone should be prepared to take

action in the first minutes of collapse.

Early Recognition of Sudden Cardiac ArrestCollapsed and unresponsive.Gasping, gurgling, snorting, moaning or labored breathing noises.Seizure-like activity.

Early Access to 9-1-1Confirm unresponsiveness.Call 9-1-1 and follow emergency dispatcher's instructions.Call any on-site Emergency Responders.

Early CPRBegin cardiopulmonary resuscitation(CPR) immediately. Hands-only CPR involves fastand continual two-inch chest compressions—about 100 per minute.

Early DefibrillationImmediately retrieve and use an automated external defibrillator (AED) as soon as possible to restore the heart to its normal rhythm. MobileAED units have step-by-step instructions for a by-stander to use in an emergency situation.

Early Advanced CareEmergency Medical Services (EMS) Responders begin advanced life support including additional resuscitative measures andtransfer to a hospital.

Cardiac Chain of Survival Courtesy of Parent Heart Watch

What is an AED? An automated external defibrillator (AED) is the only way to save a suddencardiac arrest victim. An AED is a portable, user-friendly device that automat-

ically diagnoses potentially life-threatening heartrhythms and delivers an electric shock to restore nor-mal rhythm. Anyone can operate an AED, regardless oftraining. Simple audio direction instructs the rescuerwhen to press a button to deliver the shock, whileother AEDs provide an automatic shock if a fatal heartrhythm is detected. A rescuer cannot accidently hurt a

victim with an AED—quick action can only help. AEDs are designed to onlyshock victims whose hearts need to be restored to a healthy rhythm. Checkwith your school for locations of on-campus AEDs.

A E D

FAINTINGis the

#1SYMPTOMOF A HEART CONDITION

Keep Their Heart in the Game

Recognize the Warning Signs & Risk Factorsof Sudden Cardiac Arrest (SCA)

Tell Your Coach and Consult Your Doctor if These Conditions are Present in Your Student-Athlete

What is CIF doing to help protect student-athletes?CIF amended its bylaws to include language that adds SCA training to coach certification and practice and game protocol that empowers coaches toremove from play a student-athlete who exhibits fainting—the number one warning sign of a potential heart condition. A student-athlete who has beenremoved from play after displaying signs or symptoms associated with SCA may not return to play until he or she is evaluated and cleared by a licensedhealth care provider. Parents, guardians and caregivers are urged to dialogue with student-athletes about their heart health and everyone associatedwith high school sports should be familiar with the cardiac chain of survival so they are prepared in the event of a cardiac emergency.

I have reviewed and understand the symptoms and warning signs of SCA and the new CIF protocol to incorporate SCA prevention strategies into my stu-dent’s sports program.

STUDENT-ATHLETE SIGNATURE PRINT STUDENT-ATHLETE’S NAME DATE

PARENT/GUARDIAN SIGNATURE PRINT PARENT/GUARDIAN’S NAME DATE

For more information about Sudden Cardiac Arrest visit

California Interscholastic Federation Eric Paredes Save A Life Foundation National Federation of High Schoolshttp.www.cifstate.org http:www.epsavealife.org (20-minute training video)

https://nfhslearn.com/courses/61032

Potential Indicators That SCA May Occur� Fainting or seizure, especially during or

right after exercise

� Fainting repeatedly or with excitement orstartle

� Excessive shortness of breath during exercise

� Racing or fluttering heart palpitations or irregular heartbeat

� Repeated dizziness or lightheadedness

� Chest pain or discomfort with exercise

� Excessive, unexpected fatigue during orafter exercise

Factors That Increase the Risk of SCA� Family history of known heart abnormalities or

sudden death before age 50

� Specific family history of Long QT Syndrome, Brugada Syndrome, Hypertrophic Cardiomyopathy, orArrhythmogenic Right Ventricular Dysplasia (ARVD)

� Family members with unexplained fainting, seizures,drowning or near drowning or car accidents

� Known structural heart abnormality, repaired or unrepaired

� Use of drugs, such as cocaine, inhalants, “recreational” drugs, excessive energy drinks or performance-enhancing supplements

Keep Their Heart in the Game

©Keenan & Associates for Nor Cal ReLiEF 2010 & 2016 Modified by NCSIG for its Members 2017

Page 1 of 3

ATHLETICS / SPORTS VOLUNTARY ACTIVITIES PARTICIPATION FORM

ACKNOWLEDGMENT AND ASSUMPTION OF POTENTIAL RISK

CONSENT TO PARTICIPATE

Athlete’s Name: Sport:

Address: City, State:

Home Phone: Cell Phone:

Parent/Guardian Name:

Address: City, State:

Emergency Contact Name: Emergency Contact Phone:

By its very nature, this sport, including tryouts, may put students in situations in which serious catastrophic and perhaps fatal

accidents may occur. Students and parents must assess the risks involved in such participation and make their choice to

participate in spite of those risks. No amount of instruction, precaution, or supervision will totally eliminate the risk of injury.

Just as driving an automobile involves the risk of injury; participation in this sport by students involves some inherent risk. The

importance of your awareness of these risks in determining whether or not to allow your child to participate cannot be

overstated. There have been accidents in this sport, resulting in death, paraplegia, quadriplegia, and other very serious

permanent physical impairments as a result of athletic participation.

Students will be instructed in proper techniques and in the proper utilization of all equipment or work used in practice and

competition. Students must adhere to that instruction and utilization and must refrain from improper uses and techniques.

No amount of instruction, precaution, and supervision can eliminate all risk of injury, including serious, injury. Some of the

injuries/illnesses which may result from participating in these activities include, but are not limited to, the following:

1. Sprains/strains 7. Loss of eyesight

2. Fractured bones 8. Communicable diseases

3. Unconsciousness 9. Internal organ injuries

4. Head and neck injuries 10. Brain damage

5. Neck and spinal injuries 11. Death

6. Paralysis

By signing this waiver, you acknowledge that you understand and accept such risk and authorize the student named above to

participate in this sport. By choosing to participate, you acknowledge that such risks exist.

©Keenan & Associates for Nor Cal ReLiEF 2010 & 2016 Modified by NCSIG for its Members 2017

Page 2 of 3

ACKNOWLEDGMENT AND ASSUMPTION OF POTENTIAL RISK

I authorize my son/daughter, _________ , to participate in the District sponsored sport

activities of __________________________________________________ .

I have read this form in its entirety and understand its contents. I understand that it is my obligation to ask questions about

anything I do not understand.

I understand and acknowledge that participation in this sport is completely voluntary and as such is not required by the District

for course credit or for completion of graduation requirements.

I agree to assume financial responsibility for any medical costs and expenses incurred as a result of any injury that may be

sustained by my child while participating in this sport.

I understand, acknowledge and agree that the Anderson Union High School District, its elected or appointed officials,

employees, agents 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 and I voluntarily assume all risk, known or unknown,

of injuries, howsoever caused, even if caused in whole or in part by the action, inaction, or negligence, of the released parties

to the fullest extent allowed by law.

I acknowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATION FORM and that I understand and agree

to the terms.

Parent/Guardian Signature Date

Student Signature Date

A signed VOLUNTARY ACTIVITIES PARTICIPATION FORM and AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT

AND HEALTH INSURANCE VERIFICATION FORM must be on file with the Anderson Union High School District before a student

will be allowed to participate in the above extra-curricular activities.

©Keenan & Associates for Nor Cal ReLiEF 2010 & 2016 Modified by NCSIG for its Members 2017

Page 3 of 3

AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT

AND HEALTH INSURANCE VERIFICATION

HEALTH INSURANCE:

Pursuant to Education Code 32221, the insurance shall provide the following coverage:

At least one thousand five hundred dollars ($1,500) for all medical and hospital expenses.

I have health insurance that meets the requirements under the California Education Code Section 32221.

Athletic Team/Sport: ___________________________________________________

Student's Name: ___________________________________________________

Insured (Subscribers) Name: ___________________________________________________

Insurance Company: ___________________________________________________

Policy/I.D. Number: ___________________________________________________

California Education Code 32221.5: Some students may qualify to enroll in no-cost or low-cost local, state, or federally sponsored

health insurance programs. Information about these programs may be obtained by calling Medi-Cal at 800-541-5555 or Healthy

Families Program at 888-599-7056.

AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT

In the event of an injury or illness to ________________________________ while participating on the athletic team, I do hereby authorize

the Anderson Union High School District, as agent for the undersigned, to consent to any x-ray examination, anesthetic, medical or

surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under, the general or special

supervision of any physician and/or surgeon, whether such diagnosis or treatment is rendered at the office of said physician or at any

medical facility.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is

given to provide authority and power on the part of the aforesaid agent to give specific consent to any and all such diagnosis,

treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable.

This authorization shall remain effective through the conclusion of the sport season, including any playoff or championship

competition, unless revoked in writing and delivered to said agent.

Parent/Guardian Signature Date

Student Signature Date

ACKNOWLEDGEMENT OF ATHLETIC POLICIES

The undersigned fully understands that all extracurricular activity participants are governed by the policies, regulations, and standards

contained within the Athletic Handbook. The Athletic Handbook may be obtained at West Valley High School or viewed online at

www.auhsd.net/westvalleyhighschool_home.aspx .

I have read and understand the following policies: Parent Initials Student Initials

Notice of Risk to Students & Parents

High School Athletic Code

Student Athlete Code of Conduct

Student Athlete Tobacco, Alcohol & Drug Policy

Ethics in Sports

NCAA Initial Eligibility Clearinghouse

Transportation Rules & Regulations

Authorization to Use School Transportation

Use of Steroids

Has the student ever attended another high school? Yes No

If yes, please list which other high schools:

I understand fully that my performance as a participant and the reputation of my school are dependent, in part, on my conduct as an individual.

I hereby agree to accept and abide by the standards, rules and regulations set forth by the Anderson Union High School District Board of Trustees

and the sponsors for the activity in which I participate.

I also authorize the Anderson Union High School District to conduct a test on a urine specimen which I provide to test for drugs and/or alcohol

use. I also authorize the release of information concerning the results of such a test to the Anderson Union High School District and to the

parents/guardians of the student.

This shall be deemed a consent pursuant to the Family Education Right to Privacy Act for the release of the above information to the parties

named above. I also authorize the use of names and photographs to be published on the District website.

Student Name (please print)

Student Signature Date

Parent/Guardian Signature Date

HEALTH HISTORY – To be completed and signed by parent/guardian

Student Name Phone Number

9 10 11 12

M F

Grade (circle) Date of Birth Sex (circle)

Has your child ever had or currently have any of the following?

Yes No If yes, please explain:

Chronic or recurrent illnesses

Illnesses lasting more than a week

Hospitalizations

Surgery, other than tonsillectomy

Problem with blood pressure or heart

Dizziness, fainting, or frequent headaches

Ever been knocked out or had concussion

Neck/back injury or surgery

Knee injury or surgery

Ankle injury or surgery

Other joint sprains or dislocations

Broken bones or fractures

Organ missing, other than tonsils

Epilepsy or seizure disorder

Asthma or shortness of breath

Diabetes

Heat exhaustion or heat stroke

Nervous disorder or mental illness

Currently taking medication (aspirin, penicillin, etc.)

Allergy to medication (aspirin, penicillin, etc.)

Use of eye glasses or contact lenses

Use of dental appliances

Family history of death before age 50

Any reason student should not participate in sports

Date of last tetanus vaccination:

I declare that the above information is correct to the best of my knowledge. I understand this is a

screening examination to determine if any obvious medical problems exist to prevent my child from

participating in school athletic events. This examination is not a complete medical examination. You

should contact your family physician for your medical needs. If any medical problems are identified

in this screening examination, further examination and treatment should be obtained through your

physician. Please discuss family medical history with your student.

Parent/Guardian Signature Student Signature

WEST VALLEY HIGH SCHOOL 3805 Happy Valley Road | Cottonwood, CA 96022

ATHLETIC HEALTH SCREENING EXAMINATION RECORD

HEALTH SCREENING EXAMINATION – To be completed and signed by a physician

Height: Weight:

Pulse Rate: Blood Pressure:

Eye Exam: R: 20/_____ L: 20/_____ Both: 20/_____

Normal Abnormal Comments

Mouth/Pharynx

Heart

Lungs

Abdomen

Genitalia (male only)

Spine

Joints

Extremities

Based on this history and physical exam, the following abnormalities were found

and may need treatment:

RECOMMENATION

There were no history or physical findings in this exam which would prohibit

this student from participating in competitive athletics.

This student should have the above health problems evaluated or treated

PRIOR to participating in competitive athletics.

This student has health problems which would PROHIBIT him or her from

participating in competitive athletics at this time.

Physician Signature Date