Head-Royce Athletics UPPER SCHOOL Athletics Pre-Participation Packet

This Packet Is Required Only For Students Wishing To Participate On A UPPER SCHOOL Athletic Team

Please look over this packet and read the directions carefully before completing the appropriate forms. These forms have changed since last year. Return the forms to Head-Royce via mail, on-line if applicable, or drop off in the Athletic Director’s office in the gym. If any forms are not completed correctly, they will be returned with instructions on how to complete them. All students need to get a physical exam by their doctor before they will be allowed to play! If you have any questions regarding this packet, or need help completing the forms, please call the Athletic Director, Brendan Blakeley, with questions or concerns at: 510-531-1300 ext. 2246. These forms can also be found online in the US Athletics Portal page.

NO FORMS = NO PRACTICE!

Form #1: Physical exam completed and form submitted. Must be dated after June 1, 2016. You may use a form that your doctor provides, or you may use this form.

MUST BE COMPLETED EVERY YEAR. Form #2: ImPACT concussion testing consent form. Only for new US students or students who didn’t take the ImPACT test last year. ImPACT is a computerized test used to diagnose and manage concussions. This form gives consent to test the student-athlete. Form #3: CIF Steroid & Performance Enhancing Supplement policy.

Required by CIF Bylaw 524. Form #4: NCS Sportsmanship Code. Read and sign. Families should take this opportunity to discuss the Sportsmanship Code. Form #5: HRS Drug & Alcohol Policy. Read and sign. Families should take this opportunity to discuss the HRS Drug & Alcohol Policy. Form #6: NCS Ejection Policy. Read and sign. There are penalties for a student-athlete who is

ejected from any game or contest. Form #7: CIF Concussion Information Sheet. Required by California Assembly Bill 25. *Read HRS Upper School Athletics Handbook for 2017-2018. It is important for families to familiarize themselves with our athletic policies and procedures. Available on the HRS Athletics website, under “Forms and Handbooks”. *The Head-Royce BC Consent to Treat Form and DD Risk Acknowledgment and Consent to Participate Form, which are required forms for all HRS students, must be completed and submitted by August 3rd. These forms must be on file before students will be permitted to participate in any athletic event or practice.

■ Preparticipation Physical Evaluation HISTORY FORM

(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies? � Yes � No If yes, please identify specific allergy below. � Medicines � Pollens � Food � Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports for any reason?

2. Do you have any ongoing medical conditions? If so, please identify below: � Asthma � Anemia � Diabetes � InfectionsOther: _______________________________________________

3. Have you ever spent the night in the hospital?

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No5. Have you ever passed out or nearly passed out DURING or

AFTER exercise?

6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during exercise?

8. Has a doctor ever told you that you have any heart problems? If so, check all that apply: � High blood pressure � A heart murmur� High cholesterol � A heart infection� Kawasaki disease Other: _____________________

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected during exercise?

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No13. Has any family member or relative died of heart problems or had an

unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No17. Have you ever had an injury to a bone, muscle, ligament, or tendon

that caused you to miss a practice or a game?

18. Have you ever had any broken or fractured bones or dislocated joints?

19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture?

21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)

22. Do you regularly use a brace, orthotics, or other assistive device?

23. Do you have a bone, muscle, or joint injury that bothers you?

24. Do any of your joints become painful, swollen, feel warm, or look red?

25. Do you have any history of juvenile arthritis or connective tissue disease?

MEDICAL QUESTIONS Yes No26. Do you cough, wheeze, or have difficulty breathing during or

after exercise?

27. Have you ever used an inhaler or taken asthma medicine?

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

30. Do you have groin pain or a painful bulge or hernia in the groin area?

31. Have you had infectious mononucleosis (mono) within the last month?

32. Do you have any rashes, pressure sores, or other skin problems?

33. Have you had a herpes or MRSA skin infection?

34. Have you ever had a head injury or concussion?

35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

36. Do you have a history of seizure disorder?

37. Do you have headaches with exercise?

38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

39. Have you ever been unable to move your arms or legs after being hit or falling?

40. Have you ever become ill while exercising in the heat?

41. Do you get frequent muscle cramps when exercising?

42. Do you or someone in your family have sickle cell trait or disease?

43. Have you had any problems with your eyes or vision?

44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

46. Do you wear protective eyewear, such as goggles or a face shield?

47. Do you worry about your weight?

48. Are you trying to or has anyone recommended that you gain or lose weight?

49. Are you on a special diet or do you avoid certain types of foods?

50. Have you ever had an eating disorder?

51. Do you have any concerns that you would like to discuss with a doctor?

FEMALES ONLY52. Have you ever had a menstrual period?

53. How old were you when you had your first menstrual period?

54. How many periods have you had in the last 12 months?

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete __________________________________________ Signature of parent/guardian ____________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

■ Preparticipation Physical Evaluation THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

1. Type of disability

2. Date of disability

3. Classification (if available)

4. Cause of disability (birth, disease, accident/trauma, other)

5. List the sports you are interested in playing

Yes No6. Do you regularly use a brace, assistive device, or prosthetic?

7. Do you use any special brace or assistive device for sports?

8. Do you have any rashes, pressure sores, or any other skin problems?

9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?

11. Do you use any special devices for bowel or bladder function?

12. Do you have burning or discomfort when urinating?

13. Have you had autonomic dysreflexia?

14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

15. Do you have muscle spasticity?

16. Do you have frequent seizures that cannot be controlled by medication?

Explain “yes” answers here

Please indicate if you have ever had any of the following.

Yes NoAtlantoaxial instability

X-ray evaluation for atlantoaxial instability

Dislocated joints (more than one)

Easy bleeding

Enlarged spleen

Hepatitis

Osteopenia or osteoporosis

Difficulty controlling bowel

Difficulty controlling bladder

Numbness or tingling in arms or hands

Numbness or tingling in legs or feet

Weakness in arms or hands

Weakness in legs or feet

Recent change in coordination

Recent change in ability to walk

Spina bifida

Latex allergy

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete __________________________________________ Signature of parent/guardian __________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

■ Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM

Name __________________________________________________________________________________ Date of birth __________________________

PHYSICIAN REMINDERS1. Consider additional questions on more sensitive issues

• Do you feel stressed out or under a lot of pressure?• Do you ever feel sad, hopeless, depressed, or anxious?• Do you feel safe at your home or residence?• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?• During the past 30 days, did you use chewing tobacco, snuff, or dip?• Do you drink alcohol or use any other drugs?• Have you ever taken anabolic steroids or used any other performance supplement?• Have you ever taken any supplements to help you gain or lose weight or improve your performance?• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATIONHeight Weight � Male � Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected � Y � NMEDICAL NORMAL ABNORMAL FINDINGSAppearance• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)Eyes/ears/nose/throat• Pupils equal• HearingLymph nodesHeart a

• Murmurs (auscultation standing, supine, +/- Valsalva)• Location of point of maximal impulse (PMI)Pulses• Simultaneous femoral and radial pulsesLungsAbdomenGenitourinary (males only)b

Skin• HSV, lesions suggestive of MRSA, tinea corporisNeurologic c

MUSCULOSKELETALNeckBackShoulder/armElbow/forearmWrist/hand/fingersHip/thighKneeLeg/ankleFoot/toesFunctional• Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.bConsider GU exam if in private setting. Having third party present is recommended. cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

��Cleared for all sports without restriction

��Cleared for all sports without restriction with recommendations for further evaluation or treatment for _________________________________________________________________

____________________________________________________________________________________________________________________________________________

��Not cleared

��Pending further evaluation

��For any sports

��For certain sports _____________________________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________________________

Recommendations _________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If condi-tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type) _____________________________________________________________________________________________________ Date ________________

Address ___________________________________________________________________________________________________________ Phone _________________________

Signature of physician _______________________________________________________________________________________________________________________, MD or DO

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

■ Preparticipation Physical Evaluation CLEARANCE FORM

Name ___ ____________________________________________________ Sex ��M ��F Age _________________ Date of birth _________________

��Cleared for all sports without restriction

��Cleared for all sports without restriction with recommendations for further evaluation or treatment for _______________________________________________

___________________________________________________________________________________________________________________________

��Not cleared

��Pending further evaluation

��For any sports

��For certain sports _____________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________

Recommendations _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type) ___________________________________________________________________________________ Date ________________

Address _________________________________________________________________________________________ Phone _________________________

Signature of physician _____________________________________________________________________________________________________, MD or DO

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Other information _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

Athletics Form #2

UPPER SCHOOL ONLY

Dear Parent/Guardian, Head-Royce School is currently implementing an innovative program for our student-athletes. This program will assist our team coaches and athletic personnel in evaluating and treating head injuries (e.g., concussion). In order to better manage concussions sustained by our student-athletes, we have acquired a software tool called ImPACT (Immediate Post Concussion Assessment and Cognitive Testing). ImPACT is a computerized exam utilized in many professional, collegiate, and high school sports programs across the country to successfully diagnose and manage concussions. If an athlete is believed to have suffered a head injury during athletic participation, ImPACT is used to help determine the severity of head injury and when the injury has fully healed. The computerized exam is given to athletes before beginning sport practice or competition. This non-invasive test is set up in “video-game” type format and takes about 20-25 minutes to complete. It is simple, and actually many athletes enjoy the challenge of taking the test. Essentially, the ImPACT test is a preseason physical of the brain. It tracks information such as memory, reaction time, speed, and concentration. It, however, is not an IQ test. We will administer the test in the upper school computer lab. If a concussion is suspected, the athlete will be required to re-take the test. Both the preseason and post-injury test data is given to a local doctor or a doctor trained in evaluating these test results, to help evaluate the injury. The information gathered can also be shared with your family doctor. The test data will enable these health professionals to determine when return-to-play is appropriate and safe for the injured athlete. If an injury of this nature occurs to your child, you will be promptly contacted with all the details. I wish to stress that the ImPACT testing procedures are non-invasive, and they pose no risks to your student-athlete. We are excited to implement this program given that it provides us the best available information for managing concussions and preventing potential brain damage that can occur with multiple concussions. The Head-Royce administration, coaching, and athletic staffs are striving to keep your child’s health and safety at the forefront of the student athletic experience. Please return the attached page with the appropriate signatures. If you have any further questions regarding this program please feel free to contact me at the contact numbers listed below. More information on the ImPACT testing can be found on their website at: www.impacttest.com Sincerely,

Brendan Blakeley Director of Athletics Head-Royce School 510-531-1300 ext. 2246 bblakeley@headroyce.org

Athletics Form #2

Consent FormConsent Form

Do not submit if you’ve already done so in previous years For use of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

I have read the attached information. I understand its contents. I have been given an

opportunity to ask questions and all questions have been answered to my satisfaction. I agree to participate in the ImPACT Concussion Management Program.

Printed Name of AthletePrinted Name of Athlete ___________________________________

Sport(s)Sport(s) ____________________________________

__________________________________ __________________________

Signature of Athlete Date

__________________________________ __________________________

Signature of Parent Date

Athletics Form #3

Head-Royce Athletics

Policy Regarding Steroids & Performance-Enhancing Supplements UPPER SCHOOL ONLY

To safeguard the health and safety of our students, Head-Royce School endorses sound nutritional practices, specifically the guidelines issued by the USDA. Additionally, consistent with California Interscholastic Federation (CIF) regulations, Head-Royce School prohibits the use, possession, sale or distribution of all dietary, nutritional and/or performance-enhancing supplements other than those listed below. Students who violate this policy are subject to disciplinary action. The School may waive its prohibition of a supplement if the School: • Receives written approval from a student-athlete’s parent(s)/guardian(s) AND primary care physician authorizing the use of the specified supplement. • Approves the use of the supplement. Permissible Nutritional Substances Using the guidelines of the NCAA Committee on Safeguards and Medical Aspects of Sports as a standard, Head-Royce School will allow students to use any of the following nutritional substances: • Vitamins and minerals following USDA guidelines • Energy bars • Calorie-replacement drinks • Electrolyte-replacement drinks 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 or 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 (Article 5, Bylaw 524). By signing below, the participating student-athlete hereby agrees that he/she 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. The student-athlete also recognizes that, under CIF Bylaw 200.D., there could be penalties for false or fraudulent information. Signing below also acknowledges that the student-athlete and parent understand that Head-Royce School’s policy regarding the use of illegal drugs in the Athletics Handbook will be enforced for any violation of these rules.

Student’s Name ____________________ Student’s Signature_________________Date_____ Parent’s Name ____________________ Parent’s Signature___________________Date_____

Athletics Form #4

Head-Royce Athletics

Code of Sportsmanship UPPER SCHOOL ONLY

Athletes, coaches, parents, and spectators are expected to represent Head-Royce in a manner that is consistent with good sportsmanship and strong character. Head-Royce will not tolerate any behavior by athletes, coaches, or spectators, either students or adults, whose behavior is disrespectful to players, officials, coaches, or other spectators or detracts from the proper conduct of the contest.

CIF FUNDAMENTALS OF GOOD SPORTSMANSHIP • Show respect for the opponent at all times. When opponents visit our school, they should be treated as guests, greeted cordially on arriving, given appropriate accommodations, and accorded the tolerance, honesty, and generosity which all human beings deserve. When visiting another school, we should be cordial and appreciative of our host. Good sportsmanship is the Golden Rule in action. • Show respect for the officials. The officials should be recognized as impartial arbitrators who are trained to do their jobs and who can be expected to do them to the best of their abilities. Good sportsmanship implies the willingness to accept and abide by the decisions of the officials. • Know, understand, and uphold the rules of the contest. A familiarity with the current rules of the game and the recognition of their necessity for a fair contest is essential. Good sportsmanship suggests the importance of conforming to the spirit as well as the letter of the rules. • Maintain self-control at all times. A prerequisite of good sportsmanship requires one to understand his/her own bias or prejudice and the ability to prevent the desire to win from overcoming rational behavior. A proper perspective must be maintained if the potential educational values of athletic competition are to be realized. Good sportsmanship means proper behavior by all involved in the game. • Recognize and appreciate skill in performance regardless of affiliation. Applause for an opponents’ good performance is demonstration of generosity and good will. The ability to recognize quality in performance and the willingness to acknowledge it without regard to team membership is one of the most commendable gestures of good sportsmanship. I have read and understand the requirements of this Code of Sportsmanship. I understand that I’m expected to perform according to this code and I understand that there may be sanctions or penalties if I do not. Student’s Name ____________________Signature ___________________Date_____ Parent’s Name _____________________Signature___________________Date_____

Athletics Form #5

Head-Royce Athletics

Drug and Alcohol Policy UPPER SCHOOL ONLY

There is no place for substance use in athletics. All student-athletes at Head-Royce are expected to lead a drug and alcohol-free lifestyle at all times. Aside from the legal ramifications, alcohol and drugs prevent a student-athlete from performing to the best of their ability, and compromise the student-athlete’s commitment to his/her team and teammates. Student-athletes are role models on our campus, and they need to conduct themselves as such, at all times. Head-Royce students are bound by the school’s Policy on Smoking, Drugs, and Alcohol. Student-athletes found using, selling, distributing, or is in possession of illegal drugs, alcohol, steroids or tobacco during their season of sport, will be subject to the following:

A. The School administration (which may include Deans, Division Head, coaches, and the Athletic Director) will take disciplinary action. This may include the following consequences: school suspension, suspension from competitions, removal from the team, drug and alcohol assessment, and drug and alcohol counseling.

B. During the suspension from competition, the suspended athlete is required to participate in all practices and is expected to attend all games, however the student-athlete is not allowed to suit up for the games.

C. The student-athlete will be made ineligible for any individual awards given by the team (e.g. team MVP, most improved player, etc.). Post-season awards voted on by outside groups may still be awarded and received.

D. Any student-athlete in a leadership position will lose their title and responsibilities.

E. Students who are repeat offenders are subject to further disciplinary actions decided upon by the administration and in accordance with formal school policies, up to and including dismissal from the team, or expulsion from the school.

I have read and understand the requirements of the Drug & Alcohol policy. I understand that I’m expected to perform according to this policy and I understand that there may be sanctions or penalties if I do not. Student’s Name ____________________Signature ___________________Date_____ Parent’s Name _____________________Signature___________________Date_____

Athletics Form #6

Head-Royce Athletics

North Coast Section Ejection Policy UPPER SCHOOL ONLY

PARENT AND ATHLETE

EJECTION POLICY NOTIFICATION FORM* Parents are required to read and sign the North Coast Section Ejection Notification form. Once signed and returned to Head-Royce, the form will be kept on file. The following rules and minimum penalties are applicable to players as adopted by the NCS Board of Managers on April 21, 1995. This policy will be in effect beginning with the 1995-96 school year, (and will include non-league, league, invitational tournaments/events, post-season; league, section or state playoffs, etc). 1. Ejection of a player from a contest for unsportsmanlike or dangerous conduct. Penalty: The player shall be ineligible for the next contest (non-league, league, invitational tournament, post-season{league, section or state} playoff, etc.). 2. Illegal participation in the next contest by a player ejected in a previous contest. Penalty: The contest shall be forfeited and the ineligible player shall be ineligible for the next contest. 3. Second ejection of a player for unsportsmanlike or dangerous conduct from a contest during one season. Penalty: The player shall be ineligible for the remainder of the season. 4. When one or more players leave the bench to begin or participate in an altercation.

Penalty: The player(s) shall be ejected from the contest-in-question and become ineligible for the next contest (non-league, league, invitational tournament, post-season {league, section or state} playoff, etc.).

Furthermore, the Bay Area Conference has voted to impose an additional one contest suspension, in addition to the NCS one contest suspension. Therefore, any student ejected from a contest must sit out a total of TWO contests. These will be the next two contests on the team’s schedule, and will carry over to the next season if the student returns to play the following year. I have read and understand the rules and regulations of the Ejection Policy. Athletes may not participate in any contest until this document is filed with the school. Student’s Name ____________________Signature ___________________Date_____ Parent’s Name _____________________Signature___________________Date_____ SPORT(S): _________________________________________________ *These signed policy statements are to be maintained at each school. An Ejection Policy Notification Form is to be filed, according to league policy, either with the league commissioner or with the North Coast Section.

Athletics Form #7

Head-Royce Athletics

Concussion Information Sheet -California Assembly Bill 25-

UPPER SCHOOL ONLY A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

Headaches “Pressure in head” Nausea or vomiting Neck Pain Balance problems or dizziness Blurred, double, or fuzzy

vision Sensitivity to light or noise Feeling sluggish or slowed

down Feeling groggy or foggy

Drowsiness Change in sleep patterns Amnesia “Don’t feel right” Fatigue or low energy Sadness Nervousness or anxiety Irritability More Emotional Confusion Concentration or memory

problems Repeating the same comment/question

Signs observed by teammates, parents and coaches include:

Appears dazed Vacant Facial expressions Confused about assignment Forgets plays Is unsure of game, score, or

opponent Moves clumsily, or displays incoordination

Answers questions slowly Slurred speech Shows behavior or personality changes

Can’t recall events prior to hit

Can’t recall events after the hit

Seizures or convulsions

Any change in typical behavior or personality

Loses consciousness

(OVER)

Athletics Form #7

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

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.

If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new CIF Bylaw 313 now requires implementation of long and well-established return to play concussion guidelines that have been recommended for several years:

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

and

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

You should also inform your child’s coach if you think that your child may have a concussion. Remember its better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to:

http://www.cdc.gov/ConcussionInYouthSports/

Student’s Name ____________________Signature ___________________Date_____ Parent’s Name _____________________Signature ___________________Date_____

Athletics Form #9

Head-Royce Athletics

Fall 2017 - Important Dates & Coach Contacts UPPER SCHOOL ONLY

Fall season activities begin MONDAY, AUGUST 14, 2017, and continue daily until the end of the season.

Please contact the athletic director or head coach if you need additional information.

Be sure to submit all Athletic forms prior to the start of the season.

Feel free to contact Athletic Director Brendan Blakeley with questions: bblakeley@headroyce.org Fall Athletics Parent/Coach Meeting: Thursday, August 31 2017 6pm-7:30pm All parents of fall athletes need to attend to meet coaches and discuss the upcoming season. TEAM HEAD COACH COACH EMAIL AUG. 14-18 TIMES LOCATION

Men’s Soccer

Varsity John Miottel jmiottel@headroyce.org Two Practices: 10am-12pm 3pm-5pm

HRS Field

JV Antonio Gallegos Two Practices: 10am-12pm 3pm-5pm

HRS Field

Women’s Volleyball

Varsity Tate Walthall tateoneworldimports@ gmail.com

4pm-7pm HRS Gym

JV 4pm-7pm HRS Gym

Women’s Tennis

Varsity tba 4pm-6pm HRS Tennis Courts

JV William Kasoff wak.soid@gmail.com 3pm-5pm HRS Tennis Courts

Men’s & Women’s Cross Country

Carl Kadlic ckadlic@gmail.com 4pm-6pm HRS Campus

The Head-Royce Athletics web page will list all practices, games, directions to athletic venues, class dismissal times, and probable return times.