real link - Alonso High School

Transcription

STUDENT NAME:- - - - - - - -
STUDENT ID:
GRADE:- - - - - - - - - - -
SPORT:
DATE OF PHYSICAL:- - - - - - -
Alonso High School Athletic Code of Conduct
Alonso High School's athletes and coaches adhere to all of the principles of good sportsmanship, citizenship,
and behavior. All team members, and at least one parent/guardian, are required to read and sign the
following Code of Conduct contract. No athlete will be allowed to represent Alonso High School's program(s)
this season without first signing this contract.
No-tv. By s-4J~ ~CctJ.hof~ ~~/p-ovve-vvt-19~~01Jr-u-+rr~~
frr~~~~~b-eM>w:
The 2015/2016 Code of Conduct:
•
Members of the team commit to their school work with the full acknowledgement that they are
students first. They accept the mandatory lunch tutoring/Saturday Success Academy opportunit!es for
students who have lower than a 2.5 GPA. They accept that the Head Coach has access to weekly grade
reports and will monitor student achievement throughout the course of the season/school year.
•
They make a commitment to practice. Athletes who fail to practice routinely, or who routinely miss
practice, will not be allowed to compete. This is a coaching decision.
•
Alonso High School will not tolerate disrespectful comments and/or behavior in person or online.
o
Students will not engage in commentary or content that is unsportsmanlike, derogatory,
demeaning, or threatening toward another individual or entity (for example, derogatory
comments regarding another individual; taunting comments aimed at a student athlete,
coach, or team at another institution; derogatory comments regarding someone's race,
gender, and sex).
No photos, videos, posts, or comments should depict or encourage unacceptable,
o
violent, or illegal activities (for example, hazing, sexual harassment/assault, nudity,
inappropriate gestures, discrimination, fighting, vandalism, academic dishonesty,
underage drinking, and/or illegal drug use).
•
Further, members of the team acknowledge that conduct (in or out of school/online) is a reflection of
the program. No athlete-under any circumstances-is to participate in cheating, stealing, bullying,
hazing, or any activity-intentional or otherwise-that ridicules or embarrasses a teammate,
classmate, or the school. Severe sanctions, including dismissal, could be applied.
•
Members of the team will abide by the principals of respect, responsibility and relationships at all
times. As a result they will express an appreciation for the volunteer work put in by coaches, teachers,
administrative staff, and dedicated parents, and they should treat those people with respect.
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•
Members of the team treat their uniform with the dignity it deserves. They acknowledge that the
uniform is NOT to be worn by someone who is NOT a member ofthe team.
•
Members understand and respect that a healthy athletic program must exist, one in which all students
feel safe and welcome and can be proud of the school and program they represent. They must
understand that hazing of any kind is not allowed on this campus and in the athletic program. This
includes mental, verbal, and/or physical acts. Athletes must further understand that it is their duty to
report any acts of hazing to their coach or a campus administrator.
•
Members of the team recognize that the coaching staff/administration reserve the right to implement
new rules, regulations, and guidelines-as the school year progresses-for the protection of the
athlete and the program.
Student-athletes in violation of the Alonso High School Athletic Code of Conduct may be subject to the
following penalties:
1. Written and/or Verbal Warning
2. Meeting with the Head Coach and Assistant Principal for Administration
3. Game Suspension or Removal from the Athletic Team
By signing below, the student-athlete and adult representative acknowledge the terms of this contract and
accept that violations can/will lead to sanctions that range from suspension to dismissal.
Athlete:
-----------------------------------
Parent/Guardian:-------------
Date:
-------------------------
Date: _______________________
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ALONSO HIGH SCHOOL
INSTRUCTIONS FOR ATHLETIC PARTICIPATION
Your student has expressed an interest to participate in the Hillsborough County interscholastic sports,cheerleading,
band, or dance programs. The application packet, required for participation, can be accessed online at
http://www.sdhc.k12.fl.us/, go to "quick links" tab, and select "Athletics department." Open and print the application,
two medical release cards, FHSAA physical forms, and the Unsportsmanlike Conduct Agreement.
Please also click on the
insurance link and purchase the mandatory athletic insurance. All information, required for participation, is in compiance
with the FHSAA and the School District of Hillsborough County athletic requirements, and must be submitted prior to
student participation.
1) All participants must receive a physical examination BEFORE STARTING ANY PRACTICE OR ACTIVITY.
ONLY FHSAA PHYSICAL
A physician's signature must appear on the form and dated for school year.
FORMS WILL BE ACCEPTED (EL2). Your physical is good for 365 days.
2) Two medical release cards must be signed and notarized BEFORE STARTING ANY PRACTICE OR
TRAVEL. Part I of the card states that in an event of an injury,all attempts will be made to contact
Part II states that you do
you. lfyou cannot be reached, medical treatment is allowed to be given.
not wish to sign part I. PLEASE ONLY SIGN PART I OR II, NOT BOTH.
3) County policy requires the purchase of MANDATORY ATHLETIC INSURANCE. The medical insurance is
for treatment of sports-related injuries. The athletic insurance is a secondary insurance, and it is
applicable only after the parents' health insurance,if any, has been submitted.
Questions regarding
insurance coverage and benefits can be answered by calling the insurance carrier. The insurance fee
is non-refundable, and must be purchased online at www.hcpsathleticprotection.com.
4) Student athletes that have not participated in athletics at Alonso High School must submit a certified
copy of their birth certificate 0JVE CAN MAKE COPIES FOR YOU).
5) The Unsportsmanlike Conduct Agreement must be signed by both the student athlete and the
parent/guardian.
In order for your student athlete to participate in Alonso High School's interscholastic athletic program, he/she
must complete and submit to the coach/sponsor BEFORE THE FIRST PRACTICE SESSION.
1)
2)
3)
4)
5)
6)
7)
8)
9)
Be enrolled at Alonso High School.
Completed APPLICATION FOR ATHLETIC PARTICIPATION forms with all required signatures.
FHSAA Physical form (EL2) signed and dated, for the school year, by a physician.
Two signed and notarized medical release cards.
Concussion and heat accumulation form signed by both parent and athlete (EL3CH).
Signed Unsportsmanlike Conduct Agreement.
Signed Media Release form.
Insurance Confirmation Page or return email receipt.
Birth certificate (certified copy-WE CAN MAKE COPIES FOR YOU). Please do not submit original
certificate.
10) A current utility bill.
11) lfyour son or daughter is starting lOth, 11th, or 12th grade and they did not attend Alonso High School
last year,they are required to complete the GA4 form.
Otherwise it is not needed.
12) Must meet state and district academic eligibility requirements (2.0 overall grade point average).
If you have any questions regarding eligibility or this process, please do not hesitate to contact
the coach or the athletic office at Alonso High School (813/356-1525 x239, Scott Hazlett, Athletic
Director).
Concussion Video Requirement (All Athletes)
1.) Open up Google Chrome or Mozilla Firefox (Explorer is not the best option)
2.) Go to nfhslearn.com
3.) Click on Register in the upper right hand corner
4.) In the account setup section; type in your e-mail and your password in the personal information
section type in your first name, last name, address and phone number information, then hit
next.
5.) On the profile information page click, student and then, type in State: Florida; City: Tampa;
School: Alonso High School and then mark weather or not you would like to receive e-mails
from NFHS or not, then click finish.
6.) On the next screen hit order course under "Concussion in Sports"
7.) Next click "course for myself"
8.) The next screen will be your shopping cart, for state select "florida" from the drop down menu.
9.) Then click "checkout"
10.) Then click "I agree to the terms", then click "continue"
ll.)The next page will be your order receipt
12.)0n the left side you will see "to access your courses click here" click in that box.
13.) Then click begin course.
14.)After you finish the course please download the certificate and print it out.
lS.)Piease attach the completion certificate to your ADA Packet!
To access the Concussion In Sports video, ,please go to:
http:Unfhslearn4com/course.s/38000
There is no registration fe-e, but you must click "order course"
to proceed. Print completion form at the end of the
presentation.
CONCUSSION IN SPORTS
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What You Should Know About Senior High Athletic Eligibility
~
Hillsborough Coun9'
PUilLIC
SCHOOLS
~"""'""~--
Academic Requirements
If you are in the 11th grade or 12th grade, you must have a cumulative 2.0 grade point average on a 4.0 unweighted
scale in all courses taken through the end of the previous semester. If you are in the ninth grade or 10th grade, you
must have a cumulative 2.0 grade point average on a 4.0 unweighted scale in all courses taken through the end of the
previous semester; OR you must have earned a 2.0 grade point average on a 4.0 unweighted scale in the courses taken
in the previous semester alone, provided you sign an academic performance contract (FHSAA form ELS) with your school
and attend summer school as necessary. (Article 9.4, FHSAA Handbook. Bylaws and Policies)
Ninth Grader Eligibility
A student shall be eligible during the first semester of his/her ninth-grade year provided that it is the student's first entry
into the ninth grade and he/she was regularly promoted from the eighth grade the immediate preceding year.
Residence
A student will be eligible at the first school in which he/she enrolls, or participates in an athletic practice, at the beginning
of each school year. The student will be eligible in his/her first school of choice each year as long as the student remains
enrolled in that school. (Florida Law 97-53) Additionally, home school students who are registered through Hillsborough
County Public Schools and charter school students who are enrolled in a Hillsborough County registered charter school
are eligible for athletic participation at their school of residence.
Transfers
If you transfer during the school year from one school to another, you must transfer from your previous school before the
first day of practice and secure a "Notice of Transfer" (FHSAA form EL6) and an "Affidavit of Compliance with Policy on
Athletic Recruiting (FHSAA form GA4). If you transfer on or after the first day of practice in a sport you cannot participate
in that sport. If you transfer from a school at which you were ineligible because of disciplinary action or unsatisfactory
conduct, you will be ineligible at your new school for one full semester. If you participate on a non-school team [i.e. AAU,
American Legion, club settings, etc.] that is affiliated with a school other than the one you attend, or have attended, and
then transfer to that school, it will be assumed you have been recruited to attend that school and you will be ineligible
there for one year. If you transfer to a school that your head coach or assistant coach [paid or volunteer] has relocated to
within the past year, it will be assumed you transferred to that school for athletic reasons and you will be ineligible there
for one year. If you transfer to a school as a result of undue influence exerted by or special inducement offered by
anyone associated with the school in an attempt to encourage you to attend the school for the purpose of participating in
its athletic programs, you will be ineligible at that school for the remainder of your high school career and at all other
FHSAA member schools for one year.
Additionally, Hillsborough County Public School policy states: Students previously enrolled in a different high school prior
to their current Hillsborough County Public School (HCPS) who wish to participate in athletics will be defined as studentathlete transfers by HCPS. Student-athletes changing schools during the summer are also deemed to be student-athlete
transfers. This policy may be viewed in its entirety at Http://athletics.mysdhc.org. Please contact the APA at the school
site once you have enrolled in that school for more information
Ag§
Students enrolled in high school prior to 7/1/2014 may participate at the high school level until the day he/she reaches the
age of 19 years 9 months if the student has not exceeded his/her four-year limit of eligibility. For students initially entering
81
high school after 7/1/2014, reaching the age of 19 before September 1 will make them ineligible to participate in
interscholastic athletics for that school year and beyond.
Limit of Eligibility
A student shall be eligible for no more than four (4) consecutive academic years upon first entrance to ninth grade as
defined by the pupil progression plan of the school in which the student is enrolled. Four years from the date he or she
first successfully completes the eighth grade, he or she shall become ineligible for further interscholastic athletic
competition. A student who does not attend school, repeats any grade, is declared ineligible to participate, or otherwise
fails to exercise the opportunity to participate for any reason for any length of time during this four-year period shall not
be entitled to any additional period of eligibility. Original school records shall be submitted to the Commissioner in the
event of conflicting information as to the date of first successful completion of the eighth grade. (Article 9.5, FHSAA
Handbook. Bylaws and Policies)
P3
HILLSBOROUGH COUNTY PUBLIC SCHOOLS
Eligibility Requirements for Extracurricular Participation
2016-17
. : ~·i¥r~iMtt~~tc~·••··,~~e·LzS,~~~~;;··•,. }~,_~til. ::,~·~~t~~~i;W~~ui~~~~~'··· .·-· · · ·.
First semester
2016-17
Students first entering the
ninth grade in 2016-17
Students entering lOth
grade
Must be regularly promoted from the 8th grade to
the gth grade.
Must have a cumulative 2.0 grade point average
on a 4.0 unweighted scale in all courses taken
through the end of the previous semester; OR
must have earned a 2.0 grade point average on a
4.0 unweighted scale in the courses taken in the
previous semester alone, provided he or she
signed an academic performance contract with
his or her school and attended summer school as
necessary.
Students entering 11th and Must have a cumulative 2.0 grade point average
12th grades
through the end of the previous semester
gth and 10th grade
Second semester
2016-17
through the end of the previous semester; OR
must have earned a 2.0 grade point average on a
4.0 unweighted scale in the courses taken in the
previous semester alone, provided he or she
signed an academic performance contract with
his or her school and attended summer school as
necessary.
11th and 12th grades
through the end of the previous semester
A student shall be eligible for no more than four (4) consecutive academic years upon first successful
completion of the eighth (8th) grade as defined by the pupil progression plan of the school in which the
student is enrolled. Four years from the date he or she first successfully completes the eighth grade, he
or she shall become ineligible for further interscholastic athletic competition. A student who does not
attend school, repeats any grade, is declared ineligible to participate, or otherwise fails to exercise the
opportunity to participate for any reason for any length of time during this four-year period shall not be
entitled to any additional period of eligibility. Original school records shall be submitted to the
Commissioner in the event of conflicting information as to the date of first successful completion of the
eighth grade. (Article 9.5 FHSAA Handbook Bvlaws and Policies)
Note 1: A grading period is defined as one semester. A semester is defined as one half of a school year
(approximately 18 school weeks or 90 school days). This definition is applicable to all schools regardless
of the type of class scheduling format used (i.e. block, traditional, etc.)
Academic Performance Contract for Athletic Eligibility found at http:/jc2cschools.com
H24
4J
Hillsborough Counnr
PUBLIC SCHOOLS
&,~. ~
Application
for Athletic Participation
Senior High School
Name {as it appears
on birth certificate}
Street Address
aty I State I Zip Code
I
M F
Date Entered
(circle one}
~ Grade
Ust all previous high schools attended:
Sex
I
Home
Phone
Parent Work
Phone
School
Parent Cell
Phone
I
ICurrent
Grade
Level
FHSAA Bylaws, Article 9.8.1:
Student Must Provide School with Signed Consent and Release Form to Participate. A student must have the consent of
hiS/Iter parent(s) or legal gutJrdlan(s) to participate In Interscholastic athletic programs at a membllr school. The student and
his/Iter parent(s) or legllf guiJf'llii!Jn(s) must also release the FHSAA, Its member sclteols and contest oHidals from all/lability
lor any Injury or cllllm that m11y rtl$8/t from the student's participation In lnterscltolastlc llthletlcs. This consent and release
from liability must be prott/dfld In writing tNIIIform developed by this AsstiCiatlon for that purpose. The form must be signed
by the student 11/Jd hiS/Iter parent(s) or legal guardiM~S. The student cannot be 111/owed to participate In any activity rel11ted
to lnterscho/a$llc athletic progralll$ untutlte ftllly executed consent form Is on 11/e In the school.
Prepartlclpatlon Physical -In compliance with Rorlda Statute 1006.20 -this physician's certificate Is valid for one year (365 days) from the
date of the physical examination.
Florida Statutes 1006.10(2)(c) The organ/Z;Itlon (FHSAA) shall adopt bylaws t.fNit requite all students partldpa(ing ;n irlter$d7clasti athletic competition or who
fire c:ilndkl6tes for an hltei'SChoiiJsl:/ athletic teem to sii1tisfadorlly pass a met:llci11 evaluation each yur prior to participating in Interscholastic athletic
competition or enpaglng In any pnctic!l, tryout, workout, or other physical ilct!VIty assocl11ted with the student's candidacy for 11n
lnterscholllstlc athletic tum. SUCh medici1l evaluiltion c:iln only be administered by a prilCtitioner licensed under the fJI1)Vislons of cMpter 458, chapter 459.
chapter 460, or s. 464.012, and ;n good stilnding with 11M f)l"iiCtitfones regulatory board. The bylaws s/160 establish requirements for elidtlng a student's
medk:IJ.I history and performing the mt!diCIII tMJiuation required under this paragrafJ4 which shi1/llnclude a physical assessment of the student's physiall
atpabi/ltles to~ In lntetschol8stJc IJthleiJc competition as contained In a unifolm preparticlpat;on physiatl evaluation and history form. The evaluation
form s/1611 incorporate the recommendations of the American Heart Association for partldpatlon c:ilrdioViiSCtllilr screening and sMH provide a place for the
sigl'18trlre of the practitionerpetforinlng the evaluation with an at:tesliltlon that each examination fJfr)Ce(lure listed on the form WiiS pelformed by the ptaditloner
or by someone under 1M direct supervision of the pradllioner. The form shaH also contJJ/11 a place for the prlfCtlt.iont!r to Indicate If a referral to anotlter
praattJoner was mat:NJ ;n /leu of t;DI17pletJon of a certain examination prct;edure. The form shalf provide a place for the practitioner to whom the student was
referred to complete the remaining sections and attest to that portion of the examination. The prepartit:lpali physiatl evaluation form shall advise students to
complete a carrlfowlsr::ulr ~t and shall Include lnl'otmi1tlon concemlng altem<ftlve cardlovctscular eva/uati<Jn and d/agnostfc tests. Results of such
medical evaluation must be provfded to the sdlool. No student shall be eligible to part/dpate in any lntei$Cholastic Rh/etfc competition or engage In any
practice, tryout; ~ or other phy$/aiiiJCflvlty 8SSOCfated with the student's Glndldacy for an lnterscholiiSIIr: athletic team until the 151.1/ts of the medical
evaluation have been receM!d and iiPPif'ved by the school
The following items must be properly completed 11nd submitted to the Assistant Principal for Administration before the student-athlete is
issued equJpment or begins participatiOn In any form in accordance with Articles 9.7.1 and 9.8.1 of the FHSAA Bylaws.
Pre-participation/Physical Examination (FHSAA El2)
Agreement to pay fines for unsportsmanlike conduct
Birth Certificate - Initial eligibility
Completed Medical Release cards (2 total)
Completed Application for Athletic Partldpatlon
(FHSAA EL3 and B.3CH induded}
Mandatory insurance coverage
Affidavit of Compliance with Polley on Athletic RecruJting (FHSM GA4)
Current utility bill or proof of residence
Completion of NFHS Concussion In Sports Video
HCPS Revised 6/21201 S
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Florida High School Athletic Association
Revised 04/16
Consent and Release from Liability Certificate
(Page 4 or 4)
This oornpleted form must be kept on file l)y tho $Chool. This fonn is valid fur 365 calendar dayt from tho date of tho most recent signature.
Attention Student and Parent(s)/Guardian(s)
Your school is a member of the Florida High School Athletic Association (FHSAA) and fullows established rules. To be eligible to represent your
school in interscholastic athletics. in an FHSAA recognized sport (i.e. bowling, competitive cheedeading, girls ftag football, lacrosse, boys voUeybal~
water polo and girls weigbttiftillg or saru:tioned sport (i.e. baseball. basketball, cross country, tackle footbaU, golf, soccer, tast-pitcb softball, swimming
&: diving, twmis, track & field, girls volleyball, boys weightlifting and wrestling), the student:
1. Tbis form is non-traasferable; a separate form must be completed for eaoh different school at which a student participates.
2.
3.
Must be regularly enrolled and in regular attendance at your school. If tbe studeat Is a home education student or atteads a ebarter sebool or
Florida Virtual ~bool- htl dme Program or a spedal/alteraative sebool or eertsiD small no..,.member private sebools, the student •ust
dedare lD writiDg hb/her Intention to pa~pate in adlletits to the sehoolat which the student Is permitted to partkipat-. Home education
students and students attending small non-member private schools must be approved through the use ofa separate form prior to any participation.
(FHSAA Bylaw 9.2. PoHoy 16 and Administrative Procedure 1.8)
Must attend school within 10 days ofthe beginning of each semester to be eligible during that semester. (FHSAA Bylaw 9.2)
4.
Must maintain at least a cumulative 2.0 gracle point average on a 4.0 unweighted seale prior to the semester in which the student wishes to
participate. This GPA mu&"t include all courses taken since the student entered high school. A sixth, seventh or eighth grade student must have
eanted at least a 2.0 grade point average on 4.0 unweighted scale the previous semester. (FHSAA Bylaw 9.4)
5.
Must not have graduated from any high school or its equivalent. (FHSAA Bylaw 9.4)
6.
Must not have earolled ill tbe nilltb pade for the first tlnte m01e than mur school years ago. If the student is a sixth, seventh or eighth grade
student. the student must not participate if repeating that grade. (FHSAA Bylaw 9.5)
7.
Must have signed permission to participate from the student's parent(s)llegal guantian(s) on a form (ELJ) provided the schQ(~I. (Bylaw 9.8)
8.
Must be less than 19 years 9 months old to participate in high school; 16 years 9 months old to participate in junior high school; and IS years 9
months old to participate in middle school, otherwise the student becomes ineligible to participate at that level. Students entering 9th grade in
2014-15 and thereafter must not tum 19 before September lst, otherwise the student becomes ineligible to participate. (FHSAA Bylaw 9.6)
9.
Must undergo a pre-participation physical evaluation and be certified as being physically fit for participation in interscholastic athletics (form
EL2).
10. Must be an amateur. This means the student must not accept money, gift or donation for participating in a sport, or use a name other than his/her
own whea participating. (FHSAA Bylaw 9.9)
11. Must not participate in an all-staroontest in a sport prior to completing his/her high school eligibility in that sport. (FHSAA Policy 26)
12. Must display good sportsmaosbip and follow the rules of competition ~fore, during and after every contest in which the student participates. If
not, the student may be suspended from participation for a period of time. (FHSAA Bylaw 7.1)
13. Must not provide false information to his/her school ortotbe FHSAA to gain eligibility. (FHSAA Bylaw 9.1)
14. Youth exchange, other international and immigrant students must be approved by the FHSAA office prior to any participation. Exceptions may
apply. See your school's principal/athletic director. (FHSAA Policy 17)
IS. Must refrain from hazing/bullying while a member of an athletic team or while participating in any athletic activities sponsored by or affiliated
with a member school.
If the student is declared or ruled ineligible:: due to one or more of the FHSAA rules and regulations, the student has the right to request that tbe school
file an appeal on behalf oftbe student See tbe principal or athletic director for information regarding this process.
By sipia& tlaif qree~neat. tile udenipecl ack.Dewledpt tlalt the information on the Conseat and Release from Liability Certiftt~te Ia repnb to Ike J<JJSAA's
Hta.n.hecl rulft aad eligibility have beea nad aad IJIIdersfood.
Nalnc ofSiudent-Athlcte (printed)
--'
Date
Name ofParcnfiGuardian (printed)
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..
Revised 04/16
Coasent aad Release from Liability Certificate
(Page 1 of 4)
This oonipletcd form must be kept on file by tho school. This form is valid for 365 calendar days from the date of the most rceent signatwe.
Tllia form is aoa.mtasfendllej a cbaap of lldloola dllrilag the
period of this form riJ n:qaire this form fo be l'MUilmifted.
ve
Sebool: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ School District (ifapplkable)~ - - - - - - - - - - Part 1. Student Acknowledgement and Release {to be s~ed by student at the bottom)
1have read the(~ PHSAA Sli,JII:Illity Ruleaprintcdon Paae4 oflhis 'Consent and Release Certificate" andknowofnoreason why I am not eligible tore)lfCM'nt
my school in athletic f!B!ticipation. lf accepted as a representative, [ agredo follow the rules of my school and FHSAA and to abide bY their decisions. I know that athletic
particiJ)IItlon is a privilege. I know of the iisks involved in athletic pwticipation. ~stand that serious injury, including the potential for a concussion, and even death, i!
possible in such participation, and clloo$e to accept such risks. I vo[untarily accept any and all responsibili~ for my own safety and welfare while participati113 in athletics,
with !WI undcrSianding of the risks involved. Should I be 18 years of • or older, or should I be emancipated from my jlillent{s)lgt.lllrdian(s), I hereby .release and hold
harmless my schoOl, die school! apinst which it competes, the school district, the school board, the contest officials and FHSAA (hcteafter "the parties released") of any
and all ~lity and lia~ility ~r any_ uyury or cla!m te!~ins. from such athletic !'articipation ~ agree to take oo ~I action ~inst the partiJ:s reJeas~ because
of any &CC!dent, Jlllle$$, or mishap tnvoivmg my .athlet.c pemcipation I hereby autborll.C the 1M or disclosure of my mdividually tderltifiable health mformahon sboukl
treatment fur iliiiCISi or injury boc:om\l neocssary. I hereby grant to FHSAA the rifU to review all records relevant to my athletic elisibility inch~ng. but not limited to.
my recOI'Ih relating to enrollment and attendance, academic standing. age, disciplme, nn.nces, te!idence and physical fitness. I hereby grant the released partie$ the right
to photograph tlndhlr v~ 1110-and ·fWthcr to use my name. fllcc, lil«lnets, voice and appearance in connection with exhibitions, publicity, advertising. promotioilal
and commereial ~s Without reservalion or limitation. The .released parties, however, are under no obligation to exorcise said ri~ herein. I undcistand that the
authorizations and rig&ts lttllllted herein are vol~ and 1hat I may revoke any or all ofthcm at any time by $Ubmitting said "'vocation m writing to my school . By doing
so. however, I underStandthat l will no 10f18er be ehgible for participation i~t interscholastic athletics.
Part :Z. PareutaiJGuardiaR CoRSeD~ Aeknowledgemeut and Release (to be completed and siped by a pareat(s)/panliall(s) at the l:lot·
tom; wlten~ divon:ed oneparated. pareat/pardiP with legal custody mllilt iligu.)
A.
I hereby give consent for my child/ward to jllllticipate in any FflSAA recognized or sanctiom:d sport EX£Efi fur the following sporl(s):
List sport(s) exceptions here
B. I understand that participation may necessitate an early dismissal from classes.
C. I know of, and acknowledge that my child/ward kno~ or; the risks involved in athletic participation, understand that serious injury, and even death, is possible in
such participation and ehoosc to accept any and all responsibility for his/her 5111\ty and welfare whrle particip~ in athletics. With full unde~ of the risks involved, I release and hold harmless my child'llward's $Cbool, the schools against which it competes, the school distriCt, the schooll:loard, the contest officials and FHSAA
(hereafter "the J?ll1ies released") of any and all !CSJ'O~Sibility and !iabili!Y fur l!I1Y injury or ~!aim ~ulti?8 from sue~ athletic participation and agree to~ no legal action
againSt the parttcs rcleu-1 because of_ Iany acc«tent, illness, or mishap 1nvolvmg the athletic patttc1pat10n of my cbddlwatd. J authonze emelgellcy medical treatment for
my child/ward should tho need arise for such trea~ while my chifdlward is under the supervision ofthe schooL 1 further hereby authorize the usc or disclosure of my
child'st'Ward's individually iclcntifi&bJc health information should treatment for illness or injury become necessary. 1 consent to the disclosure to the FHSAA, upon its
~of all recOids r~evant ro_ my cl!ildlwanre >tthletic eligibility inc!~ b~ ®t limited to, records re~lifl8 to enroll~ and atlcndancc, 8Cadem!c ~ding, age,
4iactphnc, finances. rmdencc I!Rd physical fitness. I grant the released parties tlie right to photograph and/or videotape my childlw8rd and further to usc said chtld'slward's
name, tllce,likenes$, voice and liP~ in connection with exhibitions, publicity, advertisill@. promotional and commercial materials without reser.tation or limitation.
The released parties, however, are under no ®ligation 1o eJ<IIrcisc said ri&htS herein,
D.
·
i
and/or
· ur · in athletics. I alw have knowled
ri ·
contin · to
ici to once
suehantn
:9, i!\\Tk'2f'trf~e::~%(:t!;{:.U•ftlPJff:JC1:e:~~!!~l!;IJf.Jr.l\:::me;rv
child CiadivjduaJM or
my cbjfd'a tum partjsipa-
1 UDderstand 1hat the authonzatt0115 and r~ts granted herein are voluntary and that 1 may revoke any or all of them at any time by submitting said revocation in
wri1i~to my school. By doing so, bowocvcr, l uildcmand that my child/ward will no longer be eligible for participation in intcrscholaslic athletics.
G. ~~ cbpck the !QlproQriale boxtes>:
_My child/ward is covered under our family health insurance plan, which bas limits of not less than $25,000.
F.
Compllll)':
-My ehildlwatd is eovcred by his/her scboOI's activiti¢$ medillalbil$t imlrancc plan.
_ 1 have purcbascd supplemental football insurance ~my ehild~slward's school.
Polley N u m b e r : - - - - - - - - - - -
I HAVE READ THJS CAREFULLY AND KNOW IT CONTAINS A RELEASE (Only one panntlguardian Jignature Is required)
NameOtJiiienr/Guiiit.an (PriJiid}
Signature ofPareniiGUiifdtan
I
Name oflSarcntiGUilidian {printed)
Signatwe ofParentiG\IIItdian
Date
I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (student must sign)
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PERMISSION TO PARTICIPATE AND TRAVEL
The undersigned as parent or legal guardian gives consent for the athlete identified herein to engage in athletics as a representative of
- - - - - - - - - - - - - S c h o o l and to accompany the team as a member on its many trips.
Date:
Signature:-------=::'---::------:--:---:-:----Signature of parent or legal guardian
INSURANCE
As parents or legal guardians of the athlete identified herein, I understand that all student-athletes shall be required to purchase athletic
Insuranc:e provided through the school board Insurance program In order to participate In the Hillsborough County Interscholastic sports
listed below (Athletic Guidebook of Procedure Article 8-1-3).
Varsity Football (fall)
Varsity Footban (spring)
Junior Varsity Football (fall)
Baseball
Varsity Basketball
Junior Varsity Basketball
Soccer
Girls Flag Football
Softball
Varsity Cross Country
Jooior Varsity Cross Coootry
Volleyball
Junior Varsity Volleyball
Varsity Wrestling
Junior Varsity Wrestling
Varsity Cheerleaders
Junior Varsity Cheerleaders
Lacrosse
Golf
Swimming
Tennis
Track
Student Trainer
Other non-sport Participant
Manager
Signature:-----~----::------:--:----:-:---
Date:
Signature of parent or legal guardian
UNIFORMS, EQUIPMENT, AND SUPPLIES
I understand that I,
(student-athlete), and my parents/legal guardians, (parents/legal guardians)
. I agree to repair or
are responsible for uniforms, equipment, $J1dlor supplies issued to me while participating in the sport of
replace any Item that is damaged or lost while issued to me.
Date:
Signature:------..,.---...,------:--:-------Signature of student-athlete
Date:
Signature;-----------..,.-------.,.,---Signature of parent or legal guardian
I HAVE REVIEWED THIS APPLICATION FOR ATHLETIC PARTICIPATION FORM COMPLETELY.
Signature of Student-Athlete
Date
Signature of Parent/Guardian
Date
Signature of Head Coach
Date
Signature of Assistant Principal for Administration
Date
HCPS Revised 6121201 S
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High School Athletic Association
Revised 04/16
Consent aad Release from LiabiUty Certificate for Concussions (Page 2 of 4)
This compleled form must be kept on file by tbe schooL This furm is valid fur 365 calend111 days from 1he date of the most recent signature.
Sebool: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ School District (ifapplkable)! - - - - - - - - - - -
Co. . .Oft Information
COI'ICIISilOIIu i brain iqjwy. Concussions, as -11 as all other head injuries, are serious. They can be caused by a bump, a twist of the head, sudden deceleration or
~.lwatioa. a blow or jolt to the head, or by a blow to anoUtot partoftlte body with force ttansmitted to the head. You can't see a concussion, and mote than 90"/o of
all concussions occur without loss of consciousness. Silns and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. All
concussions are potentially serious.and, if not JtlllllagCd properly, may result in complications including brain dama~ and, in rare cases, even death. Even a "ding" or a
bump on tile head ean be sorious. Jfyour child fCP(Irt$ any sylllptOms of concussion, or ifyou notice 1he symptoms or signs of conctiS$ion yourself; your child should be
immediately ramoved from play, evaluated by a medical professional and cleared by a medical doctor.
Sips and SyiiJtoms ofa Coapnion;
Concussion S)'lllJ)toms may appear im.nlcdiately after the injwy or can take SlM'ral days to appear. Studies bavc shown that it takes on average I0-14 days or longer
fur symptomS to resolve and, in rare cases or if tho adllete has sustained multiple concussions, tbe sylllptOms can be pro!ongod. Signs and sYmptoms of concussion can
ineludt; (not all-inclusive)
• Vacant st111c or seeing stars
• Lack of awareness of SUJToundiOSS
• Em.otlons out of proportion to cifcumstances {.inappropriate crying or anger)
• Headache or persistent headache, nausea, vomiting
• Altered vision
• Sensitivity to light or noise
• Delayed verbal and motor responses
• Disoricntatioa, slurred or i.ncohet'cnt Sj)COCh
• Dizziness. including Jight-headodncss, vertigo(.spinning) or loss of equilibrium (being oft' balance or swimming sensation)
• Decreased coordination, reaction time
• ConfUsion and inability to focus attention
• Memoryloss
• Sudden change in academic performance or drop in grades
• Irritability, deprt!tsion, anxiety, steep disturbances, CBsY t'atigability
• ln rare cases, loss of conscio~JSt~eSS
DANGERS !hogr cl!iJd gpntipM to olav with a COPSJ!ssion or nturas too SOOJ!!
Athletes with signs and symptoms of concussion should be removed fuJm activity (play or practice) immediately. Continuing to play with tbe signs and symptom$ of a
concussion leaves lhc young athletr; especially vulnerable to sustaining another concussion. Athletes wllo sustain a second concussion before tbe sYiftp!Oms of the first
eoncussion have resolved and the brain has bad a chance to heal are at risk for prolonged concussion symptoms, pertnlllWilt disability and even death (called "Second
Impact Syndlome" where lhc brain swells uncontrollably). There. is also evidence that multiple concussions can lead to Jong~term symptoms, including early dementia
••put
Steps to take ihu
vow eflild hu gtJered a C1tJKussion;
Aily atbletr: ~of suffering a concussion should be removed from the activity immediately. No athlete may return to activity after an apparent bead injury or
eoneussion, rcpnfless ofhow mild it seems or how quickly symptoms cleat, without written medical clearance fi'om an appropriate health-care professional (AHCP).
In Florida, an appropriate health-care professional (AHCP) is defined as either a licensed physician (MD, as per Chapter 458, Florida Statutes), a licensed osteopathic
physician (00, as per Chapter 459, Florida Statutes). Close observation oftbe athlete should contimle for several hours. You should also seck medical care and inform
your child's coach if you thinlt that your child may have a concussion. Remember, it's better to miss~nc 811fRC than to have your life changed furcver. When in doubt, sit
them out.
Return to plv or.pnctig:
Following physician evaluation, the ntz~m t11 tu:til1if,y prtJCIU requires the athlete to be completely sYmptom free, after which time they would complete a step-wise
protocol under lhe supervision of a licensed athletic trainer, coach or me<lical professional and then, receive written medical clelllaOCC of an AJICP.
For current and up-to-date information on concussions, visit htlp:l/www.cdc.gov/concussioninyoutbsportsl or http://www.sceingstarsfoundation.org
S!atelll!•t ofStwl!nt Atltlete fttml!!ibifity
Pareatsa.tstvdeuts llboalcl be aware of prel~Dliaary evicleace tllat Sllfillll repeat coacumou, aud evoltit$ that do aot eause asymptomatic eoaeussiou,
may lead to abuormal bniu ebauga wlrich eau ouly be Me! oa autopsy {kaowa as Chroak Traumatic E11cephaiopathy {CTE}). There have been ease reports
suggutl~~& the develop.-at ofParldllsoa'Hike ~ymptoms, Amyotropll: Lateral Sduuis {,U.S), severe f111Dmatic braiD injury, depreaioa, al'ld long term
memory lnuts tllat may be related to eo.teii$Jitll history. Further resean:h 011 this topic is needed before lilly coadusieJU raa be dnnrJJ.
I aetaowtedce the aaoual nqaln:meat for my childlwlml to view "COJJCU1Sioa ill Sports-What You Need to KaoW" at www..afbJie&l'll.c:om. laeccpt respoaslbility for reporti.DJ' aU illjviet alltl Wllftlfl to my pareDQ, team doctor, athletic traiuer, or eGaehes a110dated with my sport iadlltliagaay sips alltl symptoms
of CONCUSSION. l have read a11t1 vadei'Staltd the above iafonnatiOD 011 eom:11Ssio11. I wm laform the illlpervUiJIIr coach. athletic: traiaer or team physlc:iaa
immediately ifl n.perleaee aay of.fllue symptoms or witocss a tealllnUite with these sYmptoms. Fvrthvmore, I have beeu lldvlml ol'the ciJuagen of partitlpatloa for myself alltl that of my ehttdlward.
Nama ofStudent-Athlete{printed)
I
Signature ofParent/Guardian
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ReviSed 04116
Consent and Release from Liability Certifieate for
Sudden Cardiae Arrest and Heat-Related Illness (Page 3 or 4)
This completcd t'otm miiSt be kept on file by the scboot Tbls form is valid fur 365 calendar days from the date ot'the most recent signature.
Sebool: - - - - - - - - - - - - - - - - - - Se)lool Distriet {lfapplkaltle): - - - - - - - - - - -
§udden Cardiae Arrest Information
Sudden eardiae art'est is a leading cause of sports-l:elated death, This policy provides procedures for educational requirements of all paid coaches and recommends
added lnlining. Sudden cardiac arrest is a:eond:ition in which the heart suddenly and ~y stops beating. lfthis happen$, blood $tops flowing to the brain and
other vital organs. SCA can cause death if it's not 1n1ated within minutes.
Symp!Dm! of mdclea elll'dlae armt iad!dt, but DOt llmlftd to: sucldea collapse. uo pulst, ao breatltiag.
Waru!q ~~ aoodated wkll tuddta eanlift arrett iuduct.: failltiag clurill&: exereite or ac:cMty, sbormess of breath, rac:iag heart rate, dizzillfSs, ellest pain5,
extreme rafilve.
It is st'rongly recommended all C)Oa()hes, whether paid or volunteer, are regularly trained in CPR and the use of an AED. Training is encouraged through agencies that
provide hands-on training and offer certificates that include an expiration date.
At.Jtomatk: external defibrillators (AEI>s} are required at all FHSAA State Series games. tournaments and meet&. The FIISM also strongly recommends that they be
available at all preseliSbn and regular season events as welf along with coache$fmdividuals ttained in CPR.
What te ckt if)'9ur studeat-atltlete collapses:
l.
Clll9ll
l.
Seaclfor uAED
J.
Beci• temprellioas
FHSAA Heat-Related Illnesses Information
People suffer heat-related illness when their bodies cannot properly cool themselves by sweatil18. Sweating is the body's natural air conditioning, but when a person's
body temperature rises rapidly, sweating just i•n't enough. Heat.related illnesses can be serious and life threatening. Very high body temperatures may damage the brain
or other vital organs. and can cause disability and even death. Htlat-related illnesses and deaths are preventable.
HeatS~ is the most serious heat-related. illness. It happens when the body's temperatw'e rises quickly and the body cannot c(Xll down. Heat Stroke can cause perma·
nent disability and death.
Heat Exllautioa is a milder type ofheat-n:lated illness. It usually develops after a number of dayll in high temperature weather and not drinking enough lluids.
Heat Cramps usually efi'ect people who sweat a lot during demanding activity. Sweating reduces the body's salt and moisture and can cause painfUl cramps, usually in
the abdomen, atms, or Jess~ Heat enunps may also be a symptom of heat exhaiAStion.
Who's atllisk?
Those at higllest risk include the elderly, the very young. people with mental illness and people with chronic diseases. However, even young and healthy individuals can
suecumb to heat ifthey participate in demanding physical activities during hot weatber. Other conditions that can increase your risk for heat-related illness include obesity,
fever, dehydration. poor circulation. surdnun, and prescription drug or alcohol usc.
By sipiaJ dais ~ the lliiCimdped -ac.lmowledgea that dae iafonnatiea oa Sudden Cardiae Arrest aod Heat-Related Dfaess llave been resd alld aaderltood. I aekaowttdp optioaa.l edtlfatioual opportuitits ia cardiae •rrest at www.afbsleara.org. Please go to www.lhsaa.o'1fd,epartmeatslhealth for fartber
ia$tn~ttioas to view the eftl'lts. I ban belli advised of tile dngers of partldpatioa for myself aad tllat of my drildl-rd.
I
Name ofStudent-Athlete {printed)
Oak
Name of Patent/Guardian {printed)
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Preparticipation Physical Evaluation (Page 1 of 3)
-
Revised 03/16
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.
Part 1. Student Information
(to be completed by student or parent)
Student's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Sex: _ _ Age:
Date of Birth: _ _/ _ _/ _ _
School: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Grade in School: _ _ Sport(s): - - - - - - - - - - - - - - - - - - - Home Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Home Phone: ( _ _ j _ _ _ _ __
Name of Parent/Guardian: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E - m a i l : - - - - - - - - - - - - - - - - - Person to Contact in Case of E m e r g e n c y : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Relationship to Student: _ _ _ _ _ _ _ _ _ Home Phone: ( _ _ j _ _ _ _ _ _ Work Phone: ( _ _ j _ _ _ _ _ Cell Phone: ( ____j _ _ _ __
Personal/Family Physician: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _City/State:------------ Office Phone: ( _ _ j _ _ _ _ __
Part 2. Medical History (to be completed by student or parent).
Yes
Have you had a medical illness or injury since your last
check up or sports physical?
2. Do you have an ongoing chronic illness?
3. Have you ever been hospitalized overnight?
4. Have you ever had surgery?
5. Are you currently taking any prescription or nonprescription (over-the-counter) medications or pills or
using an inhaler?
6. Have you ever taken any supplements or vitamins to
help you gain or lose weight or improve your
performance?
7. Do you have any allergies (for example, pollen, latex,
medicine, food or stinging insects)?
8. Have you ever had a rash or hives develop during or
after exercise?
9. Have you ever passed out during or after exercise?
I 0. Have you ever been dizzy during or after exercise?
I L Have you ever had chest pain during or after exercise?
12. Do you get tired more quickly than your friends do
during exercise?
13. Have you ever had racing of your heart or skipped
heartbeats?
14. Have you had high blood pressure or high cholesterol?
15. Have you ever been told you have a heart murmur?
16. Has any family member or relative died of heart
problems or sudden death before age 50?
17. Have you had a severe viral infection (for example,
myocarditis or mononucleosis) within the last month?
18. Has a physician ever denied or restricted your
participation in sports for any heart problems?
19. Do you have any current skin problems (for example,
itching, rashes, acne, warts, fungus, blisters or pressure sores)?
20. Have you ever had a head injury or concussion?
21. Have you ever been knocked out, become unconscious
or lost your memory?
22. Have you ever had a seizure?
23. Do you have frequent or severe headaches?
24. Have you ever had numbness or tingling in your arms,
hands, legs or feet?
25. Have you ever had a stinger, burner or pinched nerve?
I.
No
Explain "yes" answers below. Circle questions you don't know answers to.
Yes No
26. Have you ever become ill from exercising in the heat?
27. Do you cough, wheeze or have trouble breathing during or after
activity?
28. Do you have asthma?
29. Do you have seasonal allergies that require medical treatment?
30. Do you use any special protective or corrective equipment or
medical devices that aren't usually used for your sport or position
(for example, knee brace, special neck roll, foot orthotics, shunt,
retainer on your teeth or hearing aid)?
31. Have you had any problems with your eyes or vision?
32. Do you wear glasses, contacts or protective eyewear?
33. Have you ever had a sprain, strain or swelling after injury?
34. Have you broken or fractured any bones or dislocated any joints?
35. Have you had any other problems with pain or swelling in muscles,
tendons, bones or joints?
Ifyes, check appropriate blank and explain below:
Head
Elbow
_Hip
Neck
Forearm
_Thigh
Back
Wrist
Knee
Chest
Hand
Shin/Calf
_Finger
Ankle
Shoulder
_UpperArm
Foot
36. Do you want to weigh more or less than you do now?
37. Do you lose weight regularly to meet weight requirements for your
sport?
38. Do you feel stressed out?
39. Have you ever been diagnosed with sickle cell anemia?
40. Have you ever been diagnosed with having the sickle cell trait?
41. Record the dates of your most recent immunizations (shots) for:
Tetanus:
Measles: _ _ _ _ _ __
Chickenpox: _ _ _ __
Hepatitus B: _ _ _ __
FEMALES ONLY (optional)
42. When was your first menstrual period? - - - - - - - - - 43. When was your most recent menstrual period? _ _ _ _ _ _ __
44. How much time do you usually have from the start of one period to
the start of another? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
45. How many periods have you had in the last year? _ _ _ _ _ __
46. What was the longest time between periods in the last year? _ _ __
Explain "Yes" answers here: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
We hereby state, to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.l 006.20, Florida
Statutes, and FHSAA Bylaw 9. 7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic
tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.
Signature of S t u d e n t : - - - - - - - - - - - - - - - Date: __/ __/ __ Signature of Parent/Guardian:------------- Date: __! __! __
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Revised 03/16
Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed physician assistant or certified advanced registered nurse practitioner).
Student's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Birth: _ _/_ _/_ _
Height: _ _ _ _ _ Weight:
%Body Fat (optional): _ _ _ _ _ Pulse: _ _ _ _ Blood Pressure: __ / __ ( __/__ , __ /__ )
Temperature:
Hearing: right: P _ _ F _ _ left: P _ _ F _ _
Visual Acuity: Right 20/
FINDINGS
MEDICAL
I.
Appearance
2.
Eyes/Ears/Nose/Throat
3.
Lymph Nodes
4.
Heart
5.
Pulses
6.
Lungs
7.
Abdomen
8.
Genitalia (males only)
9.
Skin
Left 20/
NORMAL
Corrected:
Yes
No
Pupils: Equal
Unequal
ABNORMAL FINDINGS
INITIALS*
10. Neurological
II. Psychiatic
MUSCULOSKELETAL
12. Neck
13. Back
14. Shoulder/Arm
15. Elbow/Forearm
16. Wrist/Hand
17. Hip/Thigh
18. Knee
19. Leg/Ankle
20. Foot
• - station-based examination only
ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):
Cleared without limitation
__ Disability: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Diagnosis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Precautions:------------------------------------------------Not cleared for: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Reason:
__ Cleared after completing evaluation/rehabilitation for: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Referred to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ For:
Recommendations:-----------------------------------------------Name of Physician/Physician Assistant/Nurse Practitioner (print): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _/_ _/_ __
Address: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Signature ofPhysician/PhysicianAssistant/Nurse P r a c t i t i o n e r : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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Revised 03/16
Student's N a m e : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable)
I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s):
Cleared without limitation
__ Disability: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D i a g n o s i s : - - - - - - - - - - - - - - - - - - - - - - - - -
Precautions:---------------------------------------------------
Not cleared f o r : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Reason:
__ Cleared after completing evaluation/rehabilitation for:
Recommendmions: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Name of Physician ( p r i n t ) : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date: __/__/___ _
Address: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Signature of P h y s i c i a n : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopoedic Society for Sports Medicine and American Osteopothic Academy for Sports Medicine.
-3-
Parental Permission to Release Student Data
We would like your permission to use your child's information to evaluate the effectiveness of: The Positive
Coaching Alliance trainings that we are offering at some schools. We need this data to track your student's
progress and examine if the PCA training is having a measurable effect on your child's success.
This form tells you about the program and any data that will be used by the evaluation.
As a student athlete, your child will still benefit from the PCA training, even if you do not want us to use the
information to evaluate the effectiveness ofthe program. Your allowing us to use the data Jets us improve our
program for your child and future students.
What educational records are needed?
To evaluate this program, we will need to have your permission to ask Hillsborough County Public Schools to
provide your child's data to an external evaluator. This is private information that we must have your approval to
use. The requested records are: pre-Post survey results; grades; discipline records; attendance records; district and
state test scores.
Federal law (FERPA) requires us to keep educational information about your child private. We will keep your
child's records private by not providing any of the information to anyone not directly involved in the evaluation of
PCA training, reviewing analyses and reports to make sure students are not identified, only releasing analyses
that do not identify individual students, and only keeping the individual information necessary for analysis for two
years.
We will only use the educational data for the purposes explained in this document, and all copies of your child's
education information will be destroyed or returned to the school district office at the conclusion of the project.
No individually identifying educational data will be saved by the researchers.
What happens if you decide not to let your child take part in this study?
You should only agree to release your child's information if you want to. You should not feel that there is any
pressure to release it. If you decide not to release your child's data, or change your mind, your child will still
be able to participate in the program, will not be in trouble or lose any of his/her rights.
You can get the answers to your questions, or concerns.
If you have any questions, concerns or complaints about this study, call Lanness Robinson at 813-273-7536 or
Hillsborough County Public Schools' Department of Assessment, Evaluation, & Accountability at (813) 2724341.
Consent for Child to Participate in this Research Study
I consent to release my child's data. I understand that by signing this form I am releasing educational
data about my child and I have verified my child's Hillsborough County Public Schools district ID
number (i.e., Student Number).
Printed Name of Child &DOB
7-digit School District ID Number of Child
Parent/Guardian Signature
Date
Printed Name of Parent/Guardian
-----------------Initial below only if you don't consent to release your child's data--~----Initial __ only if you DO NOT consent to release your child's data for the research project.
- -
~------~~----------
~
Hillsborough Coun~
PUBLIC SCHOOLS
~til~
School District of Hillsborough County
Payment of Fines
Student Name
Parent/Guardian Name
School
Sport
We (student and parent/guardian) understand that as an athlete representing my school, I
am responsible for my conduct and behavior in the athletic program of the School District
ofHillsborough County.
We realize that the Florida High School Athletics Association (FHSAA) charges a fine
against my school if I am ejected or disqualified for unsportsmanlike conduct or gross
unsportsmanlike conduct. In the event of my ejection or disqualification while
representing my school, we agree to pay the fine or fines as follows:
1. General Unsportsmanlike Conduct*
2. Gross Unsportsmanlike Conduct**
$50.00
$250.00
We further understand that the FHSAA may not allow me to participate in athletic
contests as a result of my ejection or disqualification for unsportsmanlike conduct. We
understand that I will not represent my school in any athletic contests until all fines have
been paid to my school. We understand that as a student-athlete I am subject to
additional disciplinary action by the principal of my school depending on the severity of
my actions.
Furthermore, any fines or penalties assessed against the school as a result of the actions
of any student and/or parent will be the responsibility ofthe student and/or parent.
Print Student's Name
Date
Print Parent/Guardian Name
Date
*General unsportsmanlike conduct includes, but may not be limited to, use of profanity, fighting,
flagrant foul, or other unsportsmanlike acts.
**Gross unsportsmanlike conduct is an act of malicious and hateful nature toward a contest official
or opponent. Such acts include, but are not limited to: cursing, striking, or threatening a contest
official during a contest or at any other time because of resentment over occurrences or decisions
during a contest; physical contact with an opponent that is beyond the normal scope of competition
and appears to be with the intent of inflicting bodily harm on the opponent; spitting on contest
official or opponent; directing gender, racial, or ethnic slurs toward a contest official or opponent; or
other such acts that may be deemed unacceptable conduct by the principal of the school.
--~--------
------------'--
~
Hillsborough County
PUBLIC
MEDICAL RELEASE FORM
c·o p\jr 1
PART I
SCHOOlS
~c~&.nr/" t7t i5:£cottion
Name of Student: ________~-------------------------------------------------------------------------------Name of Parent: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Parent home phone:
Parent business phone:
Parent cell phone: _ _ _ _ _ _ _ _ _ __
PART I (ONLY COMPLETE PART I OR PART II )
do hereby consent to any
The undersigned as the parents and/or legal guardians of
and all medical and surgical treatments, including anesthesia and operations that may be deemed advisable by any qualified physician selected by agents or
officials of the Hillsborough County School Board. The intention hereof is to grant authority to administer and to perform all and singularly any examination,
treatments, anesthetics, operations, and diagnostic procedures that may now or during the course of the patient's care, be deemed advisable or necessary by
any qualified physician. Noactionwillbetakenuntilanattemotismade tocontactmeatthe phonenumber(s)listedabove.
IN WITNESS of our consent and agreement to the matters stated above, we have subscribed our signature below.
Signature of parent or guardian:
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
SUBSCRIBED AND SWORN TO BEFORE ME A NOTARY PUBLIC, THIS----~ DAY O F - - - - - - - - - - 20_ _ _ __
My Commission expires: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
... Not~ry
~~b_l_i_~:·=·····=··=·====-:-=============-=-c=====-=-=========
PART II (ONLY COMPLETE PART I OR PART II)
As parent or guardian of the athlete listed above, Idonot desire to sign the medical and surgical release form above.
Signature of parent or guardian::---,---------,------,--..,-,---.,------,-----Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Do not sign both parts. This form does not need to be notarized if Part II is signed.)
~
Hillsborough County
PUBLIC
MEDICAL RELEASE FORM
Co Q'\)
I (
~
PART II
SCIIOOlS
f.trr,..§;Jtre in lGikmttPn
Name of Student: _________________________________________________________________________
Name of Parent: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Parent home phone:
Parent business phone:
Parent cell phone: _ _ _ _ _ _ _ _ _ __
PART I (ONLY COMPLETE PART I OR PART II )
The undersigned as the parents and/or legal guardians of
do hereby consent to any
and all medical and surgical treatments, including anesthesia and operations that may be deemed advisable by any qualified physician selected by agents or
officials of the Hillsborough County School Board. The intention hereof is to grant authority to administer and to perform all and singularly any examination,
treatments, anesthetics, operations, and diagnostic procedures that may now or during the course of the patient's care, be deemed advisable or necessary by
any qualified physician. No action will betakenuntilanattemptismade tocontactme at the phonenumber(s)listedabove.
IN WITNESS of our consent and agreement to the matters stated above, we have subscribed our signature below.
Signature of parent or guardian:
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
SUBSCRIBED AND SWORN TO BEFORE ME A NOTARY PUBLIC, THIS
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
DAY O F - - - - - - - - - - - 20_ _ _ __
My Commission expires: ____________________________________
N?t~I)I~~-l:J.I_i~::::::.....=.=-=================================::-::.
PART II (ONLY COMPLETE PART I OR PART II)
As parent or guardian of the athlete listed above, Idonot desire to sign the medical and surgical release form above.
Signature of parent or guardian: __________,--___________________ Date: ___________________
(Do not sign both parts. This form does not need to be notarized if Part II is signed.)
-
Revised 05/14
Consent and Release from Liability Certificate for
Concussion and Heat-Related Illness (Page 1 of2)
This completed fonn must be kept on file by the school. This fonn is valid for 365 calendar days from the date of the most recent signature.
Concussion Information
What is a concussion?
Concussion is a brain injury. Concussions, as well as all other head injuries, are serious. They can be caused by a bump, a twist of the head, sudden deceleration or
acceleration, a blow or jolt to the head, or by a blow to another part ofthe body with force transmined to the head. You can't see a concussion, and more than 90% of
all 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. All
concussions are potentially serious and, if not managed properly, may result in complications including brain damage and, in rare cases, even death. Even a "ding" or a
bump on the head can be serious. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, your child should be
immediately removed from play, evaluated by a medical professional and cleared by a medical doctor.
What are the signs and symptoms of concussion?
Concussion symptoms may appear immediately after the injury or can take several days to appear. Studies have shown that it takes on average 10-14 days or longer
for symptoms to resolve and, in rare cases or if the athlete has sustained multiple concussions, the symptoms can be prolonged. Signs and symptoms of concussion can
include: (not all-inclusive)
·
• Vacant stare or seeing stars
• Lack of awareness of surroundings
• Emotions out of proportion to circumstances (inappropriate crying or anger)
• Headache or persistent headache, nausea, vomiting
• Altered vision
• Sensitivity to light or noise
• Delayed verbal and motor responses
• Disorientation, slurred or incoherent speech
• Dizziness, including light-headedness, vertigo(spinning) or loss of equilibrium (being off balance or swimming sensation)
• Decreased coordination, reaction time
• Confusion and inability to focus anention
• Memory loss
• Sudden change in academic performance or drop in grades
• Irritability, depression, anxiety, sleep disturbances, easy fatigability
• In rare cases, loss of consciousness
What can happen if my child keeps on playing with a concussion or returns too soon?
Athletes with signs and symptoms of concussion should be removed from activity (play or practice) immediately. Continuing to play with the signs and symptoms of a
concussion leaves the young athlete especially vulnerable to sustaining another concussion. Athletes who sustain a second concussion before the symptoms of the first
concussion have resolved and the brain has had a chance to heal are at risk for prolonged concussion symptoms, pennanent disability and even death (called "Second
Impact Syndrome" where the brain swells uncontrollably). There is also evidence that multiple concussions can lead to long-tenn symptoms, including early dementia.
What do I do if I suspect my child has suffered a concussion'!
Any athlete suspected of suffering a concussion should be removed from the activity 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 written medical clearance from an appropriate health-care professional (AHCP).
In Florida, an appropriate health-care professional (AI-ICP) is defined as either a licensed physician (MD, as per Chapter 458, Florida Statutes), a licensed osteopathic
physician (DO, as per Chapter 459, Florida Statutes). Close observation of the athlete should continue for several hours. You should also seek medical care and inform
your child's coach if you think that your child may have a concussion. Remember, it's better to miss one game than to have your life changed forever. When in doubt, sit
them out.
When can my child return to play or practice?
Following physician evaluation, the return to activity process requires the athlete to be completely symptom free, after which time they would complete a step-WJse
protocol under the supervision of a licensed athletic trainer. conch or medical professional and then, receive written medical clearance of an AHCP.
For current and up-to-date infonnation on concussions, visit http://www.cdc.gov/concussioninyouthsports/ or http://www.seeingstarsfoundation.org
Statement of Student Athlete Responsibility
I accept responsibility for reporting all injuries and illnesses to my parents, team doctor, athletic trainer, or coaches associated with my sport including any
signs and symptoms of CONCUSSION. I have read and understand the above information on concussion. I will inform the supervising coach, athletic trainer
or team physician immediately if I experience any of these symptoms or witness a teammate with these symptoms. Furthermore, I have been advised of the
dangers of participation for myself and that of my child/ward.
Name of Student-Athlete (printed)
Name of Parent/Guardian (printed)
-I-
_ _/_ _!_ _ _ _ _
Date
__/
Date
Revised 05/14
Concussion and Heat-Related Illness (Page 2 of2)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.
FHSAA Heat-Related Illnesses Information
People suffer heat-related illness when their bodies cannot properly cool themselves by sweating. Sweating is the body's natural air conditioning, but
when a person's body temperature rises rapidly, sweating just isn't enough. Heat-related illnesses can be serious and life threatening. Very high body
temperatures may damage the brain or other vital organs, and can cause disability and even death. Heat-related illnesses and deaths are preventable.
Heat Stroke is the most serious heat-related illness. It happens when the body's temperature rises quickly and the body cannot cool down. Heat Stroke
can cause permanent disability and death.
Heat Exhaustion is a milder type of heat-related illness. It usually develops after a number of days in high temperature weather and not drinking
enough fluids.
Heat Cramps usually affect people who sweat a lot during demanding activity. Sweating reduces the body's salt and moisture and can cause painful
cramps, usually in the abdomen, arms, or legs. Heat cramps may also be a symptom of heat exhaustion.
Who's at Risk?
Those at highest risk include the elderly, the very young, people with mental illness and people with chronic diseases. However, even young and healthy
individuals can succumb to heat if they participate in demanding physical activities during hot weather. Other conditions that can increase your risk for
heat-related illness include obesity, fever, dehydration, poor circulation, sunburn, and prescription drug or alcohol use.
By signing this agreement, the undersigned acknowledges that the information on page I and page 2 have been read and understood.
_ _ _!_ _ _/_ _ __
Date
_____!_ _ _/______
-2-
Date
~
Hillsborough
Coun~
STUDENT MEDIA RElEASE FORM
901 E Kennedy Blvd., Tampa, FL 33602
l'UDLTC SCHOOLS
&r.edb1et' bt i5'r~.adt~'/l
SCHOOL: _ _ _ _
STUDENT IDENTIFICATION NUMBER: _ _ _ __
STUDENT NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.DATE: _ _ _ _ _ __
ADDRESS:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
CITY_ _ _ _ _ _ _ _ _ _ __
____ZIP_ _ _ _ _ __
Dew ParenVGuardian:
Throughout the schpol yea,r, the media may visit your child's school to covt3r specie.) events. Hillsborough
County Public Schools may also Wish to interview, photo~raph or videotape your child for promotional and
educational reasons to utilize in publications, posters. brochures and newl'Miters; on the district web site,
radio station
or Cable TV channel; or other special district events.
Before your chifd ce~n participate in any of the above activities, you must give your permission by signing
and returning this page to your school. Thank you foryour co9peration.
0 I give my permission for my child to be jnterviewed, photographed or videotaped for l1Se in
schooVdistrict publications, school district productions, or for use by the genera,! news-medi,a for print or
broadcast pL!rposes; and for his/her name to be published ln school/district publications and websites,
and in news publications and broadcasts.
0 I do not give my permission for my child to be interviewed, photographed or videotaped for use in
school/district publications, school district productions, or for use by the general news media for print or
broadcast purposes; and for his/her name to be published in school/district publications and websites,
and in news publications and broadcasts.
Parent/Guardian s i g n a t u r e : - - - - - - - - - - - - - - - -
Date: _ _ _._ _ _ __
Parent!Guardian name (please prlot): _ _ _ _ _ _ _---,After you have read and signed the permission form. please return it to your child's school. The form will
be retained at the school, with the student's records.
07/06
_ _ _ c..._ _ _ __
DID YOU ATTEND ANOTHER HIGH SCHOOL
OTHER THAN ALONSO THIS SCHOOL YEAR?
IF YOUR ANSWER IS YES, PLEASE CONTACT
THE ATHLETIC DIRECTOR, YOU ARE
CONSIDERED A TRANSFER STUDENT
TRANSFERING STUDENTS
PLEASE CONTACT
SCOTT HAZLETT AT {813) 356-1525 EXT 226
OR AT THE FOLLOWING E-MAIL:
[email protected]
If you are going into
10th, 11th, or 12th grade, and you did not
attend Alonso High School last school year
Or
You are a transfer student
PLEASE COMPLETE THE FOLLOWING
PAGES (GA4)
Returning and incoming gth grade
students do not have to complete the
GA4
----
- - - - -
~~~
-
Revised 08/12
Affidavit of Compliance with Policy on Athletic Recruiting
For:
Action:
Due date:
Required by:
Purpose:
Verification:
A student who changes attendance to your school at any time during his/her high school career after having begun the 9th grade in another school,
regardless of whether the change occurs during the school year or during the summer period between school years.
Must be read and signed in the presence of a notary public by the student and his/her parent(s)/legal guardian(s).
Must be received by the school BEFORE the student is permitted to represent the school in interscholastic competition.
FHSAA Policy on Athletic Recruiting.
To heighten the awareness of and compliance with rules prohibiting athletic recruiting on the part of student-athletes, their parents/legal guardians, and
member schools.
Page 3 will be checked for completeness. Submission of this form DOES NOT grant eligibility.
TO: STUDENT-ATHLETE
This school that you have chosen to attend is a member of the Florida High School Athletic Association (FHSAA). The FHSAA has rules that prohibit
a member school from making any effort to encourage or entice a student to attend there for athletic purposes. This is called athletic recruiting, and it is
not permitted on the high school level. The Florida Legislature, in fact, has directed the FHSAA to "adopt bylaws that specifically prohibit the recruiting
of students for athletic purposes."
What follows is an explanation of athletic recruiting rules and the penalties for violating them. You and your parent(s) or legal guardian(s) must read
this document and declare that you were not recruited to attend the school for athletic purposes by signing the attached "Affidavit of Compliance with
Policy on Athletic Recruiting" in the presence of a notary public. The signed affidavit must be submitted to the FHSAA Office before the school
can permit you to participate in interscholastic athletic competition.
Please read this information carefully. Sign the affidavit truthfully and honestly. Do not sign the affidavit if you have any questions about these rules
or believe that a violation of these rules may have occurred. Instead, have your school's athletic director contact the FHSAA Office by phone at
352.372.9551 ext. 340 or by e-mail at [email protected]. Violations of athletic recruiting rules can and do result in severe penalties for the school
and the student-athlete. Making an inaccurate statement by signing the affidavit when you j<now you should not will only make these penalties worse
for all involved if violations are later determined to have occurred.
What is athletic recruiting?
\thletic recruiting is any attempt by any employee or athletic department staff member of an FHSAA member school, a representative of the school's
,thletic interests or a third party to pressure, urge or entice a student who does not attend that school to change his/her attendance there for the purpose
,f athletic participation. This occurs when the school employee, athletic department staff member or representative of the school's athletic interests
1akes improper contact with the student or a member ofhis/ber family in an effort to pressure or urge the student to go to that school OR promises,
ffers or gives the student an impermissible benefit in an effort to entice the student to go to that school.
Vho is "a representative of the school's athletic interests?"
ny person, business or organization that participates iu, assists with, and/or promotes a school's athletic program is considered to be a representative
'the school's athletic interests. This includes, but is not limited to:
A student-athlete or other student participant in the athletic program, such as a team manager, student trainer, etc., at that school;
The parents, guardians or other family members of a student-athlete or other student participant in the athletic program at that school;
Relatives of a coach or other members of the athletic department staff at that school;
A volunteer worker in that school or that school's athletic program;
An athletic booster organization of that school;
A member of an athletic booster organization of that school;
A person, business or organization that makes financial or in-kind contributions to the athletic department or to an athletic booster organization
of that school; and
Any other person, business or organization that is otherwise involved in promoting the school's interscholastic athletic program.
-1-
R.
Affidavit of Compliance with the Policies on
Athletic Recruiting & Non-Traditional Student Participation
What is a "third party"?
A "third party" is an independent person, business or organization who may or may not be a representative of the school's athletic interests.
What are the penalties for violations of athletic recruiting rules by a member school?
A member school that violates athletic recruiting rules will be assessed one or more of the following penalties:
A public reprimand;
A financial penalty;
Forfeiture of all contests and awards won in which the student who was athletically recruited or received an impermissible benefit participated or
contributed;
One or more forms of probation (administrative, restrictive or suspension) for one or more years;
Prohibition against participating or coaching in certain competitions, including state playoffs, for one or more years in the sport(s) in which the
violation(s) occurred;
Prohibition against participating in any competitions for one or more years in the sport(s) in which the violation(s) occurred;
Restricted membership for one or more years during which some or all of the school's membership privileges are restricted or denied;
Expulsion from membership in the FHSAA.
What are the penalties for a student who is found to have been athletically recruited or receives an impermissible benefit?
A student who is athletically recruited or receives an impermissible benefit will be ineligible for athletic competition for one or more years at the school
where the violation occurred, and may be declared ineligible for athletic competition at all FHSAA member schools for one or more years.
What are the regulations regarding the participation of "Non-Traditional" students?
A Non-Traditional student is eligible to participate provided:
The student meets the same residency requirements as other students in the school at which he/ she participates; and
The student meets the same standards of acceptance, behavior and performance as required of other students in extracurricular activities; and
The student registers with the school his/her intent to participate in interscholastic athletic competition as a representative of the school, utilizing
the official Association process as approved by the Executive Director, prior to a date not earlier than the first day of practice for the sport(s) in
•
which he/she wishes to participate, as posted on the FHSAA website; and
The student complies with all FHSAA regulations, including eligibility requirements regarding age and limits of eligibility, and local school
regulations during the time of participation; and
The student provides proof of basic medical insurance coverage and both independently secured catastrophic insurance coverage and liability
insurance coverage which names the FHSAA as an insured party in the event the school's insurance provider does not extend coverage to such
students; and
.The student provides his/her own transportation to and from the school; and
The student provides to school authorities all required forms (including, but not limited to, the EL2, EL3, EL3CH and, where applicable, the EL 7,
EL7V, EL12 and EL14) and provisions.
What are the penalties for violations of regulations regarding "Non-Traditional" student by a member school?
Allowing students to participate without properly registering a non-traditional student will subject the school to a monetary penalty.
-2-
Ill
Florida High School Athletic Aksociation
Revised 05113
Affidavit of Compliance with the Policies on
Athletic Recruiting & Non-Traditional Student Participation
The student/parent must complete, obtain all applicable signatures before a notary public and submit this form to the school by a date not .earlier
than the lint day of practice a the lint sport in which the student wishes to participate, as posted on the FHSAA Website. Submission of this
form DOES NOT grant eligibility. The student must be ELIGmLE in all other respects.
We, the undersigned, being sworn, certify that the following statements are true:
I. Student {foil legal n a m e } - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ("THIS STUDENT'),
, 19 _ . a n d who is currently in the {number} _ _ _th grade, now attends or wishes to
who was born on {date)
participate for {school now attending/participating for}
("THIS SCHOOL"),
commencing on { d a t e } - - - - - - - - - - - - - - - ' 20
THIS STUDENT has previously attended/participated for {list all previous secondary schools beginning with the most recent and working back in time}
2. I have read and understand the definition of athletic recruiting, including the explanation of the terms "representatives of the school's athletic interests", "improper
contact" and "impermissible benefit", or I have read and understand the regulations regarding participation as a "Non-Traditional" student.
3. No employee, athletic department staff member, representative of the athletic interests of THIS SCHOOL, any person or organization acting on their behalf or a
third party has bad communication, directly or indirectly, through intermediaries, or otherwise with THIS STUDENT or any member of his/her family in an attempt to
pressure, urge or entice THIS STUDENT to change attendance to THIS SCHOOL for the purpose of participation in interscholastic athletics.
4. No employee, athletic department staff member, representative of the athletic interests of THIS SCHOOL, any person or organization acting on their behalf or a
third party is giving, bas given, bas offered or promised to give, directly or indirectly, through intermediaries, or otherwise any impermissible benefit to THIS STUDENT
or anymember of his/her family for the purpose of participation in interscholastic athletics.
5. If THIS STUDENT bas participated on a non-school team affiliated with THIS SCHOOL prior to attending THIS SCHOOL that THIS STUDENT has signed a
GA6Form.
6. If THIS STUDENT is a "Non-Traditional" student, THIS STUDENT has submitted to THIS SCHOOL the EL2, EL3, EL3CH forms and, where applicable, the
EL7, EL7V, EL12 and EL14 forms prior to a date not earlier than the first day of practice of the first sport in which the student wishes to participate, as posted on
the FHSAA Website..
7. IfTHIS STUDENT is a youth exchange (J-1 and F-1 Visas), international or immigrant student, THIS STUDENT bas submitted to THIS SCHOOL the EL2, EL3,
EL3CH forms and, where applicable, the EL4 Form.
I understand that I am swearing or affirming under oath to the truthfulness of the starements made in this affidavit and that the punishment for knowingly
making a false statement includes fines and/or imprisonment. I further understand that the penalties for knowingly making a false statement may subject THIS
SCHOOL to fines, forfeitures, probations and possible expulsion from membership in the FHSAA, and may subject THIS STUDENT to a loss of athletic eligibility.
FOR STUDENT/PARENT(S)ILEGAL GUARDIAN(S):
STATE OF FLORIDA, COUNTY O F - - - - - - - - - - - Signature of Student
Date
Sworn to or affirmed before me on { d a t e } - - - - - - - - - - - [Notary Seal:)
Printed Name of Student
Signature of Parent/Legal Guardian
Date
Signature of Notary
Printed Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian
Printed Name ofNotary
Date
NOTARY PUBLIC
My commission e x p i r e s : - - - - - - - - - - - - ' 20_ _.
Printed Name of Parent/Legal Guardian
Personally known to me _ _
OR Produced Identification
Type of Identification P r o d u c e d - - - - - - - - - - - - - - -
-3-
created 06/15
Sudden Cardiac Arrest and Concussion
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.
Sudden Cardiac Arrest
Sudden cardiac arrest is a leading cause of sports-related death. This policy provides procedures for educational requirements of all
paid coaches and recommends added training. Sudden cardiac arrest is a condition in which the heart suddenly and unexpectedly stops
beating. If this happens, blood stops flowing to the brain and other vital organs. SCA can cause death if it's not treated within minutes.
Symptoms of sudden cardiac arrest include. but not limited to: sudden collapse, no pulse, no breathing.
Warning signs associated with sudden cardiac arrest include: fainting during exerCise or activity, shortness of breath, racing heart rate,
dizziness, chest pains, extreme fatigue.
It is strongly recommended all coaches, whether paid or volunteer, are regularly trained in CPR and the use of an AED. Training is
encouraged through agencies that provide hands-on training and offer certificates that include an expiration date.
Automatic external defibrillators (AEDs) are required at all FHSAA State Series games, tournaments and meets. The FHSAA also
strongly recommends that they be available at all preseason and regular season events as well along with coaches/individuals trained in
CPR.
What to do if your student-athlete collapses:
1.
Call911
2.
Send for an AED
3.
Begin compressions
Concussions
Concussion is a brain injury. Concussions, as well as all other head injuries, are serious. They can be caused by a bump, a twist of the
head, sudden deceleration or acceleration, a blow or jolt to the head, or by a blow to another part of the body with force transmitted to
the head. You can't see a concussion, and more than 90% of all 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. All concussions are potentially serious and, if
not managed properly, may result in complications including brain damage and, in rare cases, even death. Even a "ding" or a bump on
the head can be serious. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself,
your child should be immediately removed from play, evaluated by a medical professional and cleared by a medical doctor.
I acknowledge the annual requirement for my child/ward to view "Concussion in Sports-What You Need to Know" at www.nfhsleam.
com. As well, I acknowledge optional educational opportunities in cardiac arrest at www.sportsafetyintemational.org. Please go to
www.fhsaa.org/departments/health for further instructions to view the courses.
I have been advised of the dangers of participation for myself and that of my child/ward.
_ _!_ _!_ __
Date
_ _!_ _!_ __
Date
---Beginning with the 2016-2017 school year, the EL3CH will be revised to include the EL3CH addendum language-
----------
---·---
Dear Parents,
If you permit your child's unofficial transcripts to be shared with a
college recruiter for the purpose of athletics or academics, please sign
the form below. If you do not permit the distribution of this
information, please check the uNo" Box.
Yes, I permit my child's unofficial transcripts to be given to
recruiters
No, I do not permit my child's unofficial transcripts to be
given to recruiters.
Student Name
Parent Name:
Parent Signature
-----
---

real link - Alonso High School

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