SCHOOL DISTRICT OF INDIAN RIVER COUNTY PARENT AND PLAYER AGREEMENT, PERMISSION, AND RELEASE Vero Beach High School, Academic Year 2021-2022 (Use blacblue pen only) S p ort ( s ) ___________fs_ _ S d ent I.D. # ______ _ Grade __ _ (9th graders must include Birth Certificate) School attended last year _ ________ City/State __ _ __ _ __ _ Currently Enrolled at ____ __ __ __ __ _ __ ___ __ _ _ _ Name of Student Athlete (Please Print) __________________ _ Home Address ___________________ _ Z i p Code___ _ _ Home Phone Cell Phone Date of Birth ------ ------ -------- Name of Parent/Guardian ------------------------- Work Phone Parent e-mail address -------- ------------- I/We, the undersigned parent(s) of the above named student (Student Athlete), acknowledge that competing in interscholastic athletics in the School District oflndian River County is entirely voluntary and subject to the eligibility les and regulations of the Florida High School Athletic Association. I/We rther acknowledge that we have not violated and i n the ture will abide by all the rules set down by the School District of Indian River County, the Florida High School Athletic Association and the school in which the Student Athlete is enrolled. Student Athletes and parents/guardians of Student Athletes should have a thorough understanding of the responsibilities and implications of participating in a volunta extracurricular activity. For this reason, each Student Athlete in the School District of Indian River County and his/her parent(s)/guardian(s), shall read, and sign this agreement, peission, and release prior to the Student Athlete being allowed to participate in any rm of athletic practice or contests. I/We, the undersigned Parent(s)/Guardian(s) of the above Student Athlete acknowledge the llowing: l. Recognize that in any athletic practice or competition there is the possibility of serious injury or possibly death to a participant, and that such risks have been explained lly. Waive any and all claims, actions and demands against the School Board, the Association, and their respective officers, agents and employees, r any damage, injury, loss, liability, or expense whatsoever sustained by the Student Athlete as a result of the Student Athlete participating in athletic activities or travel incidental to such activities. 2. Consent to the Student Athlete engaging in athletics as a representative of his/her School.
Transcript
SCHOOL DISTRICT OF INDIAN RIVER COUNTY
PARENT AND PLAYER AGREEMENT, PERMISSION, AND RELEASE Vero Beach High School, Academic Year 2021-2022
(Use black/blue pen only)
Sport(s) ___________fs_ _
Student I.D. # _______ Grade ___ (9th graders must include Birth Certificate)
School attended last year _________ City/State ________ _
Currently Enrolled at ______________________ _
Name of Student Athlete (Please Print) __________________ _
Home Address ____________________ Zip Code ____ _
Home Phone Cell Phone Date of Birth ------ ------ --------
Name of Parent/Guardian -------------------------
Work Phone Parent e-mail address -------- -------------
I/We, the undersigned parent(s) of the above named student (Student Athlete), acknowledge that competing in interscholastic athletics in the School District oflndian River County is entirely voluntary and subject to the eligibility rules and regulations of the Florida High School Athletic Association. I/We further acknowledge that we have not violated and in the future will abide by all the rules set down by the School District of Indian River County, the Florida High School Athletic Association and the school in which the Student Athlete is enrolled.
Student Athletes and parents/guardians of Student Athletes should have a thorough understanding of the responsibilities and implications of participating in a voluntary extracurricular activity. For this reason, each Student Athlete in the School District of Indian River County and his/her parent(s)/guardian(s), shall read, and sign this agreement, permission, and release prior to the Student Athlete being allowed to participate in any form of athletic practice or contests.
I/We, the undersigned Parent(s)/Guardian(s) of the above Student Athlete acknowledge the following:
l. Recognize that in any athletic practice or competition there is the possibility of serious injuryor possibly death to a participant, and that such risks have been explained fully. Waive any andall claims, actions and demands against the School Board, the Association, and their respectiveofficers, agents and employees, for any damage, injury, loss, liability, or expense whatsoeversustained by the Student Athlete as a result of the Student Athlete participating in athleticactivities or travel incidental to such activities.
2. Consent to the Student Athlete engaging in athletics as a representative of his/her School.
3. Understand that athletic insurance provided by the District is excess of any coverage provided by the family. There may be instances where some portions of a bill will not be paid at 100% by the insurance, and that any such unpaid balance is the responsibility of the student and/or family.
4. Understand that only a supplementary insurance premium for the Student Athlete is to be paid from the School Board funds. Acknowledge that consent and insurance coverage will extend into any and all summer athletic programs/conditioning.
5. Understand that in the event of an accident or injury, only District required accident fonns will be completed by School officials, and that all claims under any applicable insurance policy for injuries received while participating in athletic activities or travel incidental to such activities shall be processed by the Parent(s)/Guardian(s) or the Student Athlete through the company agent handling the Student Athlete's insurance policy, and not through School officials.
6. Accept financial responsibility for any athletic equipment lost by the Student Athlete.
7. Authorize the School to transport the Student Athlete and to obtain, through a physician of the School's choice, any emergency medical care that may become reasonably necessary for the student in the course of athletic activities or travel incidental to such activities; and agree that the expenses for such transportation and treatment shall not be borne by the School Board or its employees.
8. Accept full responsibility and grant permission for the Student Athlete to travel to any approved related school activity.
9. Acknowledge and represent that the Student Athlete is in good health and physically able to compete in athletic activities and has had no past illness or injury that would prevent him/her from participating in such activities.
10. Acknowledge that consent and insurance coverage will extend into any and all summer athletic programs/conditioning.
11.Due to budget reductions, the School District of Indian River County has implemented a "Pay to Participate" fee of $65.00 for all student athletes at the high school level. The fee will be a one time, per year, non-refundable payment requirement for any student wishing to participate in athletics at his/her respective high school. Funds generated from this fee will be used to support the athletic program at each high school. This participation fee has nothing to do with playing time, as the privilege of participation in high school sports is determined by the head coach of each sport; it is this coach who decides who plays and how much playing time he/she receives. Students are encouraged to participate in multiple sports throughout the school year. The "Pay to Participate" fee covers all sports.
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12. Acknowledge that consent and drug testing policy will extend into any and all summer athletic programs/conditioning.
I/We the undersigned parent(s)/guardian(s) and Student Athlete acknowledge having received an adequate opportunity to review this agreement, permission, and release; to ask questions of the Principal and/or coach; and to consult with any other advisor of my/our choice prior to signing.
Date:
Mother or Guardian's Signature
Print Name
Father or Guardian's Signature
Print Name
STUDENT ATHLETE ACKNOWLEDGEMENT AND AGREEMENT
I acknowledge that I have read and understand the above Parent and Player Agreement, Permission and Release; that I agree to its tenns; that I will comply with all School Board, Association, and other rules applicable to athletic activities and travel incidental to such activities; and that I will comply with all safety rules and instructions provided to me for such sport, competition, practice, or other athletic activity in which I engage.
Dated this ___ day of __________ _, 20 __ .
Student Athlete Signature
Print Name
3
SCHOOL DISTRICT OF INDIAN RIVER COUNTY
ATHLETIC, CHEERLEADING AND MARCHING BAND
ANTI-HAZING EDUCATION ACKNOWLEDGEMENT
The School District of Indian River County (SDIRC) Board Rule 5.37 prohibits bullying and hazing. Hazing is defined as recklessly or intentionally endangering the mental or physical safety or health of any student for purposes including, but not limited to, initiation or admission into or affiliation with any organization operating under the sanction of a high school and in accordance with section 1006.63, F. S.
Hazing is prohibited under the SDIRC Code of Student Conduct and discipline of a student engaging in hazing shall be carried out consistent with the SDIRC Code of Studenl Conduct.
I am aware the video: "Dying to Belong", is available online http://www.indianriverschools.org. The district home page will appear, click on the left side on school links, look on the bottom right-hand side of the page for hazing video. I understand that hazing of any type (mental, verbal, and physical acts) is not allowed on this campus or in relation to any athletic, band or cheerleading activity in which I am participating. I further understand that it is my responsibility to report any acts of hazing that I become aware of to a coach or administrator on campus.
By signing this acknowledgement, I agree to uphold this SDIRC policy for the entire academic school year and understand that any violation will result in my immediate suspension from the activity in which I am participating, and further disciplinary action as outlined in SDIRC policy, procedure and Student Code of Conduct.
Student Participant Signature Date
Parent/Guardian Signature Date
August 20, 2008 gjk
CONSENT FORM
RANDOM STUDENT DRUG TESTING FOR INTERSCHOLASTIC EXTRACURRICULAR COMPETITIVE ACTIVITY PARTICIPANTS.
THIS FORM MUST BE COMPLETED AND SIGNED BY EACH HIGH SCHOOL STUDENT PARTICPATING IN INTERSCHOLASTIC EXTRACURRICULAR COMPETITIVE ACTIVITES AND HIS/HER PARENT OR LEGAL GUARDIAN.
ELIGIBILITY FOR PARTICIPATION WILL NOT BE GRANTED UNTIL THIS FORM HAS BEEN SIGNED AND RETURNED TO THE STUDENT'S SCHOOL.
By signing this form, I affirm that I have read the School Board of Indian River County's Random Student Drug Testing for Interscholastic Extracurricular Competitive Activity Participants policy and I agree to comply with the conditions in the policy in order for my child to participate in interscholastic extracurricular competitive activities.
I affirm that my child and I have reviewed and understand the procedures for the testing program attached to this form and understand the test procedures, penalties for a positive test result and my child's right to challenge a positive finding.
I agree to allow the Random Student Drug Testing Coordinator to test my child if he/she is randomly selected in order to maintain eligible for participation in any interscholastic extracurricular competitive activities.
I further consent to the release of any drug test results taken from my child to the school principal, coordinator and testing lab MRO. In the event my child is a student athlete in an FHSAA sanctioned, recognized or club activity and receives a positive drug test for a schedule 3 narcotic, I understand the positive drug test will be reported to the FHSAA, but not my child's name.
I understand that test results will not be made a part pf my child's permanent school record.
!"Jame of Student (PRINT} __________________________ _
Signature of Student·--------=--=------------------------"
Date --------=-----' Name of Parent/Guardian _____________ ....;;. ________ =--------'
Signature of Parent. ___ ....;._ _____ ......:;. ___________________ ...;
Date ________ _
Home address ___________ _.:.;,___City, __ __;=--------.....:::=--=---...: Zip code _______ ...;
Please be advised ..... if you have a primary insurance carrier, the School Board is a supplementary insurance only.
Full Excess: Means benefits are payable for covered expenses that are not recoverable from another Plan Providing Medical Expense Benefits to the applicable maximum. If the Insured is not covered by another Plan providing medical expense benefits, the excess provision shall not apply, and benefits are payable to the limits described less the $200.00 deductible before reasonable and customary charges are paid.
Plan Providing Medical Expense Benefits: Means any group type policy, contract, or other arrangement for benefits or services for medical or dental care treatment.
Basis of Benefits: Expenses which are incurred within the Maximum Incurred Period. The first treatment must be received within 90 days after the date of the injury.
Usual & Reasonable: Means the fees and prices charged in the area where the services are offered. The services and supplies used are those that are usually required for similar injuries and do not include charges that would have been made if no insurance were in force.
Injury: Means a bodily injury caused by an accident, which occurs directly and independently of all other causes while the insured is covered under the policy.
Deductible: Before usual and customary charges are paid a $200.00 deductible is applied to a family with no medical coverage.
Benefit and Claim Correspondence or Questions: Gerber Life Insurance
90% Attendance Policy Requirement Vero Beach High School is committed lo providing a safe and secure environment conducive to learning. Students must be in attendance and in their classes in order for them to receive classroom instruction from their teacher. This will facilitate learning and increase student achievement.
Vero Beach High School has adopted a 90% Attendance Polley for unexcused absences reviewed/approved and vetted by the VBHS School Advisory Council, which means that students must attend 90% of their classes in order to participate in sports, extra-curricular activities, clubs and/or privileges (including parking). Only unexcused absences affect the student's attendance percentage for this policy. Students who allow their attendance to fall below 90% due to unexcused absences as calculated by the total number of class periods they are enrolled In and expected to attend, will be subject to all of the following In the pollcy ...
The 90% Attendance Policy will be monitored by the total number of classes a student is scheduled to attend. NI students must attend 90% of their classes avoiding unexcused absences that will lower their attendance percentage. Monitoring will begin on the 30111 day of each semester. Scheduled monitoring will take place as often as every ten days of the semester, after the first thirty days; random monitoring may be done al any time. Compliance can be achieved on any single day.
Students who fall below the 90% Attendance Policy for unexcused absences will not be pennltted to participate in any of the following sports, extra-curricular activities, or privileges listed, as specmed. Other school related activities may be added to this list by the administration ofVBHS.
► Students m participate in practices, rehearsals, etc. in preparation for athletic contests, perfo1111ances, clubs and extra-curricular events even !hough he/she is below the 90% attendance requirement due to unexcused absences.
► Students .!!!iY.!!21 play, participate, r.ompele or perfonn In interscholastic alhlellc contests (games, matches, etc.) perfonnances (r.oncerts, plays, etc.) and extra-curricular events (Math Club, FBLA, dub competitions etc.) if he or she Is below !he 90% attendance pollcy requirement due to unexcused absences.
► Playing, participating, or perfonning privileges are earned or restored when 1he student meets the 90% Attendance Policy requirement and does not have below 90% attendance by unexcused absences as calculated by the total number of class periods a student Is scheduled.
PARTICIPATION AS A SPECTATOR and for SPECIAL TICKETED EVENTS (90% Attendance Policy Requirement)
► Students m attend athletic events and performances as a spectator for !he price of admission even though he/she is below !he 90% Attendance Polley Requirement.
► Students l!!il.!!91 pu1thase tickets for any dances, homecoming events, prom, Grad Bash, etc. if !he student Is below the 90% Attendance Polley Requirement. The privilege to pulthase these tickets Is earned or restored when the student meets the 90% Attendance Policy Requirement and does not have below 90% attendance by unexcused absences, as calculated by the total number of class periods a student ls scheduled.
► Students purchasing more than one ticket for dances, homecoming events, prom, etc. must provide !he name of !he guest lo enable confi1111alion ol !he guest's compliance with !he 90% Attendance Polley Requirement for all those ticketed. Tickets will not be sold for students who are below !he requirement.
► Students .!!!iY.!!21 attend field trips if !hey are below the 90% Attendance Polley Requirement The privilege lo attend field trips is earned or restored when the student meets the 90% Attendance Polley Requirement
Students who have met the requirements to purchase a parking sticker must also meet the 90% Attendance Policy Requirement to maintain parking privileges. Parking privileges will be suspended for students wl'to fall below the 90% Attendance Policy Requirement due to unexcused absences. Student's vehicles are not permitted on campus during school hours while privileges are suspended. Nso, no vehicle may park in that student's parking space. Parking privileges will be earned or restored when the student meets the 90% Unexcused Attendance Policy Requirement. School Security and school adm:nistration will monitor the parking privileges of all student drivers.
► Students must meet the 90% Attendance Policy Requirement for the current school year to purchase a parking sticker/permit for the following school, beginning July/August of 2017 and beyond.
Two parking permit suspensions may result in a loss of parking privileges for the remainder of school year. This will be decided on a case by case basis by school administration. ALL of the following are subject to adherence for the 90% Attendance Policy Requirement.
• Mock DUI participation • extra-curricular activities
• field trips
• concerts
• plays
• performances
• National Honor Society
• Scholars Ceremony
• parking permits • Pep Rally participation
.. Other school related activities may be added to this lisl al the sole discretion of the VBHS administration. ► At any time monitoring for 90% compliance has been completed by school administration and a student found lo be out of
compliance, the student, the students coach, sponsor, and/or teacher will be notified about the non-compliance and the student immediately become ineligible to play, participate, compete or perform In interscholastic athletic contests (games, matches, etc.) performances {concerts, plays, etc.) and extra-curricular events (Math Club. FBLA, club competitions etc.) as ouUines in the above policy conditions. Returning to compliance is then the student's responsibility to establish with good attendance, monitor the' r standing, worl< with administration, their coach, sponsor/teacher, retum to eligibility on the attendance report and return to lull participation.
To be used for the 2021 2022 school year -
Florida High School Athletic Association Revised 06/21
Consent and Release from Liability Certificate (Page 1 of4) This completed fonn must be kepi on file by the school This fonn is vol id for 365 calendar days from lhc date oflhc most recent s1gn:11ure This form Is non-transrcrablc; 11 chHEc ohchools durlnE lhe validity period oflhls form will require this fonn lo be rc-submllled,
School: ___________________ School District (irapplicablc): ___________ _
Part 1. Student Acknowledgement and Release (to be signed by s1udcn1111 the bottom) I have read 1hc (condensed) FHSAA Ehg1bil ity Rules printed on Page 4 of this "Consent an<.! Release Certificole" and know of no reason why l om not chg1ble to represent my school in interscholastic athletic competition. If accepted 115 11 representative, I agree lo follow the rules of my school Dnd FHSAA and to :ibide by their decisions. I know that athletic partic1p:11ion ,s II privilege. I know of the risks involved in athletic p:irt1c1palion, understand that serious injury, including the polentiol for II concussion, and even death, is possible in such participation, 11nd choose 10 accept such risks I voluntarily accept :iny and all responsibility for my own safety Dnd welfare wlule part1cipa1ing in athletics, with full understanding oflhc risks involved Should I be 18 years of age or older, or should I be emanc,potcd from my parcnt(s)/guardian(s), I hereby release and hold hannlcss my school, the schools against which ii competes, the school district, the contest officials and FHSAA of any and all responsibility and liability for any injury or claim resulting from such nthlctic participation and ngrce to take no legal action against FHSAA because of any accident or mishap involving my athletic participation. I hereby authorize the use or disclosure of my individually idcn1i6:iblc health information should trentment for illness or mJury become necessary I hereby grant lo FHSAA the ri11ht to review all records relevant 10 my othleuc eligibility including, but not limited to, my records relating to enrollment and 111tendancc, ilcadcmic s1andmg, aac, discipline, finances, residence and physical fitness I hereby grant the released parties the right to photograph and/or videota~ me and further lo use my name, face, likeness. voice and appearance in connection with cxh1b1t1ons, publicity, advertising. promotional and commercial miltcrials w11hout reservation or hmitallon. The released parties. however. ore under no obligation to exercise said rights herein I understand that lhe oulhorizalions and rights granted hercm arc voluntary and that I may revoke any or all of them at any time by submitting said revocation in writing 10 my school By doing so. however, I understand that I wtll no longer be eligible for participation in interscholastic athletics.
Part 2. Parental/Guardian Consent, Acknowledgement and Release (to be camplcted and signed by II p1m:n1(s)/gu11rdlun(s) 111 the bottom; where divorced or separ,lled, pnrcnt/guardian with lcg11I custody must si1n.) A. I hereby give consent for my child/ward to panic1patc in 11ny FHSAA recognized or sanctioned sport EXCEPT for the following sport(s):
List sport(s) exceptio11s ltere B I undcrSUlnd that participation m:iy nccessillltc an early dismissal from classes C I know of, and acknowledge thal my child/ward knows of. the risks involved in interscholastic othlct1c participation. understand lhal serious inJurv, and even death, is possible in such part1c1pat1on and choose to accept any and oil respons1b1hty for his/her safely and welfare while participating in olhleucs With ful( underSlllnding of the risks involved. I 11:lease and hold harmless my child·stward's school. the schools against which II competes, the school district, the contest offic111ls and FHSAA of any and all responsibility and habihly for any injury or claim resulting from such athlcllc participation and agree to lake no legal acllon against the FliSAA because of any accident or mishap involving lhe athletic participation of my child/ward As required by F.S. 1014.06( I), I specifically authorize healthcare services to be provided for my ch1ld/ward by a healthcare J>fllClllioner, as defined in F.S. 4S6.001, or someone under lhc direct supervision of o healthcare praclllloner, should the need arise for such treatment, while my child/ward is under the supervision of the school I further hcrc:by authorize the use or disclosure ofmy child's/ward's md1v1dually 1dcnt1fiablc health information should treatment for illness or injury become necessa,y. I consent to the disclosure 10 the FHSAA. upon its request, of all records relevant 10 my child/ward's othlctlc ehg1b1li1y including, but not limited lo, records relating to enrollment and attendDnCe, academic slanding, age. discipline. finances. residence and physical fitness. I grant lhe released port1es the nght to photograph and/or video1ape my child/ward and further to use said child's/ward's nan1c, face, likeness. voice and appearance in connection with exhibitions, publiclly, advertising, promollonul and commercial materials without reservation or limillltion. The released parties, however, arc under no obligation to exercise said rights heretn D I nm P»:Prs o(Jhe ootcoJ,ol danc~r of concussions pnd/or b£Ad und neck 1munes jn jnJcrscholps11c pthlctics I nlso hove knowledge nhout the risk ofcont1numg to port1c1pate once such an injury is sustained without proper medical clearance READ THIS FORM COMPLETELY AND CAREFULLY, you ARE AGREEING JO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY, you ARE AGREEING THAT, EVEN IF MY CHU,,D'S/WARD'S SCHOOL, THE SCHOOLS AGAINST WHICH II COMPETES, THE SCHOOL DISTRICT. THE CONTEST OFFICIALS AND FHSAA USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED, BY SIGNING THIS FORM you ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO RECOVER FROM MY CHILD'S/WARD'S SCHOOL. THE SCHOOLS AGAINST WHICH IT COMPETES. THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKSTHATAREANATURALPARTOFTHEACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND MY CHILD'S/WARD'S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM,
E. I aeccc 1h11 in the event we/I nuauc litigation seeking ioiuurlivc rrlir!or other legal as:lion imoactinr mY shUd <individu■IIY) or mx child', team o■rtidpa• Jjop Ip DJSAA !liUC min SPDIWS, such erJion sbaU ht filed jn th• Alubun County, Flpridg. Ch:ruit C0urt, F. I understand that the au1hor1za11ons and rights granted herein arc voluntary 11nd thnt I may revoke any or all of them al any time by submilling said revocation in writing 10 my sthool. By doing so, however, I understand that my child/ward will no longer be eligible for part1c1p111Jon in mterscholaslic alhleucs G. Please check the approprjate boxCes}· __ My child/ward is covered under our family health insurance ph111, which has hmits of not less than $25,000
Company: ________________________ Polley Number: ____________ _ __ My child/ward 1s covered by his/her school's acuvillcs medical base insurance plan.
__ I hove purchased supplemcnllll footooll insurance through my child's/ward's school I HAYE READ THIS CAREFULL\' AND KNOW IT CONTAINS A RELEASE (Only one parent/guardian signature ls required)
Name of PorentfGll3l'd1an (pnnted) Signature of PorcntfG1131'd1an Dale
I Name of Parent/Guardian (prmted) Signature of Parent/Guardian ~
I HAYE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (student must sign)
Name of Student (printed) Signature of Student
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To be used for the 2021 2022 school year -Revised 06/21
•
-- Florida High School Athletic Association
Consent and Release from Liability Certificate for Concussions (Page 2 of 4) This completed form must be kepl on lite by the school. This form is valid for 36S calendar dnys from the d:itc of the most recent signature
School: ___________________ School District (Ir applicable): ___________ _
Concussion Information Concussion is a brain injury Concussions, ns well ns oil other head injuries, arc serious. They con be caused by II bump, a twist of 1he head, sudden dccclcmt1on or acceleration, o blow or jolt to the head, or by II blow to 11no1her p:irt of lhc body with force transmitted to the he:id. You c11n "t sec o concussion, and more than 90% of oil conc11SSions occur without loss of consciousness. Signs ond symptoms of concussion may show up right nfter the inJ ury or con toke hours or days lo fully appear. All concussions ore potentially serious and, if nol ma1111ged properly, may result in complications including brain damage and, in r11re cases, even death Even 11 ~ding'" or o bump on the hcnd can be serious. If your child reports nny symptoms of concussion. or 1f you notice the symptoms or signs of concussion yourself. your child should be immedi11tcly removed from piny, evaluated by o medical professional and cleared by a mcdicnl doctor.
Sign!i and Symplom!l or u ConcU~!iinn: Concussion symptoms may appear immediately after the injury or can toke several days to appear Studies have shown that 11 takes on average 10-14 days or longer for symptoms to resolve and, in rare cases or if the athlete hns sustained multiple concussions, the symptoms can be prolonged Signs and symptoms of concussion can include. (not all-inclusive)
• Vacant store or seeing stars • Lack of aw:ireness of surroundings • Emotions out of proportion lo circumstances (inappropriate crying or anger) • Headache or pcrsistcnl headache. nausea. vomiting • Altered vision • Sensitivity to light or noise • Delayed verbal and motor responses • Disoricnllltion, slurred or incoherent speech • Dizziness, including lighl-headcdness, vertigo(spinning) or loss of equilibrium (being off b:lloncc or swimming sensation) • Decreased coordination, reaction time • Confusion and inability to focus atlenlion • Memory loss • Sudden chance in academic performance or drop in grades • Irritability, depression, anxiety. sleep distwbances, easy fa1igability • In rare cases, loss of consciousness
DANGERS iryour child continurs to play with a concussinn or returns tnn soon; Athletes wilh signs and symptoms of concussion should be removed from ac11v1ty (play or practice) 1mmcdiotcly Continuing to play with the signs and symptoms ofa concussion lc:ives the young othlclc especially vulnerable to sustaining another concussion Athletes who sustain a second concussion before the symptoms of the first concussion have resolved 1md the brain hns had a chance lo heal ore al risk for prolonged concussion symptoms, pem1anenl disability and even death (called "Second Impact Syndrome"' where the brain swells unconlroltably}. There is also evidence th:it multiple concussions can lead 10 long•lerrn symploms. Including early dementia
Steps to take if you !iU!ipCct your child h11~ Juffcntl II concuJsion: Any othlcle suspected of suffering a concussion should be removed from the activity immediately No 11thlctc may return to activity ofter an apparent head injury or concussion, regardless of how mrld ii seems or how quickly symptoms clear, without written medical clearance from on appropriate health-care profcs5ional (AHCP), In Florida, an appropriate health-care professional (MICP) is defined ns either a licensed physician (MD, ns per Chapter 458, Flond:i Statutes), o liceMCd o51copalhic physician (00, ns per Chapter 4S9, Florida Statutes}. Close observation of the athlete should continue for several hours You should al~ seek medical care ond inform your child"s coach 1f you think thal your child may have a concussion. Remember. it's better to miss one game than to have your hfc changed forever When in doubt,~•• them out
Return to play or practice; Following phys1c1an evaluallon, the ntur11 '" actMty prr,c~ss requires the athlete lo be completely symptom free, .ifter which lime 1hcy would complclc: a step-wise protocol undc:r the supervision of II liccnsed athletic trainer, coach or medical professional and then, receive wriucn medical clc:ar.incc of an AHCP
For current and up-to-date information on concuuioM, v1s1t http.//wwwcdc.gov/concussionmyouthspons/ or hllp //wwwseemgstarsfoundalmn org
Slatemenl or Sludent Athlete Resnonsibililv Parents and students should be aware or preliminary evidence I hat suggests n:pul concussions, and even hils that do not cause • symptomatlc concussion, may lead to abnormal brain changes which can only be seen on autopsy (known IIS Chronic Traumatic Encepbalopatl1y (CTE)). There hi\ e been case reports suggesting the dc,·clopmenl of Parkinson's-like symptoms, Amyotroplc L:iter11I Sclerosis (ALS), sn·en: traumatic brain injury, depression, and long term memory issues that may be related to concussion history, Further resurcb on this topic is oeeded before any conclusions can be drawn.
I acknowledge the annual requirement form)' child/ward to view "Concussion In Sports" at www.nfhslearn.com. I accept responsibility for reporting all injuries and illnusu to my parents, team doctor, athletic trainer, or coaches associated 'ft'itb my sport including any signs and symptoms of CONCUSSION. have read and understand the above information on concussion. I will inform the supervisinit coach, athletic trainer or learn physician immediately if I uperience any of lhesc symptoms or witness a teammate with these symptoms. Furthermore, I l1ave been advised of the danitcrs of partidpDtion for myself and I hat of my child/ward.
Name of Student-Athlete (printed) Signature of Student-Athlete Dale
Name of Parent/Guardian (printed) Signature of Parent/Guardian D:ue
Name of Parent/Guardian (prm1cd) S1gna1urc of Parent/Guardian Date
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To be used for the 2021 2022 school year -
Florida High School Athletic Association Revised 06/21 Consent and Release from Liability Certificate for Sudden Cardiac Arrest and Heat-Related Illness (Page 3 or 4) This completed fonn must be kept on file: by the school This fonn is valid for 365 calendlll' days from the date of the most recent sigmllurc
School: ____________________ School District (if applinble1: ____________ _
Sudden Cardiac Arrest Information
Sudden cardiac arrest (SCA) is II leading cause of sports-related death. This policy provides procedures for c:duc11tional requirements of all patd coochcs and recommends added training. Sudden cardiac arrest is II condition in which the heart suddenly and unexpectedly stops beating. If this happens, blood slops flowing to the brain und other vital organs. SCA can c:iuse dcnth if it's not treated within nunutes
S1·mploms of SCA Include, bul nol llmllcd lo: sudden col111psc, no pulse, no bruthini:,
Warning signs associated wilh SCA Include: fainting durin&: exercise or aclivily, shortness or bruth, racing hurt rale, dizziness, chcsl pains, nlreme faliguc:.
II is strongly recommended that all coaches, whether paid or volunteer, be regularly trained in cardiopulmonnry resuscit.illon (CPR) nnd the use of an nulomated extc:r• nal defibrillator (AED) Training is encouraged through agencies that provide: hands-on training and offer ccrtificates that include nn expiration dale: Beginning June 1, 2021, a school employee: or volunteer wnh current Ira ming in CPR and the use: of an AED must be present al each 11thlc:11c c:vc:nt d1mng ,md outside of the school year. including practices, workouts and conditioning sessions
The: AED must be in a clearly marked and publicized location for each othleuc contest, practice:, workout or conditioning sess10n, including those: conducted outside of the: school year
Whal lo do If your s1udcnl-11thle1c collapses: I, Call 911 2, Send for ■n AED 3. Begin compressions
FHSAA Heat-Related Illnesses Information
People suffer heat-related illness when their bodies cnnnol properly cool themselves by sweating. Swc:uting is the: body's notural air conditioning. but when o person's body temperature rises rapidly, sweating just 1sn 't c:nough. Hc:111-related 1llnc:sscs can be: serious and life threatening. Very high body temperatures may damage the brain or other vital organs, nnd can cause d1sab1lity and even death. Heal•relatc:d illnesses and deaths arc preventable
Heal Stroke is the most serious hcal•relatc:d illness It happens when the: body's lempc:ralurc rises quickly and the body c.innot cool down Heal Stroke can cause permanent disability and death.
Ilea! Ellhauslion is a milder type of heat-related illness. It usually develops after a number of days in high tc:mpcrnturc weather nnd not drinking enough ftu1ds
llcal Cramps usually affect people who sweat a lot during demanding oc1ivi1y. Sweating reduces the body's salt and moisture and can cau5C painful cramps, usually in the abdomen, anns, or legs. Heat cramps may nlso be II symptom of heat exhausllon
Who's al Risk? Those at highest risk include the c:lderly, the very young. people with mental illness and people with chronic diseases. However. even young and healthy individuals can succumb to heal iflhcy participate: in demanding physical activities during hot weather Other conditions that can increase your risk for heat-related illness include obcsny, fever, dehydration, poor cuculation, sunbum, and prescription drug or nlcohol use.
By signing Ibis 1grecmenl, I atknowltdgc lht annual rcqulrunenl for my child/ward lo view bolh lhe "Sudden Cardiu Arrest" and "llcal lllnus Prcvcnlion" counts al www.nfhslurn.com. I acknowledge lhal lhe informalion un Sudden Cardiac Arrtsl and Jlenl•Relaltd Illness have been rud and unduslood, I have been advised of the dangers or parlidpalion for myself and thal or my child/ward.
Name of Student-Athlete: (printed) S1gnalut'C of Student-Athlete
I / ____ _ ~---
I I Name of P~nt/Gulll'd111n (printed) Signature of Parc:nt/GUlll'dian ~--------
Name of Parent/Guardian (printed) Signature of Parent/Guardian I I ~--------
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To be used for the 2021 2022 school year -•
Florida High School Athletic Association Revised 06/21
Consent and Release from Liability Certificate (Page 4 or 4)
This comple1ed form must be kept on file by the school This form 1s valid for 365 4;'alcndar days from lhc date of the most rc:cc:nl s1gna1ure
Attention Student and Parent(s)/Guardian(s) Your school is a member of the Florida High School Athletic Association (FHSAA) and follows established rules. To be eligible to represent your school in interscholastic athletics, in an FHSAA recognized and/or sanctioned sport, the student:
1. This form Is non-transferable; a separate fonn must be completed for each different school at which a student participates.
2. Must be regularly enrolled and in regular attendance at your schooL If the student is ll home education sludent, ll charter school sludenl, a speciaUllllernative school student, non-member privale school student or Florida Virtual School Full-time Public Program student, the student must declare in writing his/her intent to participate in athlelics lo the school at which the student is permitted to pllrticipate. Home education students and students attending non-member private schools must be appro\·cd lhrough the use of a separate fonn prior to any participation. (FHSAA Bylaw 9.2, Policy 16 and Administrative Procedure 1.8)
3. Must attend school within lhe first 10 days of the beginning of each semester to be eligible during that semester. (FHSAA Bylaw 9.2)
4. Must maintnin at lenst a cumul11tivc 2.0 grade point average on a 4.0 unweighted scale prior to the semester in which the student wishes to participate. This GPA must include all courses taken since the student entered high school. A sixth, seventh or eighth grade student must have earned at least a 2.0 grade point average on 4.0 unweighted scale the previous semester. (FHSAA Bylaw 9.4)
5. Must not have gradu11ted from 11ny high school or its equivalent. {FHSAA Bylaw 9.4)
6. Must nol have enrolled in the ninth grade for the first time more than eight semesters ago. lfthe student is n sixth, seventh or eighth grade student, the student must not participate if repeating that grade. (FHSAA Bylaw 9.S)
7. Must not tum 19 before ~uly !!! lo porticipate at the high school level; must not tum 16 prior to Seplembcr 1st to participate at the junior high level; and must not tum IS prior to September 1st to participate at the middle school level, otherwise the student becomes pennanently ineligibile. (FHSAA Bylaw 9.6)
8. Must undergo a pre-participation physical evaluation and be certified 11s being physically fit for participation in interscholastic athletics on II fonn (EL2). (FI-ISAA Bylaw 9.7)
9. Must have signed pennission to pnrticipale from the student's parcnt(s)llegal guardinn(s) on a fonn (EL3) provided lhe school. (FHSAA Bylaw 9.8)
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 when participating. (FHSAA Bylnw 9.9)
11. Must not participate in an all-star contest in a sport prior to completing his/lier high school eligibility in that sport. (FHSAA Policy 26)
12. Must display good sportsmanship and follow the rules of competition before, during and afler every contest in which the student participates. If not. the student m11y be suspended from participation for a period of time. (FHSAA Bylaw 7.1)
13. Must not provide false infonnation to his/her school or to the FHSAA to gain eligibility. (FHSAA Bylaw 9.1)
14. Youth exchange, other intemalional 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)
15. Must refrain from hazing/bullying whih: n member of an nlhletic team or while participating in any athletic octivities sponsored by or affiliated with a member school.
If the studenl is declared or ruled ineligible due lo one or more of the FHSAA rules and regulations, the student has the right to request that the school file an appeal on behalf of the student. See the principal or athletic director for infonnation regarding this process.
B)· sii:nini: this agreement, the undersigned 11cknowledgcs that the information on the Constnl and Rrltasc from Liabilily Ccrtiliute in regards to lhc FIISAA's cslabllshed rules and cligiblllty have been rtad and underslood.
Name of Student-Athlete (printed) Signature of Student-Athlete Date
Name of Parent/Guardian (pnntc:d) Signature of Parent/Guardian Date
Name of Parent/Guardian (prmlcd) Signalure of Parent/Guardian Date
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-J!l!!IJ/ Florida High School Athletic Association
" Preparticipation Physical Evaluation (Page 1 of 3)
Revised 03/16
This completed fonn must be kept on file by the school This form 1s valid for 365 calendar days from the date of the evaluation as wnttcn on page 2. This rorm Is non-tnnsrcrablc; a chance of schools during the validity period or this form wlll require page I or thb form to be rc-submlltcd.
Part 1. Student Information (to be completed by student or parent) Student's Name: _______________________________ Sex: __ Age: __ Date of Birth: ___J __ , __
School: Grode in School __ Sport(s). __________________ _
Home Address: ____________________________________ Home Phone: ( __) _____ _
Person to Contact in Ct1Se ofEmcri;cncy: --------------------------------------------Relationship 10 Student; _________ Home Phone: (___) _____ Work Phone: ( __) _____ Cell Phone: ( __) ____ _
Part 2. Medical History (to be completed by student or parent). Explain "yes" answers below. Circle questions you don't know answers to.
I. Have you had u medicul illness or injury since your last check up or spons physical?
2. Do you have an ongoing chronic illness? 3. Have you ever been hospitalized overnight? 4. Hove you ever had surgery? 5 Arc you currently tokins any prcscnption or non
prescription (over-the-counter) medications or pills or using an inhaler?
6. Hove you ever lllken uny supplements or vitamins to help you gain or lose weight or improve your pcrfonnance?
7. Do you have any allergies (for example, pollen, latex, medicine. food or stinging insects)?
8. Hnve you ever had o rash or hives develop during or after exen:ise?
9. Have you ever passed out during or after exercise? I 0. Have you ever been dizzy during or after excn:ise? 11. Hnvc you ever had ches1 pnin during or ofter exercise? 12. Do you get tired more quickly than your friends do
during excn:isc? 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 o heart murmur? 16. Has any family member or relalive died of heart
problems or sudden death before age SO? 17. Have you had a severc 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. worts, fungus, blisterS or~ son:s)? 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. Hove you ever had numbness or tingling in your arms,
hands, legs or feet? 25. Have you ever had a stinger, burner or pinched nerve?
Yes No Yes No 26. Have you ever become ill from exen:ising in the heat? 27. Do you cough, wheeze or have trouble brc,nhins 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
medico) devices that oren 't usUDJly used for your spon or position (for example, knee brace. special neck roll, foot orthotics, shunt. retlliner on your teeth or henrins aid)?
31. Hnve you had any problems with your eyes or vision? 32. Do you wear glasses, contacts or protective eyewear'? 33. Have you ever hod 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 wuh pain or swelling in muscles.
tendons, bones or joint~? lfycs, check appropriate blank and cxplai11 below:
36. Do you wont to weigh more or less than you do now? 37. Do you lose weigh• rcgularly 10 meet weight rcquircments for your
sport? 38. Do you feel stressed out? 39. Have you cver been diagnosed with sickle cell anemia? 40. Have you ever been dinsnoscd with having the sickle cell trait? 41. Rcconl the dotes of your most recent immuniZlltions (sho1s) for;
We hereby state, 10 the bcit of our knowlcdic, tluu our answers to lhc above questions Gil: complcic and come I. In addilion to the roulinc medical cvalua1ion required bys. 1006.20, Flori® Sllltutcs, and FHSAA Bylaw 9. 7, we understand and acknowledge that we""' hereby advised !lull lhc student should undcfllO a cardiovascular assessment, which may include such diagnostic tests as c)ccll'Oconliogram (EKG), cchocardiogram (ECG) and/orcardio slll:SS test
Signature of Student: ______________ Date; __ / __ / __ Signature of Pall:nt/Gulltllian: _____________ Date: __ / __ / __
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-Revised 03/16
Preparticipation Physical Evaluation (Page 2 of3)
•
Florida High School Athletic Association
This completed form musl be kept on file by the school This form 1s valid for 365 c~lendar days from the date of the evaluation 115 IYl'illcn on page 2. This form Is non-transrcrable; a cbani:c or schools during the validity period or this rorm wlll require pngc I of this form to be re-submitted.
Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed physician assistant or certified advanced rcgistcn:d nunc (lractilioncr). Srudcn1's Nome: ____________________________________ Date of Birth: __ / __ / __
Tempcrarurc: _____ Hearing: right: r __ F __ left: P __ F __
Yisnol Acnit.Y' Bicht ?Q/ I c020' Corrccrcd· Yes No Pupils· Eqnol 1 Iorqnul FINDINGS NORMAi. ABNORMAi. FINOINGS INITIALS*
MEDICAL
I. Appearance
2. Eyes/Eors/Nosc/Thront
3. Lymph Nodes
4. Heon
5. Pulses
6. Lungs
7. Abdomen
8. Genitalia (moles only)
9. Skin
MUSCULOSKELETAL
10. Neck
11. Bock
12. Shoulder/Arm
13. Elbow/Forcnnn
14. Wrist/Hand
IS Hip/Thigh
16. Knee
17. Leg/Ankle
18 Foot
• - stotion-bas,;d examination only
ASSESSMENT QE EXAMINING PHYSICMNtPHYSIClt\N 4SSIS'.fANTINPBSE PH4CTIIIQNEH I hc:n:by certify that each e:1111mi1111tion listed above was pcrfonned by myself or an individual und<:r my direct supervision with the following conclusion(s):
Cleared without limitation __ Disability: _____________________ Diagnosis: ______________________ _
Signature of PhysicilllllPhysician Assistant/Nurse Practition<:r: --------------------------------
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-Revised 03/16
Preparticipation Physical Evaluation (Page 3 of3)
•
Florida High School Athletic Association
This completed form must be kepi on file by the school. This fonn is v:ilid for 365 c.ilendar days from the date of the evaluation ns written on page 2. This Corm Is non-transrcrablc; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.
ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (If appllublc) I hcn:by certify lho11hc cxomination(s) for which referred wus/werc performed by myself or an individual under my dirccl supervision with the following conclusion(s);
Cleared without limi1a1ion __ Disability. ______________________ Dingnosis: _______________________ _
Based on rtcommcndalions dc-.'f:/npcd by the American ,kadcm> nf Family Physicians, Amcrkan Academy of Pcd1a1ric1, Amcrlean Medical S,,cietyfor Sp<>rts Medicine, American Orthopae, die Society for Sports Medicine and American Ostcopatlrlt Acadcmyfnr Sports Medicine,
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SCHOOL DISTRICT OF INDIAN RIVER COUNTY EMERGENCY INFORMATION AND CONSENT
(One for Each Athlete)
Athlete's Name _______________ Student ID# ________ _ Date of Birth Current Grade _________ _ Address _____________________ Z.ip ________ _
Father's Name ___________________________ _ Address ______________________________ _ Parent e-mail address _________________________ _ Employer ________________ Work Phone _________ _
Home Phone Cell Phone -----------Mother's Name ___________________________ _ Address ______________________________ _ Employer ________________ Work Phone _________ _ Home Phone Cell Phone __________ _
Family Health Accident Insurance: (IF YOU HAVE NO INSURANCE PLEASE WRITE BELOW "NO INSURANCE". HOWEVER, ALL INFORMATION MUST BE COMPLETED INCLUDING SIGNATURES)
Carrier ______________________________ _
Policy# ____________ Group# _______ ID# _______ _ Family Physician Name _________________________ _ Address ______________________________ _ Phone ______________________________ _
Allergies (List) ___________________________ _ Serious Medical Condition(s) _______________________ _
I/We hereby grant consent to any and all health care providers designated by Vero Beach High School to provide my child ___________________________ _
(Name) any necessary medical care as a result of any injury/illness.
