athletic handbook - edl · revised july 22, 2013 athletic handbook . revised july 22, 2013 1...

Wilkes County

Middle School

Revised July 22, 2013

Athletic Handbook

Revised July 22, 2013 1

Greetings,

It is time once again to start a new school year. Wilkes County Middle Schools look forward to an excellent academic and athletic school year.

We have a full array of sports for our students to participate in Middle School. The sports offered and the season breakdown is as follows:

Fall Winter Spring

Volleyball Cheerleading Boys and Girls Track Boys Soccer Boys Basketball Baseball

Girls Soccer Girls Basketball Softball

BRYF Football Wrestling

We are members in the Blue Ridge Middle School Athletic Conference (BRMSAC). The schools in our conference are North Wilkes, West Wilkes, Central Wilkes, East Wilkes, Elkin, Alleghany, Starmount, Forbush and Ashe County.

Enclosed in this student/parent handbook you will find explanations of Wilkes County Middle Schools and Wilkes County Policies regarding school athletics. Please note, this is not a complete list, but a list that is most relevant and most frequently inquired about. This is provided for your information to assist you in answering any questions or concerns that you may have regarding our athletics program.

Also, you will find the Wilkes County Athletic Participation Form

as they apply to athletics. Please complete and send to school with your child as they participate in seasonal sports.

We are looking forward to a successful school year, both academically and athletically.

Sincerely,

Chris Skabo, CAA

Director of Athletics and Healthful Living Wilkes County Schools


Insurance The Wilkes County Board of Education now provides insurance to

all students who are trying out, practicing, competing in, and/or traveling to and from school athletic events as a representative of the school and under supervision of a school employee. This does not include school time activities such as P.E., field trips,

classes, etc. Additional school time purchase of insurance is optional for each student at the parent/guardian’s request.

All accidents/injuries must be reported to the Athletic Director

that day or the next morning. An accident form and claim report must be completed by the coach, Athletic Director, and parent/guardian of the injured student athlete. Link to K&K athletic claim form: http://americanadvantageinsurance.com/files/Brochures/K%20&%20K%20Claim%20form.pdf

Gfeller-Waller Act The Gfeller-Waller Concussion Awareness Act was drafted and

implemented to protect the safety of student-athletes in North Carolina and was signed into law on June 16, 2011 by Governor Beverly Purdue.

There are three major areas of focus in the law and these include: education, emergency action and post-concussion protocol

implementation, and clearance/return to play or practice following concussion. Go to the Gfeller-Waller website by clicking the link below

http://gfellerwallerlaw.unc.edu/GfellerWallerLaw/gwlaw.html

This information is also available at the NCHSAA web site at

www.nchsaa.org. Click on the Health and safety tab at the top of the page.

Discipline The Head Coach must establish a set of team rules. These rules

should be discussed with his/her athletes and parents in a parent meeting that is held prior to the first scheduled game. A copy of these rules should be signed by the coach, the player, and the player’s parent/guardian. The Head Coach should make sure that the athletic director has a copy for reference if problems arise.

These rules should be consistent with the Wilkes County Board of

Education policy, the Athletic Manual of DPI, and the Wilkes County Middle School discipline policy.

O88 – Athlete may not participate in any practice, game, or team activity due to being Out Of School for the period of time set. 2nd OSS occurrence will result in removal from the team.

I88 - Athletes may not participate in any practice, game, or team activity on days that students are in ISS for disciplinary reasons. If sport

activity is on the last day off ISS student may still not participate. Excessive ISS occurrences could result in removal from the team.

http://americanadvantageinsurance.com/files/Brochures/K%20&%20K%20Claim%20form.pdf

http://gfellerwallerlaw.unc.edu/GfellerWallerLaw/gwlaw.html

http://www.nchsaa.org/


Policy on Alcohol, Tobacco, and Drug Use Wilkes County Middle School athletes are expected to set an

example for other students. The use of alcohol, tobacco or drugs in any form will not be tolerated. The following guidelines will be used in dealing with such offenses.

Tobacco

Any student found guilty of the use of tobacco will be suspended

for two games mandatory on the first offense. Second offense will result in suspension for the remainder of the school year.

Alcohol and Drug Use

Any student found guilty of alcohol or drug use, or possession of

alcohol or drugs will be suspended for the remainder of the school year.

Sportsmanship Students and spectators of Wilkes County Middle Schools should:

realize you represent the school as a member of the team;

therefore, you have an obligation to be a true sportsman, encourage through this behavior the practice of good

sportsmanship by others;

recognize that good sportsmanship is more important than

victory by approving and applauding good team play, individual

skill and outstanding examples of sportsmanship and fair play exhibited by either team;

remember that the primary purpose of interscholastic athletics is to promote the physical, mental, moral, social, and emotional

well-being of the players through the medium of contest; and

be modest in victory and gracious in defeat respect the

judgment and integrity of game officials. Any athlete or spectators who are ejected from any athletic contest will be penalized as follows:

Spectators: -1st offense: reprimanded and suspended for the next TWO games. -2nd offense: person will be suspended for remainder of year from all sports. (Note: Penalties are cumulative from sport to sport and from season to season.)

Student Athlete:

-1st offense: reprimanded and suspended for the next TWO games.


-2nd offense: person will be suspended for remainder of year from all sports. (Note: Penalties are cumulative from sport to sport and

from season to season.)

Hardship

The local board of education or the conference of which the school is a member shall have the authority to set aside the effect of any (other

than the age or 4 semester rule) eligibility rule upon the individual student when in its opinion the rule fails to accomplish the purpose for

which the rule is intended or when the rule works undue hardship upon the student.

NOTE: It is to be understood that ordinary cases in ineligibility shall

not be considered as coming under the hardship category, and that the conditions which cause the student to fail to meet the eligibility

requirements, must have been beyond the control of the school, the student and/or his/her parents. Injuries, illnesses, or accidents,

which cause the student to fail to meet one of the basic requirements, are possible causes for hardship consideration.

Timeline

All sports may be played during the sport's season and begin as

follows:

Fall, beginning of the fall semester to November 15,

Winter, November 1 to March 1; and

Spring, February 1 to the end of school.

Wilkes County Board Policy on Residence

1. A middle school student who is reassigned to a school of

choice and whose domicile is not in the attendance area of the school of choice shall be ineligible to participate in any athletic program for which

the season has already started. Such student is eligible to participate in any athletic program for which the season has not started. In addition,

if the student’s reassignment to the middle school of choice did not occur on or before the first day of the student’s eighth grade year, the

student shall be ineligible to participate in any athletic program for 365 days at the high school in the attendance area of the middle school of

choice. Exceptions may be heard in accordance with subsection I found in Policy 4150 of the Wilkes County Board of Education policy manual.

2. Coaches are strictly prohibited from recruiting athletes to leave one school for another for athletic purposes.


Athletic Eligibility Requirements Athletes in Wilkes County Middle Schools must meet all of the

following criteria in order to be athletically eligible to participate in sports.

1. They must have passed 3 of the 4 core courses and PE during the semester prior to athletic competition. Student must meet state and

local promotion standards each semester. If an athlete is "academically eligible” or "academically ineligible” at the beginning of

any semester, that status is retained throughout the full semester. It is the responsibility of the school principal to check the academic

status of each student/athlete enrolled in school at the beginning and close of a semester. Promotion is defined as progressing to the

next grade.

NOTE: An athlete becomes eligible or ineligible on the first day of the

new semester.

2. Student must be in attendance at least 85% of the previous semester.

That means they could have missed no more than 12 days of school (162 day calendar) during the semester prior to athletic competition.

3. They must be in either the 7th or 8th grade.

4. No student may be eligible to participate at the Middle School level for a period lasting longer than 4 consecutive semesters beginning with the student’s entry into 7th grade.

5. They must live in the school district or be a Board approved out of district student.

6. They cannot reach the age of 15 on or before August 31st.

7. Each student must receive a medical examination each year (365 days) by a duly licensed physician, nurse practitioner, or physician assistant.

8. A student must be in attendance one-half (1/2) of the school day

to attend any after school activity.

9. Student must be in good standing with attendance and make up time before each athletic season. Athletic activities cannot count as

make up time.


Wilkes County Schools Athletic Procedures

1. Transportation

A. The Wilkes County Board of Education expects athletic

departments to provide transportation to and from athletic games/matches, in approved vehicles, for their student

athletes.

B. The Wilkes County Board of Education realizes the many special circumstances that can arise related to transporting

student-athletes for games/matches and gives permission to the principals, athletic director, and head coach to do the

following:

1. You may release the student-athlete to their parent(s) for transportation to or from athletic events.

2. You may release the student-athlete to an adult that the parents have designated in writing. This release should be signed, dated, and have a phone number for verification.

3. Principal, Athletic Director, and Head Coach should

communicate any release to each other so that all are aware of the release.

4. Keep a written record of releases on file in athletic director’s office until end of school year.

C. When a lack of facility makes it necessary for athletic teams to

practice at a site away from campus, transportation to these practices is the responsibility of the student-athlete and his or

her parents. Schools may provide an approved vehicle to and from these practices but it is not required.

D. The following vehicles are approved to transport to and from athletic games/matches:

1. Centralized activity bus 2. School activity bus 3. Yellow school bus-if prior approval from Director of

Transportation 4. School car

5. Centralized pool car


6. Parent vehicle-driven by parent of student-athlete 7. Vehicle of an adult that has been designated in writing by

the parent to transport their child to or from athletic event/match

E. Vans cannot be used to transport student-athletes to or from athletic events under any circumstances.

F. Activity bus drivers must have a CDL license with a “P” endorsement or a school bus license. If traveling out of state, the driver must also have a DOT medical card.

G. If transportation cannot be arranged on an approved vehicle, then the athletic event/match/game should be postponed until approved transportation can be arranged.

2. Athletic events or practices on days school is cancelled for students and staff.

a. No athletic event or practice can be held on a school day that

is cancelled for students and staff due to inclement weather. This includes early dismissal due to inclement weather.

b. Violation of this rule will result in loss of practice time and

coaching privileges for Head Coach. The amount of lost practice time and coaching privileges will be determined by the principal and central office but will not be less than loss of one practice session and one game coaching at the next available practice and the next scheduled game for coaching.

3. Athletic events or practices on days school is delayed for opening due to inclement weather.

a. Athletic events and practices may be held on delayed opening days as follows:

1. The central office, principal, and athletic director feel that weather conditions will be safe for travel.

2. Consideration is given to a shortened practice schedule for the day by principal, athletic director, and head coach.

3. Consideration is given to the opponents’ travel

situation. If the opponent school is concerned and feels travel will not be safe for them, then the event/match/game will be rescheduled.


4. Athletic events or practices on days school is cancelled for students and teachers have an optional teacher workday.

a. No athletic event/practice will be held on the first day school is cancelled for students and an optional teacher

workday is held. This applies for each weather cancellation as they occur.

b. On days school is cancelled for students and a teacher workday is held athletic events may be held as

follows: 1. The central office, Principal, athletic director and opponent school feels travel conditions

and not safe before and after the event.

c. On days school is cancelled for students and a teacher

workday is held practice may be held as follows: 1. The central office, principal and athletic director

feels travel conditions are safe for student athletes.

2. The decision to have practice or not have

practice will be made at or before 11:00 am. All high schools will be notified.

3. When practice is allowed it will be voluntary and for varsity only!

4. No middle school practice, no off season skill

development sessions, no J.V. practice.

open sessions and no

5. Voluntary varsity practice can be held on school grounds from 12:00 noon until 3:00 pm. NO exceptions. Coaches that hold practice sessions during optional teacher days regular hours will make up this time on the same day after hours. If this is not possible then the coach will work with the school principal to make up the time after hours.

6. Practice is not permitted at any other time or

place on these days. 7. Violation of this rule will be punished by loss of

practice time for team and loss of coaching

privileges will be determined by the central office and principal but will not be less than loss of

one practice session and one game coaching at the next available practice time and next

scheduled game for coaching.


5. Attendance/Make-Up Time

a. Student-Athletes may make up time to remove absences and

gain eligibility under the guidelines outlined in the NCHSAA handbook. All the time made up must be in the same semester in that the absence occurred.

b. Student-Athletes must have been in attendance 85% of the previous term in order to be eligible to participate in the current term. This should be checked very closely when determining the eligibility of a student-athlete.

6. Summer School

a. Classes taken during summer vacation may not be used in determining athletic eligibility.

7. Athletic Camps/Fundraisers

a. Any Wilkes County Board of Education employee who

conducts athletic camps or fundraisers will follow guidelines established by the Board of Education for financial accounting.

1. All funds collected will be turned into the School Financial Officer.

2. The school will follow Board of Education

policies for paying any bills, fees or salaries connected with these camps/fundraisers

from those funds. 3. There are NO exceptions to this procedure.

4. Any applicable school form for fundraising will be completed by the person in charge of

the camp or fundraiser.

5. Where school facilities are being used a

rental/usage agreement will be completed.

WILKES COUNTY SCHOOLS MIDDLE SCHOOL ATHLETIC PARTICIPATION FORM

Please Print Name:____________________________________ Home Phone:_______________________ High School:_______________________________ Gender: M F Date of Birth: _____________________________ Race:____________ Age:____________ Father’s Name: _____________________________________________________________________________

Daytime Phone: _________________________ Cell Phone: _____________________________ Other: ____________________________ Mother’s Name: _______________________________________________ Daytime Phone: _________________________ Cell Phone: _____________________________ Other: ____________________________ Email:____________________________________________________________ Street Address:______________________________________________________________________ County:_____________________________ City:____________________________________________ State:___________________________ Zip Code:____________________________ Alternate Emergency Contact Person:______________________________________ Day Ph_____________________ Cell Ph________________ We certify that the home address shown in this document file is my sole bona fide residence, and I will notify the school principal immediately of any change in residence, since such a move may alter the eligibility status of my student athlete. All other information contained in this form is accurate and correct. Parent/Legal Guardian Signature: ______________________________ Athlete Signature: _________________________________ ___________________________________________________________________________________________________________________

Convictions: Check the box that applies to (student name)___________________________________________________________: ( ) Is not convicted of a felony in this or any other state OR adjudicated as a delinquent for an offense that would be a felony if committed by an adult in this or any other state. ( ) Is convicted of a felony in this or any other state. ( ) Is adjudicated as a delinquent for an offense that would be a felony if committed by an adult in this or any other state. The following must be completed if the student is convicted of a felony or is adjudicated as a delinquent: Convicted or adjudicated of: _________________________________________________________________________________ City and State:_________________________________________ Date Convicted/Adjudicated:__________________________ Description of Offense:______________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Court Counselor:_______________________________________________ Telephone Number:__________________________

This is my _____ consecutive semester in middle school, and I entered the seventh grade in the fall of (yr.)________. Last semester I attended ________________________________ School and passed _________ (number) courses. I have also not been convicted of a felony or an act that would have been a felony if I were not classified a juvenile.

Request for Permission

We, the undersigned student and the student’s parent/guardian, apply for permission to participate in interscholastic athletics in the

following sports: (Please check all that apply)

( ) Basketball ( ) Football ( ) Softball ( ) Volleyball

( ) Baseball ( ) Soccer ( ) Track ( ) Wrestling

( ) Cheerleading

Insurance: Wilkes County School (WCS) furnishes an Interscholastic Athletic Insurance Policy which provides limited benefits for all students in the system who participate in high school sponsored and supervised interscholastic athletic activities. The policy provides excess coverage for students with other insurance coverage, but it pays only when other benefits have been exhausted. It is a secondary insurance! In cases in which a student has no other coverage with either a commercial insurance agency, Medicare or Medicaid, the WCS athletic insurance policy is the primary policy. If your son or daughter should be injured while participating in a high school sponsored or supervised interscholastic athletic event, the following procedures must be followed to process a claim under the insurance provided by WCS.

Use the claim form you received in your parent meeting or download a form at http://www.americanadvantageinsurance.com/files/Brochures/K%20&%20K%20Claim%20form.pdf .

See a physician within 30 days of the injury.

Complete and submit the Accident Claim Form. The claim form must be filed with the insurance company within 60 days of the injury and should include the Explanation of Benefits form from your primary insurance carrier. Please list below the name of your primary insurance carrier and policy number.

Risk of Injury We acknowledge and understand that there is a risk of injury involved in athletic participation. We understand that the student athlete will be under the supervision and direction of a WCS athletic coach. We agree to follow the rules of the sport and the instructions of the coach in order to reduce risk of injury to the student and other athletes. However, we acknowledge and understand that neither the coach nor WCS can eliminate the risk of injury in sports. Injuries may and do occur. Sports injuries can be severe and, in some cases, may result in permanent disability or even death. We freely, knowingly, and willfully accept and assume the risk of injury that might occur from participation in athletics. Code of Sportsmanship: It is recognized that public school interscholastic athletic events should be conducted in such a manner that good sportsmanship prevails at all times. Every effort should be made to promote a climate of wholesome competition. Unsportsmanlike acts will not be tolerated. A player is under the coach’s control from the time he/she arrives at the athletic field until he/she leaves the field. The penalties listed in the North Carolina Department of Instruction Middle School Athletic Handbook will be adhered to for any athlete ejected from an athletic contest. Protect your Eligibility; Know the Rules: To represent your school in Athletics, YOU:

Must be a properly enrolled student at the time you participate, must be enrolled no later than the 15th day of the present semester, and must be in regular attendance at that school. Must also have met local promotion standards.

Must not be convicted of a felony in this or any other state, or adjudicated as a delinquent for an offense that would be a felony if committed by an adult in this or any other state.

Must not have more than 12 absences (85% attendance requirement) in the semester prior to athletic participation.

Must not have exceeded four (4) consecutive semesters of attendance or have participated more than four (2) seasons in any sport since first entering grade seven (7).

Must be less than 15 years of age on or before August 31st, 2013.

Must live with your parents or legal custodian within the high school district that you attend. School of Choice policy 4150 of Wilkes County Schools addresses exceptions and penalties for this rule.

Must be present at school half of the day in order to participate in an athletic event for that day. This includes games and practices.

Must have passed at least one less course than the number of required core courses each semester. Must also have met local promotion standards.

Must have received a medical examination by a licensed physician within the past 365 days. If you miss five (5) or more days of practice due to illness or injury, you must receive a medical release from a licensed physician before practicing or playing.

Must not accept prizes, merchandise, or anything that exceeds a value of $20 per season as a result of athletic participation . This includes being on a free list or loan list for equipment, etc. No amount of money can be accepted at any time!

Must not have signed a professional contract, have played on a junior college team, or be enrolled and attending a class in college. This does not affect a regularly enrolled high school student who is taking a college course(s) for advanced credit.

Must not participate in unsanctioned all-star or bowl games.

May not receive team instructions from your school’s coaching staff during the school year outside your sports season. Instruction is limited to the coach and one or multiple participants in small group settings (skill development sessions).

May not, as an individual or a team, practice or play during the school day.

May not play, practice or assemble as a team with your coach on Sunday.

May not dress for a contest, sit on the bench, or practice if you are not eligible to participate. Wilkes County Schools Student Athlete Pledge: As a student athlete, I am a role model. Using inappropriate language; taunting; baiting; attempting to instigate a fight; obscene gestures; disrespect to opposing players, officials coaches, and fans; or the use of unwarranted physical contact at opposing players, coaches, officials, and fans are contrary to the spirit of fair play and the good sportsmanship of my school, my community, and the members of the school’s athletic program. I accept my responsibility to model good sportsmanship. I understand I may be reprimanded and/or suspended according to handbook rules as well as any individual judgments rendered by school officials, including the coach. Student-Athlete Signature: ______________________________________________ Date:___________________________________

Wilkes County Schools Parent Pledge: As a parent of an athlete at this school, I promise to accompany my child to as many orientation and informational meetings offered by the athletic department as my schedule will permit. I will work closely with all school personnel to assure an appropriate academic and athletic experience for my child. I will assure that my child will attend all scheduled practices/games/matches and will require my child to abide by all county and school rules. I acknowledge the ultimate authority of the coach to determine strategy and individual playing time. I agree to promote mature behavior from parents and students during athletic contests while serving as a positive citizen and role model. I will work cooperatively with other parents and school personnel to assure a wholesome and successful athletic program for our school. I will work closely with coaches and other school personnel to identify a reasonable and realistic future for my child as a student athlete. Parent/Legal Guardian Signature(s): ___________________________________________ Date:____________________________ Wilkes County Schools Coaches Pledge: As a coach, I acknowledge that I am a role model. I know that the principles of good sportsmanship are integrity, fairness, and respect. While teaching the skills of the game, I must also teach student athletes how to win and lose graciously, and that sport is meant to be educational and fun. I understand that I must adhere to the rules, regulations and policies set forth in the athletic manuals of Wilkes County Schools, NCDPI and the Blue Ridge Conference. I know the behavior expectations of me by this school, conference, school system and the NCDPI, and hereby accept my responsibility to be a model of ethical behavior, integrity, and good citizenship. Coaches Signature: _______________________________ Date: _________________ Policy for Quitting a Middle School Team If an athlete quits a team after a tryout period, that athlete may not participate in skill development practice sessions or tryout for another sport until the team that he/she quit is finished with their season. A tryout period is defined as before final team selection. A team’s season is defined as the first practice after final team selection until all games are complete. This includes conference tournaments and state playoff games. If an athlete quits a team it is the responsibility of the coach to notify the athletic director immediately. There are no exceptions to this rule! A coach may not release a student-athlete if he/she quits their team! In sports where there is not a designated tryout period (football, wrestling, track, etc.), a student-athlete will have two weeks to decide whether or not to participate. After two weeks an athlete is considered an official team member. Student-Athlete Initials: _________ Parent/Legal Guardian Initials: ____________ Wilkes County Schools Hazing Policy The Wilkes County schools will not tolerate hazing of any kind. Athletes found guilty of hazing will be immediately removed from athletic participation. This suspension will not be less than one school term (18 weeks). This punishment will be in addition to any school discipline given by the principal. Student-Athlete Initials: _________ Parent/Legal Guardian Initials: ____________

NCHSAA/NCDPI Middle School Sportsmanship/Ejection Policy: The policy applies to all persons involved in an athletic contest, including student-athletes, coaches, managers and game administrators. The following examples include behavior or conduct which will result in an ejection from a contest:

1) Fighting, which includes, but is not limited to, combative acts such as: A) An attempt to strike an opponent with a fist, hands, arms, legs, or feet B) An attempt to punch or kick an opponent, regardless of whether or not contact is made C) An attempt to instigate a fight by committing an unsportsmanlike act toward an opponent that causes an opponent to retaliate D) Leaving the bench area to participate in a fight (contact or no contact)

2) Biting observed by an official 3) Taunting, baiting, or spitting toward an opponent 4) Profanity, directed toward an official or opponent 5) Obscene gestures, including gesturing in a manner as to intimidate 6) Disrespectfully addressing (physically contacting an official is subject to automatic expulsion and can result in ineligibility for

remainder of career) an official Penalty for an ejection for the above reasons:

Football-ejection from the contest and miss the next contest at that level and contests in the interim (EXCEPTION: fighting equals two missed contests All other sports-ejection from that contest; miss the next two contests at that level and all contests in the interim (EXCEPTION: fighting equals 4 missed contests) Players receiving two ejections for unacceptable behavior as defined above will be suspended from all sports for the remainder of that sport season. Receiving a third ejection in a school year will result in suspension from athletics for calendar year (365 days from the date of the third ejection). NOTE: Ejections in the last game of the season carry over to the next sport in which the individual participates that school year. Ejected players may practice but not play in a game or match.

Student-Athlete Initials: _________ Parent/Legal Guardian Initials: ____________ Transportation for Athletic Events: If student transportation is by a Wilkes County Schools System-owned vehicle, the school system vehicle liability coverage is applicable to any vehicular accident. If student transportation is by private vehicle, the vehicle owner’s liability coverage is applicable to any vehicular accident. Student athletes will travel to/from athletic events with their teams and coaches. Any athlete failing to comply will not be allowed to dress and participate at that game/match. If the violation occurs on the trip home, then the athlete will not dress nor participate in the next game. A second offense will result in removal from the team. Request for Exception to the Transportation Policy: I request that my son/daughter be given an exception to the transportation policy. I understand and agree that with this request I accept total responsibility for my child’s safe return home from his/her game for the entire season. I understand and agree that I am responsible for any and all arrangements related to my child’s ride home. I understand and agree that my child may not ride home with another person other than their parent(s) or adult(s) designated by the parent(s)! If a parent wishes to designate an adult or adults to take their child home they may list those adult(s) on a form prior to the season starting. Each form will be verified by the coach and athletic director. If he/she does not follow this policy he/she will sit out a game on the first offense and will be removed from the team on the second offense. I hereby release the Wilkes County Board of Education, its individual members, its employees and its agents from any loss, damage, injury, claim, liability or responsibility whatsoever arising out of, during, or in any way connected with the transportation of my child from an athletic event where school transportation is not utilized. Parent/Legal Guardian Initials _________ Athlete Initials: ________________ We, the undersigned student and parent/guardian, have read this document and understand all of these requirements for athletic participation at our high school, and agree to comply with the requirements set forth in this document. Student: _________________________________________________________ Date: _____________________________ Signature Parent/Guardian: ___________________________________________________ Date: _____________________________ (Please Print) Parent/Guardian: ___________________________________________________ Date: _____________________________ (Signature)

Athletic Department

Emergency Information and Parental Consent

Student Name: __________________________Birthdate__________Age___________

Parent’s Name: __________________________Home Phone: ____________________

Address: ________________________City__________________Grade____________

Day Phone Number of Parents: Father ______________Mother ___________________

In an emergency, if the parents cannot be reached, notify:

__________________________________________Phone _______________________

Family Doctor: ___________________________Phone _________________________

Known Allergies: ________________________________________________________

Permission is hereby granted to the attending physician to proceed with any medical

or minor surgical treatment, x-ray, examination and immunizations for the above named

student. In the event of an emergency arising out of serious illness, the need for major

surgery, or a significant accidental injury, I understand that an attempt will be made by

the attending physician to contact me in the most expeditious way possible. If the said

physician is not able to communicate with me, the treatment necessary for the best

interest of the above named student may be given.

Permission is also granted to the Certified Athletic Trainer to provide the needed

emergency treatment prior to the student’s admission to the medical facilities.

Parent Signature: ___________________________________Date______________

Revised: August 12, 2011

613 Cherry Street • North Wilkesboro, NC 28659 • Telephone 336.667.1121

www.wilkes.k12.nc.us

Superintendent Marty T. Hemric, Ed. D.

Associate Superintendent Wanda P. Hutchinson, Ed. D.

Assistant Superintendent Anna R. Lankford

http://www.wilkes.k12.nc.us/

INFORMATION FOR STUDENT-ATHLETES & PARENTS/LEGAL CUSTODIANS

What is a concussion? A concussion is an injury to the brain caused by a direct or indirect blow to the head. It results in your brain not working as it should. It may or may not cause you to black out or pass out. It can happen to you from a fall, a hit to the head, or a hit to the body that causes your head and your brain to move quickly back and forth. How do I know if I have a concussion? There are many signs and symptoms that you may have following a concussion. A concussion can affect your thinking, the way your body feels, your mood, or your sleep. Here is what to look for:

Thinking/Remembering Physical Emotional/Mood Sleep Difficulty thinking clearly

Taking longer to figure things out

Difficulty concentrating

Difficulty remembering new

information

Headache

Fuzzy or blurry vision

Feeling sick to your

stomach/queasy

Vomiting/throwing up

Dizziness

Balance problems

Sensitivity to noise or light

Irritability-things bother you

more easily

Sadness

Being more moody

Feeling nervous or worried

Crying more

Sleeping more than usual

Sleeping less than usual

Trouble falling asleep

Feeling tired

Table is adapted from the Centers for Disease Control and Prevention (http://www.cdc.gov/concussion/)

What should I do if I think I have a concussion? If you are having any of the signs or symptoms listed above, you should tell your parents, coach, athletic trainer or school nurse so they can get you the help you need. If a parent notices these symptoms, they should inform the school nurse or athletic trainer. When should I be particularly concerned? If you have a headache that gets worse over time, you are unable to control your body, you throw up repeatedly or feel more and more sick to your stomach, or your words are coming out funny/slurred, you should let an adult like your parent or coach or teacher know right away, so they can get you the help you need before things get any worse What are some of the problems that may affect me after a concussion? You may have trouble in some of your classes at school or even with activities at home. If you continue to play or return to play too early with a concussion, you may have long term trouble remembering things or paying attention, headaches may last a long time, or personality changes can occur Once you have a concussion, you are more likely to have another concussion. How do I know when it’s ok to return to physical activity and my sport after a concussion? After telling your coach, your parents, and any medical personnel around that you think you have a concussion, you will probably be seen by a doctor trained in helping people with concussions. Your school and your parents can help you decide who is best to treat you and help to make the decision on when you should

return to activity/play or practice. Your school will have a policy in place for how to treat concussions. You should not return to play or practice on the same day as your suspected concussion.

This information is provided to you by the UNC Matthew Gfeller Sport-Related TBI Research Center, North Carolina Medical Society, North Carolina Athletic Trainers’ Association, Brain Injury Association of North Carolina, North Carolina Neuropsychological Society, and North Carolina High School Athletic Association.

CONCUSSION

You should not have any symptoms at rest or during/after activity when you return to play, as this is a sign your brain has not recovered from the injury.

http://www.cdc.gov/concussion/

Student-Athlete & Parent/Legal Custodian Concussion Statement *If there is anything on this sheet that you do not understand, please ask an adult to explain or read it to you.

Student-Athlete Name:____________________________________________________________________ This form must be completed for each student-athlete, even if there are multiple student-athletes in each household.

Parent/Legal Custodian Name(s):___________________________________________________________

□ We have read the Student-Athlete & Parent/Legal Custodian Concussion Information Sheet.

If true, please check box.

After reading the information sheet, I am aware of the following information:

Student-Athlete

Initials

Parent/Legal

Custodian

Initials

A concussion is a brain injury which should be reported to my parents, my

coach(es), or a medical professional if one is available.

A concussion can affect the ability to perform everyday activities such as the

ability to think, balance, and classroom performance.

A concussion cannot be “seen.” Some symptoms might be present right

away. Other symptoms can show up hours or days after an injury.

I will tell my parents, my coach, and/or a medical professional about my

injuries and illnesses.

N/A

If I think a teammate has a concussion, I should tell my coach(es), parents, or

medical professional about the concussion.

N/A

I will not return to play in a game or practice if a hit to my head or body

causes any concussion-related symptoms.

N/A

I will/my child will need written permission from a medical professional

trained in concussion management to return to play or practice after a

concussion.

Bases on the latest data, most concussions take days or weeks to get better. A

concussion may not go away right away. I realize that resolution from this

injury is a process and may require more than one medical evaluation.

I realize that ER/Urgent Care physicians will not provide clearance if seen

right away after the injury.

After a concussion, the brain needs time to heal. I understand that I am/my

child is much more likely to have another concussion or more serious brain

injury if return to play or practice occurs before concession symptoms go

away.

Sometimes, repeat concussions can cause serious and long-lasting problems.

I have read the concussion symptoms on the Concussion Information Sheet.

__________________________________ _____________

Signature of Student-Athlete Date

__________________________________ _____________

Signature of Parent/Legal Custodian Date

WCS Department of Athletics

Transportation Release Form

Student Name: ________________________ Parent Name___________________________

Request for Exception to the Transportation Policy: I request that my son/daughter be given an exception to the

transportation policy. I understand and agree that with this request I accept total responsibility for my child’s safe return home

from his/her games that the student does not ride school transportation for the entire season. I understand and agree that I am

responsible for any and all arrangements related to my child’s ride home. I understand and agree that my child may not ride

home with another person other than their parent(s) or adult(s) designated by the parent(s)! If a parent wishes to designate

an adult or adults to take their child home they may list those adult(s) on this form prior to the season starting. Each form will

be verified by the coach and athletic director at the beginning of the season. The adult(s) designated to take your student-

athlete home must sign them out on the documentation sheet on the back of this letter before they leave the off campus facility

that they are visiting. If he/she does not follow this policy he/she will sit out a game on the first offense and will be removed

from the team on the second offense. I hereby release the Wilkes County Board of Education, its individual members, its

employees and its agents from any loss, damage, injury, claim, liability or responsibility whatsoever arising out of, during, or

in any way connected with the transportation of my child from an athletic event where school transportation is not utilized.

___________________________________ _________________________

Signature of Student-Athlete Date

___________________________________ _________________________

Signature of Parent/Legal Guardian Date

List below the adult designee(s) for each sport season:

Fall: Winter: Spring:

1)_______________________ 1)______________________ 1)____________________

2)_______________________ 2)______________________ 2)____________________

3)_______________________ 3)______________________ 3)____________________

4)_______________________ 4)______________________ 4)____________________

5)________________________ 5)______________________ 5)____________________

613 Cherry Street • North Wilkesboro, NC 28659 • Telephone 336.667.1121

www.wilkes.k12.nc.us

Superintendent

Marty T. Hemric, Ed. D

Associate Superintendent Wanda P. Hutchinson, Ed.D.

Assistant Superintendent Anna R. Lankford

http://www.wilkes.k12.nc.us/

Wilkes County Schools Sign Out Documentation Sheet

Student Name: ______________________ School: _______________________

Printed Name of Person Signature of Person Venue/Site Date

Transporting Student Transporting Student

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NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION

SPORT PREPARTICIPATION EXAMINATION FORM

Patient’s Name: ______________________________________________________Age: _______ Sex: _____

This is a screening examination for participation in sports. This does not substitute for a comprehensive

examination with your child’s regular physician where important preventive health information can be covered.

Athlete’s Directions: Please review all questions with your parent or legal custodian and answer them to the best of your

knowledge.

Parent’s Directions: Please assure that all questions are answered to the best of your knowledge. If you do not understand or

don’t know the answer to a question please ask your doctor. Not disclosing accurate information may put your child at risk during

sports activity.

Physician’s Directions: We recommend carefully reviewing these questions and clarifying any positive or Don’t Know answers.

Explain “Yes” answers below Yes No Don’t

know

1. Does the athlete have any chronic medical illnesses [diabetes, asthma (exercise asthma), kidney problems,

etc.]? List:

2. Is the athlete presently taking any medications or pills? 3. Does the athlete have any allergies (medicine, bees or other stinging insects, latex)? 4. Does the athlete have the sickle cell trait? 5. Has the athlete ever had a head injury, been knocked out, or had a concussion? 6. Has the athlete ever had a heat injury (heat stroke) or severe muscle cramps with activities? 7. Has the athlete ever passed out or nearly passed out DURING exercise, emotion or startle? 8. Has the athlete ever fainted or passed out AFTER exercise? 9. Has the athlete had extreme fatigue (been really tired) with exercise (different from other children)? 10. Has the athlete ever had trouble breathing during exercise, or a cough with exercise? 11. Has the athlete ever been diagnosed with exercise-induced asthma ? 12. Has a doctor ever told the athlete that they have high blood pressure? 13. Has a doctor ever told the athlete that they have a heart infection? 14. Has a doctor ever ordered an EKG or other test for the athlete’s heart, or has the athlete ever been told they have

a murmur?

15. Has the athlete ever had discomfort, pain, or pressure in his chest during or after exercise or complained of

their heart “racing” or “skipping beats”?

16. Has the athlete ever had a seizure or been diagnosed with an unexplained seizure problem? 17. Has the athlete ever had a stinger, burner or pinched nerve? 18. Has the athlete ever had any problems with their eyes or vision? 19. Has the athlete ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury

of any bones or joints?

Head Shoulder Thigh Neck Elbow Knee Chest Hip Forearm Shin/calf Back Wrist Ankle Hand Foot

20. Has the athlete ever had an eating disorder, or do you have any concerns about your eating habits or weight? 21. Has the athlete ever been hospitalized or had surgery? 22. Has the athlete had a medical problem or injury since their last evaluation? FAMILY HISTORY 23. Has any family member had a sudden, unexpected death before age 50 (including from sudden infant death

syndrome [SIDS], car accident, drowning)?

24. Has any family member had unexplained heart attacks, fainting or seizures? 25. Does the athlete have a father, mother or brother with sickle cell disease?

Elaborate on any positive (yes) answers:

By signing below I agree that I have reviewed and answered each question above. Every question is answered completely and is

correct to the best of my knowledge. Furthermore, as parent or legal custodian, I give consent for this examination and give

permission for my child to participate in sports.

Signature of parent/legal custodian: ________________________________________ Date: __________________

Signature of Athlete: ______________________________ Date: __________________ Phone #:_______________

Physical Examination (Must be Completed by a Licensed Physician, Nurse Practitioner or Physician Assistant)

Athlete’s Name ______________________________________________________ Age _______ Date of Birth _______________________________

Height ______________ Weight ________________ BP (% ile) / _________ (% ile) Pulse

Vision R 20/ L 20/ Corrected: Y N

These are required elements for all examinations NORMAL ABNORMAL ABNORMAL FINDINGS

PULSES

HEART

LUNGS

SKIN

NECK/BACK

SHOULDER

KNEE

ANKLE/FOOT

Other Orthopedic

Problems

Optional Examination Elements – Should be done if

history indicates

HEENT

ABDOMINAL GENITALIA (MALES) HERNIA (MALES)

Clearance: U A. Cleared U B. Cleared after completing evaluation/rehabilitation for : ____________________________________________ U *** C. Medical Waiver Form must be attached (for the condition of:

U D. Not cleared for: U Collision U Contact

U Non-contact ______Strenuous ______Moderately strenuous ______Non-strenuous Due to:

Additional Recommendations/Rehab Instructions:

Name of Physician Extender: _________________________________________________

Signature of Physician/Extender___________________________________MD DO PA NP

(Signature and circle of designated degree required)

Date of exam:

Address:

Physician Office Stamp:

Phone

(*** The following are considered disqualifying until appropriate medical and parental releases are obtained: post-operative clearance, acute infections, obvious growth retardation, uncontrolled diabetes, severe visual or auditory impairment, pulmonary insufficiency, organic heart disease or Stage 2 hypertension, enlarged liver or spleen, a chronic musculoskeletal condition that limits ability for safe exercise/sport (i.e. Klippel-Feil anomaly, Sprengel’s deformity), history of uncontrolled seizures, absence of/ or one kidney, eye, testicle or ovary, etc.)

This form is approved by the North Carolina High School Athletic Association Sports Medicine Advisory Committee and the NCHSAA Board of Directors. This form is reviewed annually, and was last updated April 2013.

athletic handbook - edl · revised july 22, 2013 athletic handbook . revised july 22, 2013 1...

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