RIMROCK JR. SR. HIGH SCHOOL 2021-2022

ATHLETIC PACKET

ALL ATHLETES must have the following signed paperwork on the first day of practice. NO EXCEPTIONS!

Athletes will not be allowed to participate in practices or competitions until all signed paperwork is returned.

✓Participant Release and Waiver…… Pages 2-3 ✓Drug Testing Consent………………….Page 4 ✓Concussion Acknowledgement………..Page 4 ✓COVID Waiver Form………………….Page 5 ✓Sports Physical Form (6th, 7th, 8th, 9th, 11th graders) ✓Interim Questionnaire (10th and 12th graders)

ATHLETIC FEES

Activity Card (required for ALL athletes) $30 High School Participation Fee (per season) $50 Jr. High Participation Fee (per season) $25

Activity cards are a one-time fee and will be delivered to student after fall pictures are taken. Fees are due before athlete participates in first game/competition event.

Make checks payable to Rimrock.

Home Game Admission Fees Adult Admission…………………………….$5.00 Student Admission…………………………..$3.00 Student Admission with Activity Card……..…Free Adult Yearly Pass………………………………$90 Family Yearly Pass……………………………$180

Beginning with the 2021-2022 school year, all athletic registration forms will be available for online submission through the PowerSchool Parent Portal! To access the forms, you will need a PowerSchool Parent Account with all your students added to it. If you need assistance with creating a Parent Account, please contact the Rimrock office at 208-834-2260.

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NEW! ONLINE FORMS!

ONLINE FORMS - Getting Started

1. Log into your PowerSchool Parent Portal. Once logged in, select a student from the tab along the top and then click on the Forms tab on the left side of the page.

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2. You will see what forms you have for that student. Please note that you can only look at the set of forms un-der one student at a time. Locate and click on the form “2021-2022 Athletic Program Registration”.

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3. Complete the form and click submit at the bottom. If you need to submit the form for more than one student, click on the arrow next to submit and click on “Submit for Family”. Please note: this option may not be available for other forms.

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4. You can check the submission status of the form on the Forms tab. Remember that you need to go to each student tab to view forms for that student.

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RIMROCK JR. SR. HIGH SCHOOL 39678 State Hwy. 78, Bruneau, ID 83604 PH: (208) 834-2260 FAX: (208) 834-2516

ATHLETIC PROGRAM PARTICIPANT RELEASE AND WAIVER FORM 2021-2022 SCHOOL YEAR

_____________________________________ _____ ____________________________________ Student’s Name (Print) Grade Name of Parent/Legal Guardian

________________________________________ ___________________________________________ Parent Contact Number Parent Email Address

________________________________________ ___________________________________________ Emergency Contact Name Emergency Contact’s Phone Number

To get an estimate of the number of student participants, please check which activities your student will partici-pate in, or may be interested in participating, this school year. Choose all that apply.

FALL SPORTS Volleyball Football Cross Country Cheer (9-12 grads only)

WINTER SPORTS Basketball Cheer (9-12 grads only)

SPRING SPORTS Track Baseball (9-12 grade only) Softball (9-12 grade only)

1. LIABILITY RELEASE: I, identified above as the parent/legal guardian of the above listed student (hereinafter “Stu-dent”), hereby grant the permission necessary to allow Student to participate in the Athletic Program conducted by Rimrock Jr. Sr. High School. I, in my own behalf and on behalf of the Student, further agree to release and hold harm-less Joint School District 365, Rimrock Jr. Sr. High School, the Idaho High School Activities Association, and all of the respective directors, officers, members, agents, representatives, and employees of Joint School District 365, Rimrock Jr. Sr. High School, and the Idaho High School Activities Association (hereinafter collectively “Releasees”) from any and all liability for negligence or any other claim judgment, loss, liability, cost, and expenses (including, without limi-tations, attorney’s fees and costs) arising out of or connected with the Athletic Program, including any claim arising out of or connected with any illness or injury (minimal, serious, catastrophic and/or death) that the Student may incur or sustain while participating in the Athletic Program, all activities associated with the Program and while traveling to and from the activity site whether or not the activity actually occurs. I further expressly agree to indemnify and hold harm-less Releasees and Releasees’ heirs, successors, assigns, executors and administrators against loss from any further claims, demands, or actions that may subsequently be brought by Student or by any other persons on the account of damages of any character resulting to Student in any way from the foregoing activities. I further agree to reimburse and to make good to Releasees any loss, or costs Releasees may have to pay as a result of such action, claim, or de-mand.

I, in my own behalf and on behalf of the Student, hereby warrant that I have read this Liability Release in its entirety and fully understand its contents. I, in my own behalf and on behalf of the Student am aware that this Liability Release releases Releasees from liability and contains an acknowledgment of my voluntary and knowing assumption of the risk of injury or illness. I, in my own behalf and on behalf of the Student, have signed this document voluntarily and of my own free will.

2. MEDICAL RELEASE: I acknowledge and agree, in my own behalf and on behalf of the Student, that such participa-tion subjects Student, to possibility of physical illness or injury (minimal, serious, catastrophic and/or death) and that I, in my own behalf of the Student, acknowledge that the Student is assuming the risk of such illness or injury by partici-pating in the Athletic Program. In the event of such illness or injury, I authorize Rimrock Jr. Sr. High School to obtain necessary medical treatment for the Student and hereby, in my own behalf and on behalf of the Student, release and

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hold harmless Releasees in the exercises of this authority. I further acknowledge and understand that I will be respon-sible for any and all medical and related bills that may be incurred on behalf of the Student for any illness or injury that the Student may sustain while participating in the Athletic Program and while traveling to and from the sites for the Athletic Program Activities whether or not the Activity actually occurs.

I represent that any medication to which Student is allergic or medications that Student is currently taking are listed below.

Medications (if any) __________________________________________________________________________

Allergic to (if any) ____________________________________________________________________________

I acknowledge that the Student suffers from the following medical conditions (if any) ___________________________________________________________________________________________ ___________________________________________________________________________________________

I authorize the Athletic Program administrative staff, if necessary, to give Student non-prescription medicine (Tylenol, Benadryl, cold/allergy remedy, etc,) while participating in Athletic Program Activities.

3. MEDICAL INSURANCE: (Check One)

I have insurance that will pay for medical expenses if my student is injured while participating in a school sport.

I do not have insurance for my student and understand that the school district is not responsible and will not pay any doctor, hospital and medical expenses if my child is injured while participating in any school sport.

4. EXTRACURRICULAR ELIGIBILITY (DISTRICT POLICY 3059): All athletes are expected to maintain eligibili-ty during the season through weekly grade checks. To be eligible, athletes must have a minimum 2.0 GPA and be pass-ing all classes. If an athlete’s GPA is lower than a 2.0 or has any failing grades, he/she will be ineligible for the follow-ing week and will have one week to raise grade(s). Homeschool students will also be held accountable for maintaining a 2.0 GPA with no failing grades. View this policy in its entirety at www.sd365.us/Board_Policies.

5. TRANSPORTATION (DISTRICT POLICY 4051): Athletes may not transport themselves from school to a school-sponsored activity - neither in part (stopping somewhere along the way) nor in full. Athletes may ride home with a parent/guardian, or known adult, after the school-sponsored event ends by having a parent/guardian verbally sign them out with the school staff responsible for the event. Athletes wishing to be dropped off on the way home from the event may make arrangements ahead of time by having a signed parental letter on file at the Rimrock office, indicating the parent-approved drop off location. View this policy in its entirety at www.sd365.us/Board_Policies.

SIGNATURES

We, identified above as parent/legal guardian and Student, acknowledge that we have read this Release and Waiver form.

______________________________________________ ________________ Signature of Parent or Legal Guardian Date

______________________________________________ ________________ Signature of Student Date

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RIMROCK JR. SR. HIGH SCHOOL 2021-2022 SCHOOL YEAR

DRUG TESTING CONSENT Participants in the voluntary drug-testing program will be considered active when they become a member of an activi-ty program at Rimrock Jr. Sr. High School during the school year listed above.

STUDENT PLEDGE As a Student participating in a sport and/or activity, I agree to be subject to periodic drug tests for the duration of the activity or program. Furthermore, I will not partake of alcohol, tobacco, or illegal drugs while involved in Rimrock Jr. Sr. High School activities. Student Signature: ___________________________________________________________________ Student Name (print): ________________________________________________________________ PARENTS CONSENT/RELEASE We, or I, the parent(s), and managing conservator(s) of said child, give consent to collect and have tested sample of urine, saliva, or breathalyzer to determine whether or not the child’s system shows freedom of drug use. As partial consideration from such testing, will release Rimrock Jr. Sr. High School and School District 365 from any liability and agree to indemnify and hold harmless these entities from any claim which might be made by virtue of such test and the results thereof. The test will not be given through this program to a student under 18 years of age without the consent of both the stu-dent and parent(s) or guardian(s). As the parent/guardian of said child, I will abide by the principles set forth in this program and will not willingly al-low my child or any underage child in my presence to partake of any illegal drug, alcohol, or tobacco products. Parent/Guardian Signature: ____________________________________________ Date: __________

PARENT/GUARDIAN & ATHLETE CONCUSSION INFORMATION ACKNOWLEDGEMENT

I, ______________________________________, by signing below, hereby acknowledge that Rimrock Jr. Sr. High School has provided me with the necessary and appropriate education on concussion as mandated under subsection 33-1625, Idaho Code. The education included appropriate guidelines that identified the signs and symptoms of concussion and head injury, and described the nature and risk of concussion and head injury in accordance with standards of the Cen-ters for Disease Control and Prevention.

I acknowledge that in addition to receiving the education designated in the above paragraph, that I understand the nature of concussion, the signs and symptoms of concussion, and the risks of allowing a student athlete to continue to play after sustaining a concussion.

___________________________ Student Name (Please Print)

___________________________ Student Signature

___________________________ Date (mm/dd/yyyy)

___________________________ Parent/Guardian Name

(Please Print)

___________________________ Parent/Guardian Signature

___________________________ Date (mm/dd/yyyy)

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Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and

local governments and federal and state health agencies recommend social distancing and have, in many locations, prohib-ited the congregation of groups of people.

The Bruneau-Grand View School District has put in place protective measures to reduce the spread of COVID- 19; how-ever, the BGV SD cannot guarantee that you or your child(ren) will not become infected with COVID- 19. Further, attend-ing activities on the campuses of BGV SD could increase your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending activities on BGV SD campuses and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 while on BGV SD campuses may result from the actions, omissions, or negligence of myself and others, including, but not limited to, BGV SD employees, classified staff, coaches, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or ex-pense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance in activ-ities or participation in MSD programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the BGV SD, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the BGV SD, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any BGV SD activity.

The safety of our employees, students, families and visitors remains the BGV SD’s priority. To prevent the spread of COVID-19 and reduce the potential risk of exposure to all parties, we are conducting a simple screening questionnaire with this waiver. Your participation is important to help us take precautionary measures to protect you, your Child(ren) and everyone on campus. Please circle your answers.

1. Has your child had close contact with or been diagnosed with COVID-19 within the 30 days?** YES NO

2. Has your child experienced any of the symptoms below in the last 14 days?** YES NO (fever, chills, cough, sore throat, respiratory illness, difficulty breathing, or loss of taste or smell) 3. If my Child(ren) develop(s) any of the above symptoms I will keep them home, notify the Coach and seek medical care to obtain a physician’s note stating it is safe to return to participation. YES NO

** If the answer is “yes” to questions 1 or 2, access to campus activity will be denied until a physician’s note is delivered to the Athletic Director.

__________________________________________________________________________________________________ Signature of Parent/Guardian Date

__________________________________________________________________________________________________ Print Name of Parent/Guardian Name of Student Athlete

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WHAT%IS%A%CONCUSSION?%A"concussion"is"a"type"of"traumatic"brain"injury"–"or"TBI"–"caused"by"a"bump,"blow,"or"jolt"to"the"head"or"by"a"hit"to"the"body"that"causes"the"head"&"brain"to"move"quickly"back"&"forth.""This"fast"movement"can"cause"the"brain"to"bounce"around"or"twist"in"the"

skull,"creating"chemical"changes"in"the"brain"&"sometimes"stretching"&"damaging"the"brain"cells."

WHAT%ARE%SIGNS%&%SYMPTOMS%OF%CONCUSSION?%Signs"&"Symptoms"of"concussion"can"show"up"right"after"the"injury"or"may"not"appear"or"be"noticed"until"days"or"weeks"after"the"injury.""If"an"athlete"reports"one"or"more"symptoms"of"concussion"after"a"bump,"blow,"or"jolt"to"the"head"or"body,"s/he"should"be"kept"out"of"play"the"day"of"the"injury.""The"athlete"should"only"return"to"play"with"the"permission"from"a"health"care"professional"

experienced"in"evaluating"for"concussions."

Athlete%Reported%Symptoms:%• Headache"or"“Pressure”"in"the"Head"• Nausea"or"Vomiting"• Dizziness"or"Balance"Problems""• Blurry"or"Double"Vision"• Sensitivity"to"Light"• Sensitivity"to"Noise"• Feeling"Sluggish,"Hazy,"Foggy"or"Groggy"• Concentration"or"Memory"Problems"• Confusion"• Just"not"“feeling"right”"or"is"“feeling"down”"

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

“IT’S&BETTER&TO&MISS&ONE&GAME&

THAN&THE&WHOLE&SEASON”&

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

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• One"pupil"larger"than"the"other"• Is"drowsy"or"cannot"be"awakened"• A"headache"that"gets"worse"• Weakness,"numbness,"or"decreased"coordination"• Repeated"vomiting"or"nausea"• Slurred"speech"

• Convulsions"of"seizures"• Cannot"recognize"people"or"places"• Becomes"increasingly"confused,"restless"or"agitated""• Has"unusual"behavior""• Loses"consciousness"(even"briefly"should"be"taken"seriously)"

WHAT%SHOULD%YOU%DO%IF%YOU%THINK%YOUR%ATHLETE%HAS%A%CONCUSSION?%1. If"you"suspect"that"an"athlete"has"a"concussion,"remove"the"athlete"from"play"and"seek"medical"attention.""Keep"the"athlete"

out"of"play"the"day"of"the"injury"&"until"a"health"care"professional"experienced"in"the"evaluating"for"concussion"says"s/he"is"symptom\free"and"it’s"OK"to"return"to"play.""

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

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

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

Name: Sex: M / F Date of birth: Age:Address: Phone:

School: Sports: Participation Grade:

Yes No Yes No1. Have you ever been hospitalized? 6. Have you ever had a head injury?

Have you ever had surgery? Have you ever been knocked out or unconscious?

2. Are you presently taking any medication or pills? Have you ever been diagnosed with a concussion?

Have you ever had a seizure?

Have you ever had a stinger, burned or pinched nerve?

7. Have you ever had heat or muscle cramps?

Have you ever been dizzy or passed out in the heat?

8. Do you have trouble breathing or do you cough during or after exercise?

9. Do you use special equipment (pads, braces, neck rolls, mouth guard or eye guards, etc.)?

10. Have you ever had problems with your eyes or vision?

Do you wear glasses, contacts or protective eyewear?

11. Have you had any other medical problems ( infectious mononucleosis, diabetes, ect.)?

12. Have you had a medical problem or injury since your last evaluation? Yes No13. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any of bones or joints?

14. Were you born without a kidney, testicle, or any other organ?15. When was your first menstrual period?

Explain "YES" answers:

PARENT OR GUARDIAN SIGNATURE DATE:

SIGNATURE OF STUDENT DATE:

(Parent or guardian and student permission and approval) I herby consent to the above named student participating in the interscholastic athletic program at his/her school of attendance. This consent includes travel to and from athletic contests and practice sessions. I further consent to treatment deemed necessary by physicians designated school authorities for any illness or injury resulting from his/her athletic participation. I also consent to release of any information contained in this form to carry out treatment and healthcare operations for the above named student.

CONSENT FORM

If the health care provider's exam will be performed without compensation as part of the school's health examination program for participation in high school activities, I agree to the waiver provisions as set forth in Idaho Code Section 39-7703 and agree that the health care provider shall be immune from liability as specified in said section.

This application to compete in interscholastic athletics for the above school is entirely voluntary on my part and is made with the understanding that I have not violated any of the eligibility rules and regulation of the State Association.

Have you been told you have a heart murmur?

Have you ever had racing of your heart or skipped heartbeats?

Has anyone in your family died of heart problems or a sudden

neck chest elbow wrist finger thigh shin foot

Yes No

head back shoulder forearm hand hip knee ankle

HEALTH EXAMINATION and CONSENT FORMIt is required all students complete a history and physical examination prior to his/her first 9th and 11th grade practice in the interscholastic (9-12) athletic program in the State of Idaho. The exam is at the expense of the student and may not be taken prior to May 1 of the 8th and 10th grade years. This examination is to be done by a licensed physician, physician's assistant or nurse practitioner under optimal conditions. Interim history forms are required during the 10th and 12th grade years and must be submitted to the school administration prior to the first practice.

When was your last menstrual period?

What was the longest time between your periods last year?

death before age 50?

MEDICAL HISTORYFill in details of "YES" answers in space below:

3. Do you have any allergies (medicine, bees, other insects)?

5. Do you have any skin problems (itching, rash, acne)?

4. Have you ever passed out during or after exercise?

Have you ever been dizzy during or after exercise?

Have you ever had chest pain during or after exercise?

Do you tire more quickly than your friends during exercise?

Have you ever had high blood pressure?

Normal Abnormal findings

Pulses Heart Lungs Skin Ears, nose, throatPupilsAbdomen

Neck Shoulder Elbow Wrist Hand Back Knee Ankle Foot Other

Clearance: A. Cleared for all sports and other school-sponsored activates.

B. Cleared after completing evaluation/rehabilitation for:

C. NOT cleared to participate in the following IHSAA sponsored sports /activities:

D. Reason:

Recommendation:

Name of physician:

Medical

Musculoskeletal

NOT cleared for other school-sponsored activities (example: lacrosse):

Idaho High School Activities Association

Physical Examination Form

Height __________ Weight ___________ BP _____ / _____ Pulse _______

Vision R 20 / ____ L 20 / ____ Corrected: Y N

Name: Date of Birth:

Signature of physician/medical provider: Date:(This Physical Examination Form MUST be signed by a licensed physician, physician assistant or nurse practitioner)

Address: Phone:

Genitalia (males)

Student is NOT permitted to participate in high school athletics.

CLEARANCE / RECOMMENDATIONS

baseball basketball cheer/dance cross country football golf

soccer softball swimming tennis track volleyball wrestling

INTERIM QUESTIONNAIRE It is required all students complete a history and physical examination prior to his/her first 9th and 11th grade practice in the interscholastic (9-12) athletic program in the State of Idaho. The exam is at the expense of the student and may not be taken prior to May 1 of the 8th and 10th grade years. This examination is to be done by a licensed physician, physician's assistant or nurse practitioner under optimal conditions. Interim history forms are required during the 10th and 12th grade years and must be submitted to the school administration prior to the first practice.

Name: Address: School:

Date of birth: Phone: Participation Grade:

Sex: M / F

MEDICAL HISTORY SINCE LAST PHYSCAL EXAMINATION, HAS THIS STUDENT:

Fill in details of "YES" answers in space below: 1. Had surgery? 2. Been hospitalized? 3. Been under a physician's care 4. Had serious illness? 5. Had an injury requiring a physician's care? 6. Been rendered unconscious? 7. Been diagnosed with a concussion? 8. Started taking any new medications? 9. Developed any new drug allergies? 10. Developed any health problems?

Explain "YES" answers:

Yes No

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CONSENT FORM (Parent or guardian and student permission and approval)

I herby consent to the above named student participating in the interscholastic athletic program at his/her school of attendance. This consent includes travel to and from athletic contests and practice sessions. I further consent to treatment deemed necessary by physicians designated school authorities for any illness or injury resulting from his/ her athletic participation. I also consent to release of any information contained in this form to carry out treatment and healthcare operations for the above named student.

PARENT OR GUARDIAN SIGNATURE__________________________________________________________ DATE_____________________

This application to compete in interscholastic athletics for the above school in entirely voluntary on my part and is made with the understanding that I have not violated any of the Eligibility rules and regulation of the State Association. SIGNATURE OF STUDENT____________________________________________________________________ DATE_____________________

Note: The original copy of this form MUST be returned to the school