WILKES COUNTY SCHOOLS
HIGH SCHOOL ATHLETIC PARTICIPATION FORM
Please Print
Name:___ HomePhone:__HighSchool:_ Gender: M F DateofBirth: _ Race: _ Age:_ _
Father'sName:___
DaytimePhone:_CellPhone:Other:_ Mother'sName:____ _
DaytimePhone:CellPhone:Other:__ Email: _
StreetAddress:_ County:_ City:. __ State:_ _ __ZipCode:__ _ AlternateEmergencyContactPerson: _ _ Day Ph _____CellPh. _
Wecertifythatthehomeaddressshowninthisdocumentfileismysolebonafideresidence,andIwillnotifytheschoolprincipalimmediately ofanychangeinresidence,sincesuchamovemayaltertheeligibilitystatusofmystudentathlete.Allotherinformationcontainedinthis formisaccurateandcorrect.
Parent/LegalGuardianSignature:AthleteSignature:
Thisismy consecutivesemesterinHighSchool,andIenteredtheninthgradeinthefallof(yr.).LastsemesterIattended Schoolandpassed (number) courses. Ihave also notbeenconvictedofafelonyoranactthatwouldhavebeenafelonyifIwerenotclassified ajuvenile.
Request for Permission:
We,theundersignedstudentandthestudent'sparenUguardian,applyforpermissiontoparticipateininterscholasticathleticsinthefollowingsports: (Pleasecheckallsportsthatapply.)
( ) Basketball ( ) Baseball
( )Cheerleading ()CrossCountry
( )Football ( )Golf
( ) Tennis
( ) Soccer ( ) Softball
( )Swimming
( ) Track
( ) Volleyball( ) Wrestling
Insurance :
WilkesCounty School(WCS)furnishes anInterscholasticAthleticInsurancePolicywhichprovideslimitedbenefitsforall studentsinthe system who participateinhighschoolsponsoredandsupervisedinterscholasticathleticactivities.The policyprovidesexcesscoverageforstudentswithotherinsurancecoverage,butitpaysonlywhenotherbenefitshavebeenexhausted.Itisasecondaryinsurance!Incasesinwhichastudenthasno othercoveragewitheitheracommercialinsuranceagency,MedicareorMedicaid,theWCS athleticinsurancepolicyistheprimarypolicy.
Ifyoursonordaughtershouldbeinjuredwhileparticipatinginahighschoolsponsoredorsupervisedinterscholasticathleticevent,thefollowing proceduresmustbefollowedtoprocessaclaimundertheinsuranceprovidedbyWCS.
•Usetheclaimformyoureceivedinyourparentmeetingordownloadaformat
•Seeaphysicianwithin30daysoftheinjury.
•CompleteandsubmittheAccidentClaimForm.Theclaimformmustbefiledwiththeinsurancecompanywithin60daysoftheinjuryandshouldincludetheExplanationofBenefitsformfromyourprimaryinsurancecarrier.Pleaselistbelowthenameofyourprimaryinsurancecarrierandpolicynumber.
Risk of Injury
We acknowledge and understandthat thereis a riskofinjuryinvolvedinathleticparticipation. We understand thatthe studentathlete will be underthe supervisionanddirectionofaWCSathleticcoach.Weagreetofollowtherulesofthesportandtheinstructionsofthecoachinordertoreduceriskof injury to thestudent and otherathletes.However,we acknowledgeand understandthatneitherthe coach nor WCS can eliminatethe riskofinjury in sports.Injuriesmayand do occur.Sportsinjuriescan be severe and, insome cases, mayresult inpermanentdisabilityoreven death.We freely, knowingly, andwillfullyacceptand assume therisk of injurythat mightoccur fromparticipation inathletics.
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'scontrol from the time he/she arrives at the athletic field untilhe/she leaves the field. The penalties listed in the North Carolina High School AthleticAssociation Handbook willbe adhered to for any athlete ejected from an athletic contest.
Protect your Eligibility: Know the Rules: To represent your school in Athletics, YOU:
•Mustbeaproperlyenrolledstudentatthetimeyouparticipate,mustbeenrollednolaterthanthe151hdayofthepresentsemester,andmust beinregularattendanceatthatschool. Mustalsohavemetlocalpromotionstandards.
•Mustnotbeconvictedofafelonyinthisoranyotherstate,oradjudicatedasadelinquentforanoffensethatwouldbeafelonyifcommittedb anadultinthisoranyotherstate.
•Mustnothavemorethan12absences(85%attendancerequirement)inthesemesterpriortoathleticparticipation.
•Mustnothaveexceededeight(8)consecutivesemestersofattendanceorhaveparticipatedmorethanfour(4)seasonsinanysportsince firstenteringgradenine(9).
•Mustbelessthan19yearsofageonorbeforeAugust31st,2013.
•MustJivewithyourparentsorlegalcustodianwithinthehighschooldistrictthatyouattend. SchoolofChoicepolicy4150ofWilkesCounty Schoolsaddressesexceptionsandpenaltiesforthisrule.
•Mustbepresentatschoolhalfofthedayinordertoparticipateinanathleticeventforthatday.Thisincludesgamesandpractices.
•Musthavepassedaminimumofthreecoursesduringtheprevioussemesterinablockschedule.
•Musthavereceivedamedicalexaminationbyalicensedphysicianwithinthepast365days. Ifyoumissfive(5)ormoredaysofpracticedue toillnessorinjury,youmustreceiveamedicalreleasefromalicensedphysicianbeforepracticingorplaying.
•Mustnotacceptprizes,merchandise,oranythingthatexceedsavalueof$20perseasonasaresultofathleticparticipation.Thisincludes beingonafreelistorloanlistforequipment,etc.Noamountofmoneycanbeacceptedatanytime!
•Mustnothavesignedaprofessionalcontract,haveplayedonajuniorcollegeteam,orbeenrolledandattendingaclassincollege.Thisdoe: notaffectaregularlyenrolledhighschoolstudentwhoistakingacollegecourse(s)foradvancedcredit.
•Mustnotparticipateinunsanctionedall-starorbowlgames.
•Maynotreceiveteaminstructionsfromyourschool'scoachingstaffduringtheschoolyearoutsideyoursportsseason.Instructionislimitedto thecoachandoneormultipleparticipantsinsmallgroupsettings(skilldevelopmentsessions).
•Maynot,asanindividualorateam,practiceorplayduringtheschoolday.
•Maynotplay,practiceorassembleasateamwithyourcoachonSunday.
•Maynotdressforacontest,sitonthebench,orpracticeifyouarenoteligibletoparticipate.
•Mustnotplaymorethanthree(3)gamesinonesportperweek(exceptions:Baseball,Softball,Cheerleading,andVolleyball);andnotmore thanone(1)contestperdayinthesamesport(exceptions:Baseball,Softball,Cheerleading,orVolleyball).
NCHSAA Regulations Student Athlete Pledge:
Asastudentathlete,Iamarolemodel.Iunderstandthespiritoffairplaywhileplayinghard.Iwillrefrainfromengaginginalltypesofdisrespectful behavior,includinginappropriatelanguage,taunting,trashtalking,andunnecessaryphysicalcontact.Iknowthebehaviorexpectationsofmyschool, myconference,andtheNCHSM,andherebyaccepttheresponsibilityandprivilegeofrepresentingthisschoolandcommunityasastudentathlete.
Student-AthleteSignature:__
Parent Pledge:
Asaparent,IacknowledgethatIamarolemodel.Iwillrememberthatschoolathleticsisanextensionoftheclassroom,offeringlearningexperiences forthestudents.Imustshowrespectforallplayers,coaches,spectators,andsupportgroups.Iwillparticipateincheersthatsupport,encourageand uplifttheteams involved.Iunderstandthespiritoffairplayandthegoodsportsmanshipexpected byourschool,ourconferenceandtheNCHSM.I herebyacceptmyresponsibilitytobeamodelofgoodsportsmanshipthatcomeswithbeingtheparentofastudentathlete.
Parent/Legal GuardianSignature:
Coaches Pledge:
As a coach, Iacknowledgethat I am a role model. Iknowthat the principles of good sportsmanshi p are integrity,fairness, and respect. While teaching theskillsofthegame,Imustalsoteachstudentathleteshowtowinandlosegraciously,andthatsportismeanttobeeducationalandfun.Iknowthe behaviorexpectationsofmebythisschool,conference,andtheNCHSM,andherebyacceptmyresponsibilitytobeamodelofethicalbehavior, integrity,and good citizenship.
CoachesSignature:___Date:_
Policy for Quitting a High School Team
Ifanathletequitsateamafteratryoutperiod,thatathletemaynotparticipateinskilldevelopmentpracticesessionsortryoutforanothersportuntilthe teamthathe/shequitisfinishedwiththeirseason.Atryoutperiodisdefinedasbeforefinalteamselection.Ateam'sseasonisdefinedasthefirst practice after final team selectionuntil all games are complete. This includes conference tournaments and state playoff games. Ifan athlete quitsa team itistheresponsibilityofthecoachtonotifytheathleticdirectorimmediately.Therearenoexceptionstothisrule!Acoachmaynotreleasea student-athleteifhe/shequitstheirteam!Insportswherethereisnotadesignatedtryoutperiod(football,wrestling,track,crosscountry,etc.),a student-athletewillhavetwoweekstodecidewhetherornottoparticipate.Aftertwoweeksanathleteisconsideredanofficialteammember.
Student-AthleteInitials: _Parent/LegalGuardianInitials: ___
WilkesCountySchoolsHazingPolicy
TheWilkesCountyschoolswillnottoleratehazingofanykind.Athletesfoundguiltyofhazingwillbeimmediatelyremovedfromathleticparticipation. Thissuspensionwillnotbelessthanoneschoolterm(18weeks).Thispunishmentwillbeinadditiontoanyschooldisciplinegivenbytheprincipal.
Student-AthleteInitials:_Parent/LegalGuardianInitials:_
NCHSAA Sportsmanship/Ejection Policy:
Thepolicyappliestoallpersonsinvolvedinanathleticcontest,includingstudent-athletes,coaches,managersandgameadministrators.Thefollowing examplesincludebehaviororconductwhichwillresultinanejectionfromacontest:
1)Fighting,which includes,butisnotlimitedto,combative actssuchas:
A)Anattempttostrikeanopponentwithafist,hands,arms,legs,orfeet
B)Anattempttopunchorkickanopponent,regardlessofwhetherornotcontactismade
C)Anattempttoinstigateafightbycommittinganunsportsmanlikeacttowardanopponentthatcausesanopponenttoretaliate
D)Leavingthebenchareatoparticipateinafight(contactornocontact)
2)Biting observed by anofficial
3)Taunting, baiting,or spitting toward anopponent
4)Profanity,directedtowardanofficialoropponent
5)Obscenegestures,includinggesturinginamannerastointimidate
6)Disrespectfullyaddressing(physicallycontactinganofficialissubjecttoautomaticexpulsionandcanresult inineligibilityforremainderofcareer)anofficial
Penalty for an ejection for the above reasons:
Football-ejectionfromthecontestandmissthenextcontestatthatlevelandcontestsintheinterim(EXCEPTION:fightingequalstwomissedcontests
Allothersports-ejectionfromthatcontest;missthenexttwocontestsatthatlevelandallcontestsintheinterim(EXCEPTION:fightingequals4 missedcontests)
Playersreceiving two ejections for unacceptablebehavioras defined above will be suspended from all sportsfor theremainderof thatsportseason.Receivingathirdejectioninaschoolyearwillresultinsuspensionfromathleticsforcalendaryear(365daysfromthe dateofthethirdejection).
Student-AthleteInitials:___Parent/LegalGuardianInitials:_
Transportation for Athletic Events:
IfstudenttransportationisbyaWilkesCountySchoolsSystem-ownedvehicle,theschoolsystemvehicleliabilitycoverageisapplicabletoanyvehicula1 accident. Ifstudenttransportationisbyprivatevehicle,thevehicleowner'sliabilitycoverageisapplicabletoanyvehicularaccident.
Studentathleteswilltravelto/fromathleticeventswiththeirteams andcoaches.Anyathletefailingtocomply willnotbeallowedtodressan( participateatthatgame/match.Iftheviolationoccursonthetriphome,thentheathletewillnotdressnorparticipateinthenextgame.A secondoffensewillresultinremovalfromtheteam.
RequestforExceptiontotheTransportationPolicy:Irequestthatmyson/daughterbegivenanexceptiontothetransportationpolicy.Iunderstand andagree thatwiththisrequest Iaccept total responsibilityfor mychild'ssafe return homefrom his/hergame forthe entire season. Iunderstand andagree that Iamresponsiblefor any andall arrangementsrelatedtomy child'sride home.Iunderstandand agree thatmy childmay not ride home withanotherpersonotherthantheirparent(s)oradult(s)designatedbytheparent(s)!Ifaparentwishestodesignateanadultoradultstotaketheirchil(homethey may list those adult(s)ona formpriorto the season starting. Eachformwillbeverified by thecoach and athleticdirector. Ifhe/shedoes not followthispolicyhe/she w ill sitouta gameonthefirst offense and wi ll be removedfromtheteam on the second offense. I herebyreleasetheWilkesCountyBoardofEducation,itsindividualmembers,itsemployeesanditsagentsfromany loss,damage,injury,claim,liabilityorresponsibility
whatsoeverarisingoutof,during,orinanywayconnectedwiththetransportationofmychildfromanathleticeventwhereschooltransportationisnot utilized.
Parent/LegalGuardianInitialsAthleteInitials:
We,theundersignedstudentandparent/guardian,havereadthisdocumentandunderstandalloftheserequirementsforathleticparticipatio atourhighschool,andagreetocomplywiththerequirementssetforthinthisdocument.
Student:Date:Signature
Parent/Guardian:Date:(Please Print)
Parent/Guardian:Date:(Signature)
IIII Wi l kes
Superintendent MartyT.Hemric,Ed.D
=m= county Illschools L- -
Associate Superintendent Wanda P. Hutchinson, Ed.D.
Athletic Department
Assistant Superintendent Anna R. Lankford
Emergency Information and Parental Consent
StudentName:__Birthdate_Age_
Parent'sName:------HomePhone:------
-
Address:_City___ Grade__ DayPhoneNumberofParents:Father _ Mother _ __ Inanemergency,iftheparentscannotbereached,notify:
------
Phone------
-
FamilyDoctor:___Phone__ Known Allergies:------
Pennission is hereby granted to the attending physician to proceed with any medica l 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. Ifthe said physician is not able to communicate with me, the treatment necessary for the best interest of the above named student may be given.
Pe1miss ion is also granted to the Certified Athletic Trainer to provide the needed emergency treatment prior to the student's admission to the medical facilities.
ParentSignature:_____Date___
Revised: August 12, 2011
613 Cherr}Street • :\'orth \Vilkesboro, NC 28659 • Telephone 336.667.l121
,vw,r.,Yilkes.kl2.nc.us
CONCUSSION
INFORMATION FOR STUDENT-ATHLETES & PARENTS/LEGAL CUSTODIANS
What is a concuss ion? 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 Iknow if Ihave a concussion? There are many signs and symptoms that you may have followingaconcussion.Aconcussioncanaffectyourthinking,thewayyourbodyfeels,yourmood,or your sleep. Here is what to lookfor:
Thin king/Rememberin,z / Physical / Emotional/Mood / SleepDi fficulty thinking clearly / 1-kadache / Irritability-t h ings bother you / Sleeping more than usual
more easily
Taking longer to figure things out / Fuzzy or bluny vision / Sleeping less than usual
Sadness
Di fficulty concentrating / Trouble falling asleep
Feeling sick to your / Being more moody
Difficulty remembering new / stomach/queasy / Feeling tired
infom1ation / Feeling nervous or worried
Vomiting/throwing up
Crying more
Dizziness
Balance problems
Sensitivity to noise or light
Tableisadaptedfrom theCentersjar Disease ControlandPrevention (!1ttp:l/mvw.cdc.z,o.-/co11cussio11/)
What should Ido if Ithink Ihave a concussion? If you are having any of the signs or symptoms listed above,youshouldtellyourparents,coach,athletictrainerorschoolnursesotheycangetyouthehelp youneed.Ifaparentnoticesthesesymptoms,theyshouldinformtheschoolnurseorathletictrainer.
When should Ibe 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 tooearly vvitha concussion, you may have long term trouble remembering thingsor paying attention,headachesmay lastalongtime,orpersonalitychangescanoccurOnceyouhaveaconcussion,youare more likely to have anotherconcussion.
How do Iknow when it's ok to return to physicalactivity and my sport after a concussion? After tellingyourcoach,yourparents,andanymedicalpersonnelaroundthatyouthinkyouhaveaconcussion, youwillprobablybeseenbyadoctortrainedinhelpingpeoplewithconcussions.Yourschoolandyour parentscanhelpyoudecidewhoisbesttotreatyouandhelptomakethedecisiononwhenyoushould returntoactivity/playorpractice.Yourschoolwillhaveapolicyinplaceforhowtotreatconcussions.
You should not return to play or practice on the same day as your suspected concussion.
ThisinformationisprovidedtoyoubytheUNGMatthewGfellerSport-RelatedTBIResearchCenter,NorthCarolinaMedicalSociety,North CarolinaAthleticTrainers'Association,BrainInjuryAssociationofNorthCarolina,NorthCarolinaNeuropsychologicalSociety,andNorth CarolinaHighSchoolAthleticAssociation.
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.
This form must be completed for each student-athlete, even if there are multiple student-athletes in each household.
ParenULegal Custodian Name(s):
o We have read the Student-Athlete Parent/Legal Custodian Concussion Information Sheet.
If true, please check box.
After reading the information sheet, Iam aware of the following information:
Student-AthleteParent/Legal
InitialsCustodian
Initials
A concussion is a bra in injury which should be repo1ted to my paren ts, my coach(es), or a medical professional if one is ava ilable.
A concussion can affect the ability to perfonn everyday activities such as the ability to think, balance, and classroom performance.
A concussion cannot be "seen." Some symptoms might be present right avvay. Other symptoms can show up hours or days after an injmy.
I will tell my parents, my coach, and/or a medical professiona l about my
injuriesandillnesses.NIA
If I think a teammate has a concussion, I should tell my coach(es), parents, or
medical professional abouttheconcussion.N/A I will not return to play in a game or practice if a hi t to my head or bodycauses
anyconcussion-relatedsymptoms.N/A
I will/my child will need w1itten pe1mission from a medical professional trained in concussion management to return to play or practice after a
COllCUSSlO!l.
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 1am/my child is much more likely to have another concussion or more serious brain injury ifretum 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 Infonnation Sheet.
SignatureofStudent-AthleteDate
Signatur e ofParent/LegalCustodianDate
IllW ilkes
Superinte ndent MartyT.Hemric,Ed.D
Illcounty
Illschools
Associate Superintendent Wanda P. Hutchinson, Ed.D.
Assistant Superintendent Anna R. Lankford
._.
.._. J..;..••_,
----'---
\-VCS Department of Athletics Transportation Release Form
Student Name:
Request for Exception to the Transporta tion Policy: I request that my son/daughter be given an exception to the transpo1iationpolicy.I understandand agree thatwiththisrequest I accept total responsibility for my child's safe rehu11 home from his/her games that the sh1dent 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 pa rent(s)! Ifa parent wishes to designate an adult or adults to take their child home they may list those adult(s) on this fo1111 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. Ifhe/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 transporiation of my child from an athletic event where school transporiation is not utilized.
SignahireofSh1dent-AthleteDate
Signature ofParent/LegalGuardianDate List below the adult designee(s) for each sport season:
Fall:vVinter:Spring:
1)1)1)
2) / 2)2)3) / 3)3)
4) / 4)4)
5) / 5)5)
613 Cherry Street • l'lorth \Yilkesboro, NC 28659 • Telephone 336.667.1121
\\Ww .wilkes.kl 2.nc.us
\Vilkes County Schools Sign Out Docu111entationSheet
Student Name:
Printed NameofPersonSignatureofPersonTransportingStudentTransportingStudent
Venue/SiteDate
613 Che rry Street • i\'orth Wilkesbo ro, l\C 2S659 • Telepho ne 336.667.112 1
w,,w.wilkcscoun tyscho ols.o rg
016-2017 1\'orth Carolina High School A thletic Association Eligi bility and Au thoriza tion Statemen t!
This document is to be si!!Jled by the participant of an NCHSAA member school and bv the participant's parent .
I have read, understand and acknowledge rec eipt of the eligi bi lity mies of the North Carol ina High School Athletic Association. I understand that a copy of the NCHSA.-l Handbook is on file with the principal and ath letic administrator
and that I may revi ew it, in its entirety, if I so choose. All NCHSAA bylaws and regulations from the Handbook are also posted on the NCHSAA web site at ,,ww.nchs:ia.orn:
I understand that an NCHSAA member school must a dh ere to all rules and regulations that pertain to the interscholastic athletics programs that the school sponsors, but that local mies may be more stringent than 'KCHSAA mies.
I understand that part i cipation in interscholastic athletics is a priYilege not a righ t.
Studen t Code of Respon sibilitv
As a st11dent athlete, I und erstand and accept the following respons i bilities:
I ,viiirespecttherightsand beliefsof others and willtreat others with courtesy and consideration. Iwillbefullyresponsibleformyownactionsandtheconsequencesofmy actions.
I will respect the property of others.
I will respect an d obey the rules of my school and la\\·s of my community, state and country.
I wil l show respect to those who are responsible for enforcing the rules of my school and the laws ofmy community, state and country.
I u nderstand that a student whose character or conduct violates the school 's Athletic Code or School Code of Responsibility could be deemed ineligible for a period of time as dete1mined by the principal or school system Administration
I und erstand that if I drop a class, take course work through Post Secondary Enrollmen t Option, or other educational options, this action could affect compliance with NCHSAA academic standards and my eligibility.
Inform ed Consen t -By its nahire, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety mies, report all physical and hygiene problems to their coaches, follow a proper
conditioning program, and inspect thei r own equipment daily . PARENTS, LEGAL CUSTODIAN'S OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED I:\1 THIS WAR..i'i'ING SHOULD N OT SIGN THIS FOR.."i \I. STUDE:\1TS MAY NOT PARTICIPATE IN A NCHSAA-SPOSORED SPORT WITHOUT THE STUDENT'S AND
PARENT'S/GUARDIAN'S SIGNATURE.
I understand that in the case of injury or illn ess requiri ng treatm ent by medical personnel and transpo rtation to a health care facility, that a reasonable attempt will be made to contact the parent/lega l custodian in the case of the st11dent-athlete being a minor, butthat,ifnecessary,thestudent-athletewillbetreatedandtransportedviaambulancetothenearesthospital.
I consen t to medical treatmen t for the st11dent following an injury or illness suffered during practice and/or a contest.
I und erstand all concussions are potentially serious and may result in complications including prolonged brain damage and death ifnot recognized and managed properly. Further I understand tha t if my student is removed from a practice or competition due to a suspected concussion, he or she will be unable to return to participation that day. After that day, written authorization from a
physician (M.D. or D.O.) or an athletic trainer working under the supervision of a physician will be required in order for the st11dent to return to participation.
I h ave received, read and sign ed the Gfeller-\Yaller Concussion Information Sheet.
I consen t to the NCHSAA use of the h erein nam ed stu den t's name, likeness, and athletic-related infomrntion in reports of contests, promotional l iterature of the Association and other materials and releases related to interscholastic athletics.
By signing this docu ment, we acknowledge th at we have read the above inform ation and tha t we consent to the herei n na m ed student's participation.
Must Be Signed Before Participation
Sn1dent's Signan1re / Birth date / Grade in School / DateSignature of Pare111 or Legal Custodian / Date
sociaci6n de Atletismo d e las Escuelas d e Secundaria Su erior de Carolina del l\'orte ElegibilidadDeclaraci6n de Autorizaci6n2016-2017
Este documento debe ser firmado por el participante de una escuela miembro de la NCHSAA y por el padre/madre del participante.
He leido, entendido y acuso recibo de las regla s de elegibilidad de la Asociaci6n de Atletismo de las Escuelas de Secundaria Superior de Carolina de! Norte (NCHSAA, por sus siglas en ingles). Entiendo que una copia de!Manual de l a NCHSA...Aesta en archivoconel directory el administradordeatletismo y yo podria revisarlo,en sutota lidad,silo deseo.Todos los estatutos y reglamentos de la NCHSAA que estan en el manual, tambien estan publ icados en el sitio web de l a NCHSAA en
Entiendo que una escuela miembro de l a NCHSAA debe cumplir con tod as las reglas y regulacio nes que se refieren a l os programa s de atletismo inter-escolar patrocinados por la escuela, pero que las reglas locales puedeo ser mas estrictas que las reglas de la NC HSAA .
Entiendo que la participaci6n en atletismo inter-escolar es un privilegio no un derecho.
Codigo de responsabilidad del estudian te