School Health Insurance

SCHOOL HEALTH INSURANCE

The Board of Education has adopted a student accident policy for coverage of students in the following situations:

A.  Attending school during the hours and on the day when school is in session, including summer classes (but not the Town Youth Recreation);

B.  Traveling directly and uninterruptedly to or from the student’s residence and school for regular session, for such travel time as may be necessary (within one hour before school begins and one hour after dismissal from school – longer if school bus requires).

C.  Participating in or attending activities sponsored solely by the school and directly and continuously supervised by a school official or employee, including extracurricular activities and including school-furnished and school-supervised transportation to and from such activities.

ALL ACCIDENTS MUST BE REPORTED TO THE COACH OR SCHOOL NURSE IMMEDIATELY!!!

REMEMBER: If you have a health or accident policy of your own, it is the primary coverage. The school insurance policy is a supplement to your personal family policy. The plan covers “usual and customary” fees for treatment that your student receives, but is a limited policy. There is also a $25.00 deductible charge for each accident occurrence.

PLEASE READ THE ATTACHED INSURANCE POLICY PAMPHLET FOR MINOR SPECIFIC COVERAGE INFORMATION, INCLUDING ITEMS NOT COVERED.

I have read the above insurance information and agree to allow my son/daughter,

, to participate in (Sport). I also give permission for my son/daughter, , to have medical or surgical treatment necessary in the event of a sport injury during the school year.

DATE: PARENT SIGNATURE:

Person carrying insurance Policy #:

Home Address:

Telephone #: Home Work

Emergency contact when parents cannot be reached:

Name: Telephone #:

Name: Telephone #:

Appendix J

SPORTS CANDIDATES QUESTIONNAIRE

Name Date of Birth Grade

Athletic Activity

History Since Last Medical Exam

ITEM / YES / NO / IF YES, please explain and give dates.
1. Any injuries requiring medical attention?
2. Any illness lasting more than five days?
3. Taking any medication or under physician’s care at this time?
4. Have you ever passed out or nearly fainted with exertion or exercise?
5. Any significant chest pain with exercise?
6. Any family history of sudden death in otherwise healthy individual?
7. Do you wear glasses or contacts?
8. A major operation or fracture?
9. Treated in a hospital or Emergency Room?
10. Any reason why this person cannot participate in any sport?
11. Any know allergies?
12. Any chronic illness?

PERMISSION

We understand clearly that the questions are asked in order to decide if this student is in a proper condition to participate in the athletic activity named at the top of this form. The answers will be kept confidentially in his/her health record in the school health office.

Signature of Parent/Guardian: Date:

Signature of Student: Date:

NOTE: “YES” ANSWERS TO ANY OF THESE QUESTIONS DOES NOT MEAN DISQUALIFICATION FROM THE ATHLETIC ACTIVITY INDICATED. THEY WILL REQUIRE REVIEW AND EVALUATION BY THE SCHOOL HEALTH STAFF.

ATHLETIC CODE OF CONDUCT

NEWFIELD HIGH/MIDDLE SCHOOLS

At Newfield Central School, we believe that interscholastic athletics are a privilege available to all students. We feel that along with this privilege come some very important responsibilities.

Responsibilities of all Newfield student athletes

1.  Academic success is more important than athletics and that if I fail two or more subjects, I will be ineligible to participate in athletics.

2.  To show true sportsmanship whether winning or losing.

3.  I represent Newfield both on and off the field; therefore, my conduct will be exemplary both on and off the field.

4.  To work cooperatively with the athletic staff and all members of the school community.

5.  To be a good school citizen and abide by the rules of the school.

6.  To refrain from the use of alcohol, tobacco, or other drugs while a member of a Newfield athletic program.

7.  To be in regular attendance at all practices and contests.

8.  To refrain from being involved in criminal activities while a member of a Newfield athletic team.

As with any privilege, I realize that if I don’t fulfill my responsibilities, I will be subject to disciplinary action. This action can vary from a verbal reprimand to dismissal from the team.

I further realize that each individual coach may have a more stringent set of responsibilities and rules, which they wish to enforce and I agree to abide by those rules also.

I have read the above responsibilities and agree to allow (Student’s

Name) to participate in this sports season.

(Name of Sport)

(Student’s Signature) (Parent’s Signature)

(Date)