Clovis Unified School District Athletic Eligibility Form Intermediate Schools

NOTE: Please read this form completely. Failure to complete this form with accurate information can delay or prevent athletic eligibility. This is the only form that will clear a student for athletic participation including practice. This form also includes the District’s Sports Pre-Participation form that you and a Doctor must complete.

Student’s Name: _____________________________________________________________ Please Print	Last	First

Today’s Date: _________________ Grade Level for Eligibility: _______ Date of Birth: ______________ Age: _______	Sex M / F

Parent’s Name: ________________________________________	Home Address ________________________________________

City: ________________	Zip: _____________	Home Phone: _______________________	Cell: _______________________

*IMPORTANT*
Please answer all the questions “YES” or “NO”

1.	What attendance area do you live in? Please circle the proper area.

Buchanan	Clovis West	Clovis High	Clovis East	Clovis North

2.	Are you now, or have you ever been in the past school year, on an open enrollment or inter-district transfer to attend a school

outside your attendance area?	YES NO

3.	Do you live with your parent(s) or a legal court approved guardian at the above address?	YES NO 4.	Have you lived at any other residence in the last school year? YES NO
If yes, when did you move from the previous address? _______________

If yes, list previous address: ______________________________________________________________________________ 5.	Have you attended any school other than a Clovis Unified school in the past school year?	YES	NO
If the answer is yes, what is the name of the previous school? ___________________________________________________ If the answer is yes, when did you leave the previous school? ___________________________________________________
6.	Have you ever repeated any grade level? YES NO If yes, which grade? 7	8

7.	What CUSD school did your son/daughter attend in: 6th grade 2nd semester?

7th grade 1st semester

_______________

_______________

ATHLETICS -WARNING OF RISK

SERIOUS, CATASTROPHIC AND PERHAPS FATAL INJURY MAY RESULT FROM ATHLETIC PARTICIPATION. By its very nature, competitive athletics may put students in situations in which accidents may occur. Many forms of athletic competition result in violent physical contact among players, the use of equipment, which may result in accidents, strenuous physical exertion, and numerous other exposures to risk of injury. Students and parents must assess the risks involved in such participation and make their choice to participate in spite of those risks. No amount of instruction, precaution, or supervision will totally eliminate all risk of injury. Just as driving an automobile involves choice of risk; athletic participation by students also may be inherently dangerous. The obligation of parents and students in making this choice to participate cannot be overstated. There have been accidents resulting in serious permanent physical impairment as a result of athletic competition. Students will be instructed in proper techniques to be used in athletic competition and in proper utilization of all equipment worn or used in practice and competition. Students must adhere to that instruction and utilization and must refrain from improper uses and techniques. By granting permission for your student to participate in athletic competition, you, as a parent or guardian, acknowledge that such a risk exists. By choosing to participate, you, the student, acknowledge that such a risk exists. FOOTBALL PLAYERS: No helmet can prevent all head or neck injuries a player may receive while participating in football. DO NOT USE YOUR HELMET TO BUTT, RAM OR SPEAR AN OPPOSING PLAYER. This is in violation of the football rules and such use can result in severe head or neck injuries, paralysis or death to you and possible injury to your opponent. If any of the foregoing is not completely understood, please contact your school Athletic Director for further information.

CLOVIS UNIFIED SCHOOL DISTRICT ATHLETIC PROGRAM PARTICIPATION WAIVER
RELEASE OF LIABILITY and MEDICAL TREATMENT AUTHORIZATION AGREEMENT

Student Name:

District School:

Athletic Program:

I understand and acknowledge thatparticipation in the aboveAthleticProgramandany related activities(collectively knownhereinas "Activity"), by their very nature, pose the potential risk of serious injury/illness to individuals who participate. I also realize that the Activity may be strenuous, and that I havethe option to seek the adviceof aphysician before Iparticipate inthis Activity.I understand and acknowledgethat some oftheinjuries/illnesses whichmay result from participatingin this Activityinclude, butare notlimited to, thefollowing:

 Sprains
 Fracturedbones  Unconsciousness

 Headand/orbackinjuries  Paralysis
 Activityrelatedinjury/illness

 Lossofeyesight
 Communicable diseases  Death

The above list isnot intendedto be inclusive ofall injuriesthat mayoccur,but ratherto inform meof the typesof risksinherent inmy participation intheaboveActivitysothat I can make a voluntary choiceto participate or not participate.

In theeventof accident orillness, I dohereby consentto whateverx-ray examination,anesthetic, medical, surgical ordental diagnosis ortreatment andhospitalcareconsiderednecessary in the bestjudgment of the attending physician, surgeon, or dentist andperformed underthe supervision of a member ofthe medicalstaff ofthe hospital orfacility furnishingmedical or dental services. Further, I agree that Clovis Unified SchoolDistrict("District")anditspersonnel arenotlegally orfinancially responsible or liablefor any claim arising from any consent given in goodfaithin connection withdiagnosisoradvisedtreatment.

Intheeventofaccidentorillnesspleasenotify:____________________________________________________________________ Name	Telephone

In consideration of being permitted to participate in the above Athletic Program and any related activities, I agree to assume any and all liability and responsibility for the potential risks which may be associated with participation in such Activity or any activities incidental thereto. I further agree by my signature below to exempt and relieve, on behalf of myself and my heirs, executors, administrators and assigns, the Clovis Unified School District, its Board, officers, agents, employees or volunteers from any and all liability or responsibility forproperty damage,personalinjury,andbodily injury (includingwrongful death)that I might sustain which is incident to, associated withpreparing for, and/or while participating in any activity connected with saidAthletic Program, including travel provided by the District to and from Activity locations. I understand that this provision is intended to be as broad and inclusive as permitted bylaw,andthatifanyportionisheldinvalid,it isagreedthatthebalanceshall continueinfulllegalforceandeffect.

I acknowledge that I have carefully read and understand this Athletic Activity Program Waiver, Release of Liability and Medical Treatment AuthorizationAgreement,andthat Ivoluntarilyagreetoitstermsandconditions.

__________________________________________________________________ Signature of Participant or, if Participant is a minor, Parent/Guardian

__________________________________________________________________ Print Name of Participant or, if Participant is a minor, Parent/Guardian

_________________________ Date

Check Box if Participant is a Minor

Participant's Age (if minor): ____

- 1 -

Parent/Athlete Concussion Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow, or jolt to the
head or body that causes the head and brain to move rapidly back and forth. Even a “ding,”“getting your bell rung,” or what seems to be a mild bump or blow

to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?

Signs and 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 listed below after a bump, blow, or jolt to

Did You Know?

• Most concussions occur without loss of consciousness.

• Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.

• Young children and teens are more likely to get a concussion and take longer to recover than adults.

the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is
symptom-free and it’s OK to return to play.

SIGNS OBSERVED BY COACHING STAFF
	
SYMPTOMS REPORTED BY ATHLETES
	
Appears dazed or stunned
	Headache or “pressure” in head
	
Is confused about assignment or position
	Nausea or vomiting
	
Forgets an instruction
	Balance problems or dizziness
	
Is unsure of game, score, or opponent
	Double or blurry vision
	
Moves clumsily
	Sensitivity to light
	
Answers questions slowly
	Sensitivity to noise
	
Loses consciousness (even briefly)
	Feeling sluggish, hazy, foggy, or groggy
	
Shows mood, behavior, or personality changes
	Concentration or memory problems
	
Can’t recall events prior to hit or fall
	Confusion
	
Can’t recall events after hit or fall
	Just not “feeling right” or “feeling down”

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form 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:

• One pupil larger than the other

• Is drowsy or cannot be awakened

• A headache that not only does not diminish, but gets worse

• Weakness, numbness, or decreased coordination • Repeated vomiting or nausea
• Slurred speech

• Convulsions or seizures

• Cannot recognize people or places

• Becomes increasingly confused, restless, or agitated • Has unusual behavior
• Loses consciousness (even a brief loss of consciousness should be taken seriously)

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.

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 seri-ous concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.

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 the computer, or 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.

It’s better to miss one game than the whole season. For more information on concussions, visit:www.cdc.gov/Concussion.

KeepTheirHeartintheGame ASuddenCardiacArrestInformationSheetforAthletesandParents/Guardians

What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens blood stops flowing to the brain and other vital organs. SCA is NOT a heart attack. A heart attack is caused by a blockage that stops the flow of blood to the heart.SCAisamalfunctionintheheart’selectricalsystem,causingthevictimtocollapse. Themalfunctioniscausedbyacongenitalorgeneticdefectintheheart’sstructure.

How common is sudden cardiac arrest in the United States? AstheleadingcauseofdeathintheU.S.,therearemorethan300,000cardiacarrests outsidehospitalseachyear,withnineoutof10resultingindeath.Thousandsof suddencardiacarrestsoccuramongyouth,asitisthe#2causeofdeathunder25 andthe#1killerofstudentathletesduringexercise.

FAINTING
is the
#
1SYMPTOM
OFAHEARTCONDITION
Who is at risk for sudden cardiac arrest? SCAismorelikelytooccurduringexerciseorphysical activity,sostudent-athletesareatgreaterrisk. While aheartconditionmayhavenowarningsigns,studies showthatmanyyoungpeopledohavesymptomsbut neglecttotellanadult.Thismaybebecausetheyare embarrassed,theydonotwanttojeopardizetheirplay-
ingtime,theymistakenlythinkthey’reoutofshapeandneedtotrainharder,or theysimplyignorethesymptoms,assumingtheywill“justgoaway.”Additionally, somehealthhistoryfactorsincreasetheriskofSCA.

What should you do if your student-athlete is experiencing any of these

TheCardiacChainofSurvival On average it takes EMS teams up to 12 minutes to arrive

to a cardiac emergency. Every minute delay in attending to a sudden cardiac arrest victim decreases the chance of survival by 10%. Everyone should be prepared to take action in the first minutes of collapse.

Early Recognition of Sudden Cardiac Arrest Collapsedandunresponsive. Gasping,gurgling,snorting,moaning orlaboredbreathingnoises.
Seizure-likeactivity.

Early Access to 9-1-1

symptoms?
Weneedtoletstudent-athletesknowthatiftheyexperienceanySCA-related symptomsitiscrucialtoalertanadultandgetfollow-upcareassoonaspossible withaprimarycarephysician.IftheathletehasanyoftheSCAriskfactors,these shouldalsobediscussedwithadoctortodetermineiffurthertestingisneeded. Waitforyourdoctor’sfeedbackbeforereturningtoplay,andalertyourcoach, trainerandschoolnurseaboutanydiagnosedconditions.

Confirmunresponsiveness. Call9-1-1andfollowemergency dispatcher'sinstructions.
Callanyon-siteEmergencyResponders.

Early CPR
Begincardiopulmonaryresuscitation (CPR)immediately.Hands-onlyCPRinvolvesfast
andcontinualtwo-inchchestcompressions—

What is an AED? Anautomatedexternaldefibrillator(AED)istheonlywaytosaveasudden cardiacarrestvictim.AnAEDisaportable,user-friendlydevicethatautomat-
AED
icallydiagnosespotentiallylife-threateningheart rhythmsanddeliversanelectricshocktorestorenor-malrhythm.AnyonecanoperateanAED,regardlessof training.Simpleaudiodirectioninstructstherescuer whentopressabuttontodelivertheshock,while otherAEDsprovideanautomaticshockifafatalheart rhythmisdetected.Arescuercannotaccidentlyhurta
victimwithanAED—quickactioncanonlyhelp.AEDsaredesignedtoonly shockvictimswhoseheartsneedtoberestoredtoahealthyrhythm.Check withyourschoolforlocationsofon-campusAEDs.

about100perminute.

Early Defibrillation Immediatelyretrieveanduseanautomated externaldefibrillator(AED)assoonaspossible torestorethehearttoitsnormalrhythm.Mobile AEDunitshavestep-by-stepinstructionsforaby-
standertouseinanemergencysituation.

Early Advanced Care EmergencyMedicalServices(EMS) Respondersbeginadvancedlifesupport
includingadditionalresuscitativemeasuresand transfertoahospital.

Cardiac Chain of Survival Courtesy of Parent Heart Watch

KeepTheir Heart in the Game

Recognize theWarning Signs & Risk Factors of Sudden Cardiac Arrest (SCA)
Tell Your Coach and Consult Your Doctor if These Conditions are Present in Your Student-Athlete

PotentialIndicatorsThatSCAMayOccur

 Fainting or seizure, especially during or right after exercise

 Fainting repeatedly or with excitement or startle

 Excessiveshortnessofbreathduringexercise

 Racing or fluttering heart palpitations or irregular heartbeat

 Repeated dizziness or lightheadedness

 Chest pain or discomfort with exercise

 Excessive, unexpected fatigue during or after exercise

FactorsThatIncreasetheRiskofSCA

 Family history of known heart abnormalities or sudden death before age 50

 Specific family history of Long QT Syndrome, Brugada Syndrome, Hypertrophic Cardiomyopathy, or Arrhythmogenic Right Ventricular Dysplasia (ARVD)

 Family members with unexplained fainting, seizures, drowning or near drowning or car accidents

 Known structural heart abnormality, repaired or unrepaired

 Use of drugs, such as cocaine, inhalants, “recreational” drugs, excessive energy drinks or performance-enhancing supplements

What is CIF doing to help protect student-athletes?

CIF amended its bylaws to include language that adds SCA training to coach certification and practice and game protocol that empowers coaches to remove from play a student-athlete who exhibits fainting—the number one warning sign of a potential heart condition. A student-athlete who has been removed from play after displaying signs or symptoms associated with SCA may not return to play until he or she is evaluated and cleared by a licensed health care provider. Parents, guardians and caregivers are urged to dialogue with student-athletes about their heart health and everyone associated with high school sports should be familiar with the cardiac chain of survival so they are prepared in the event of a cardiac emergency.

I have reviewed and understand the symptoms and warning signs of SCA and the new CIF protocol to incorporate SCA prevention strategies into my stu-dent’s sports program.

For more information about Sudden Cardiac Arrest visit

California Interscholastic Federation http.www.cifstate.org

Eric Paredes Save A Life Foundation http:www.epsavealife.org

CardiacWise (20-minute training video) http.www.sportsafetyinternational.org

PRESCRIPTIONOPIOIDS:
		
WHAT YOU NEED TO KNOW

Prescription opioids can be used to help relieve moderate-to-severe pain and are often prescribed following a surgery or injury, or for certain health conditions. These medications can be an important part of treatment but also come with serious risks. It is important to work with your health care provider to make sure you are getting the safest, most effective care.

WHAT ARE THE RISKS AND SIDE EFFECTS OF OPIOID USE?

Prescription opioids carry serious risks of addiction and overdose, especially with prolonged use. An opioid overdose, often marked by slowed breathing, can cause sudden death. The use of prescription opioids can have a number of side effects as well, even when taken as directed:

As many as 1 in 4 PEOPLE*

•     Tolerance—meaning youmight need to take more of a medication for the same pain relief
•	Physical dependence—meaning you have symptoms of withdrawal when a medication is stopped
•	Increased sensitivity topain •	Constipation

•	Nausea, vomiting, and dry mouth •	Sleepiness and dizziness
•	Confusion •	Depression
•	Low levels oftestosterone that can resultin lower sex drive, energy, and strength
•	Itchingand sweating

receiving prescription opioids long term in a primary care setting struggles with addition.
*Findings from one study

Avoid alcohol while taking prescription opioids. Also,
	
unless specifically advised by your health care
		
provider, medications to avoid include:

U.S. Department of
		
Health andHuman Services
	
Centers for Disease
		
Control and Prevention

American Hospital
	
Association®

•	History of drugmisuse,substance use disorder, or overdose
•	Mentalhealth conditions (such as depression or anxiety)
•	Sleep apnea
•	Older age (65years or older) •	Pregnancy

•	Benzodiazepines (such asXanax or Valium) •	Muscle relaxants (such as Soma orFlexeril) •	Hypnotics (such asAmbien orLunesta)
•	Other prescriptionopioids

May9,2016

RISKS ARE GREATER WITH:

KNOW YOUR OPTIONS

Talk to your health care provider about ways to manage your pain that don’t involve prescription opioids. Some of these options may actually work better and have fewer risks and side effects. Options may include:
	
RX
Be Informed!

Make sure you know the name of your medication,how much and how often to take it, and its potential risks & side effects.
	
  Pain relievers such as acetaminophen, ibuprofen, and naproxen
  Some medications that are also used for depression or seizures
  Physical therapy and exercise
  Cognitive behavioral therapy, a psychological, goal- directed approach, in which patients learn how to modify physical, behavioral, and emotional triggers of pain and stress.

	
IFYOU ARE PRESCRIBED OPIOIDS FOR PAIN:

  Never take opioids in greater amounts or more often than prescribed.

  Follow up with your primary health care provider as directed. ◊	Work together to create a plan on how to manage your pain.
◊	Talk about ways to help manage your pain that don’t involve prescription opioids. ◊	Talk about any and all concerns and side effects.
  Help prevent misuse and abuse.

◊	Never sell or share prescription opioids.

◊	Never use another person’s prescription opioids.

  Store prescription opioids in a secure place and out of reach of others (this may include visitors, children, friends, and family).
  Safely dispose of unused prescription opioids: Find your community drug take-back program or your pharmacy mail-back program, or flush them down the toilet, following guidance from the Food and Drug Administration (www.fda.gov/Drugs/ResourcesForYou).
  Visit www.cdc.gov/drugoverdose to learn about the risks of opioid abuse and overdose.

  If you believe you may be struggling with addiction, tell your health care provider and ask guidance or call SAMHSA’s National Helpline at 1-800-662-HELP.

LEARN MORE| www.cdc.gov/drugoverdose/prescribing/guideline.html

ACKNOWLEDGEMENT OF KNOWLEDGE OF RULES

Athletes and Parents: Please take the time to read through the information in this packet. After reading the rules, please sign below as an acknowledgment that you have read and understood the policies, rules and procedures for Clovis Unified School District (CUSD) and agree to abide by them.

I understand that giving false information on this application to participate in athletics may result in

the loss of athletic eligibility.

Signature of Student _____________________________	Signature of Parent _____________________________

We have read and understood the material included in the “Warning of Risk”, including the Football Helmet warning. I certify that I have read and understood the warning.

Signature of Student _____________________________	Signature of Parent _____________________________

We have read and understood the material included in the “Parent/Athlete Concussion sheet”. I certify that I have received and read the information.

Signature of Student _____________________________	Signature of Parent _____________________________

We understand and agree that the student shall not use androgenic/anabolic steroids without the written prescription of a fully licensed physician (as recognized by the AMA) to treat a medical condition. We understand under CIF Bylaw 200.D there could be penalties for giving false/fraudulent information. We understand CUSD’s policy on illegal drug use will be enforced for any violations of these rules.

Signature of Student _____________________________	Signature of Parent _____________________________

We have read and understood the material included in the “Prescription Opioid Fact Sheet”. I certify that I have received and read the information.

Signature of Student_____________________________ Signature of Parent______________________________

I understand that my child must have medical insurance that provides at least $1500 accidental injury coverage. I, the parent, have completed the health history of my student athlete. I understand that CIF By-Law #306 requires an annual Clovis Unified School District Sports Pre-Participation Screening for athletics and that the Screening WILL NOT expire during the season of sport in which the athlete is participating.

Medical Insurance Provider:

Signature of Student _____________________________

Policy #:	

Signature of Parent _____________________________

We have read and agree to the policies stated in my schools Parental/Guardian Code of Conduct and the CUSD Code of Conduct - Board Policy 2505(B) regarding the conduct of athletes and the parents/guardians of CUSD students participating in co-curricular activities. We acknowledge that a student may be disciplined or removed from a team for violation of any of the provisions of the codes or policies for co-curricular participation in CUSD. I agree to abide by the policy and related consequences while participating in interscholastic athletics, regardless of context, site or jurisdiction.

Signature of Student _____________________________	Signature of Parent _____________________________

I understand that my child will be ineligible in the next season’s sport until all equipment obligations are met. If there are any outstanding obligations, student will be ineligible for graduation ceremonies or registration for the following year.

Signature of Student _____________________________	Signature of Parent _____________________________

We have read and understand the material included in the “Sudden Cardiac Arrest information sheet”. I certify that I have received and read the information.

Signature of Student___________________________	Signature of Parent_______________________________

CLOVIS USD SPORTS PRE-PARTICIPATION SCREENING FORM This form MUST be completed for every sports participant with parent & athlete signature

Student’s Name 	       Sex M or F	Date of Birth 	

Height: 	     Weight: 	      BMI: 	 Pulse: 	      BP: _____/_____	Hgb: __________

Vision: Grossly Intact _____	Corrected: Y or N	Pupils: Equal 	 Unequal ____

Physical Screening
	Normal Findings
	X
	Abnormal Findings
	No Exam
	
Appearance
	WDWN
				
Eyes/Ears/Nose/Throat
	WNL
				
Lymph Nodes
	WNL
				
Hearing
	Grossly Intact
				
Heart
	RRR, No Significant Murmur
				
Pulses
	WNL
				
Lungs
	Clear/equal
				
Abdomen
	Soft, No HSMT
				
Skin
	Warm/Dry/Intact
				
Neck
	FROM
				
Back
	No Scoliosis
				
Shoulder/Arm/Elbow
	FROM, = strength
				
Forearm/Wrist/Hand
	FROM, = grip/strength
				
Hip/Thigh/Knee
	FROM
				
Leg/Ankle/Foot
	FROM
				
Hernia/Squat/Duck Walk
	WNL
				
Immunizations given

CLEARANCE

	Cleared

	NOT Cleared until completed evaluation/rehabilitation for: 	

	Not cleared for: 	 Reason: 	

	Recommendations: 	

Name of Health Care Provider (print/type/stamp): 	 Date of exam: 	
Address: 	Phone:

Signature of Health Care Provider: 	Date of signature: __________

This form was developed based upon guidelines from the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Sports Medicine, the American Medical Society for Sports Medicine, the American Orthopedic Society for Sports Medicine and the American Academy of Sports Medicine, 2009.

Rev: 05/10/2013