ACTIVITY CLEARANCE PACKET

ATTENTION PARENT/GUARDIAN:

To be a member of a team is a privilege and an honor. We expect all students and parents to conduct themselves

in a manner that will make fellow players, parents, and coaches proud of them. With your interest and support, we

will continue to provide the best athletic program possible

Your Son/Daughter has indicated an interest in participating in one or more of the following high school activities

in the Lake Elsinore Unified School District.

BAND

BASEBALL

BASKETBALL

COLOR GUARD

CROSS COUNTRY

DANCE

FOOTBALL

GOLF

SOCCER

SOFTBALL

SWIM

TENNIS

TRACK & FIELD

VOLLEYBALL

WATER POLO

WRESTLING

THIS PACKET IS IN THREE PARTS

PART 1: INFORMATION (KEEP THIS SECTION FOR YOUR FILES)

Important information about Team Photo Prices, Concussion Care, Heat Illness Prevention, NCAA and NAIA

Information.

PART 2: AGREEMENT (KEEP THIS SECTION FOR YOUR FILES)

Before a student can tryout, practice or participate in an activity in our District, the parent and student must read

the five-section agreement and “Pursuing Victory with Honor” found on pages 12-18.

PART 3: EMERGENCY/MEDICAL INFORMATION PAGE & CONSOLIDATED SIGNATURE PAGE

(TURN IN THIS PAGE ONLY TO THE ATHLETIC DEPARTMENT)

Clearance to tryout and practice: The Emergency/Medical Information Page (Page 21) must be completed in its

entirety, signed by you and your student, and completed by a doctor. The Consolidated Signature Page (Page 22)

must be initialed and signed by both the parent and student. This clearance will expire one year from the date of

the physician’s signature and will suffice for *all of the above listed activities.

Clearance to compete: Eligibility to compete is based on the most recent report card; we send out four report

cards each quarter. To compete, students must maintain an un-weighted GPA of 2.0 or higher and must not have

more than one “F” on the most recent report card.

If you have any questions, please call the Athletic Director.

REMOVE AND TURN IN PAGE 21-22 OF THIS PACKET TO THE ATHLETIC DEPARTMENT PAGES 1-20 BELONG TO THE PARENT/GUARDIAN/STUDENT

*Football applicants must include current insurance carrier and policy number to become eligible.

545 Chaney Street, Lake Elsinore, CA 92530 (951)253-7000

GOVERNING BOARD: Stan Crippen • Heidi Ma es Dodd • Juan Saucedo • Susan Sco • Harold E. Stryker

SUPERINTENDENT: Dr. Doug Kimberly

Concussion Management

The Play It Safe Concussion CareSM fact sheet for parents

Wells Fargo Insurance Services

An innovative approach to concussion careYour child’s school is currently implementing an innovative program for its student athletes. The Play It Safe Concussion CareSM program will assist team physicians/athletic trainers in evaluating and treating concussions. Wells Fargo Insurance Services and ImPACT™ Concussion Management have teamed up to provide your child’s school with this concussion injury management solution. The program combines awareness and education, neurocognitive testing, access to medical professionals who are credentialed ImPACT consultants trained in the evaluation and management of concussions, and excess insurance coverage to protect the financial well-being of your family.

By purchasing this program, your school is providing your student athlete with an effective concussion management solution that helps ensure your childs return to the classroom and playing field in a safe manner.

How the program worksRecognizing the importance of the health and safety of all student athletes, your school has purchased The Play It Safe Concussion CareSM program.

Prior to the start of the season, all athletes 10 years old and over will participate in ImPACT neurocognitive testing to establish a baseline for future reference, should they be concussed at some point during the season. ImPACT is a sophisticated software tool to help medical professionals evaluate a head injury. It is a 20 minute test that is administered pre-season for a baseline result. The program evaluates multiple aspects of brain function including memory, processing speed, reaction time and post-concussive symptoms. It, however, is not an IQ test.

When an athlete appears to have sustained a concussion, he or she is pulled from play and evaluated. As needed, the athlete is sent for clinical assessment and specialty care by a medical professional who is a credentialed ImPACT consultant trained in the evaluation and management of concussion.

The athlete then undergoes a post-injury ImPACT test and evaluation, and the results are compared to the athlete’s pre-season baseline test. This will assist the medical professional in determining the scope and magnitude of the concussion and enable them to determine when return-to-play is appropriate and safe for the injured athlete. The information gathered can also be shared with your family doctor.

The medical professional provides the athlete with an individual follow-up plan that may include rest, gradual re-exertion, and re-evaluation.

Covered expenses will be determined on an excess basis over and above any other valid and collectible coverage for which an insured person may be eligible. In the absence of any other coverage, this coverage will provide primary coverage benefits subject to coverage limits and exclusions.

We are excited to implement this program with your school to provide the best available information for managing concussions and the associated medical expenses. The administration, coaching, and athletic training staffs are striving to keep your child’s health and safety at the forefront of the student athletic experience.

Please contact your school with any questions about the program.

Signs and Symptoms* Athletes who experience one or more of the signs and symptoms listed below after a bump or blow to the head may have a concussion.

Symptoms Reported by Athletes

• Headache or “pressure” in head

• Nausea or vomiting

• Balance problems or dizziness

• Double or blurry vision

• Sensitivity to light or noise

• Feeling sluggish, hazy, foggy, or groggy

• Concentration or memory problems

• Confusion

• Just not “feeling right”

* According to the Centers for Disease Control

Insurance products are offered through non-bank insurance agency affiliates of Well Fargo & Company and are underwritten by unaffiliated insurance companies, with the exception of crop and flood insurance. Crop and flood insurance may be underwritten by Wells Fargo Insurance Services’ affiliate, Rural Community Insurance Company.

© 2011 Wells Fargo Insurance Services. All rights reserved.

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How can we help? Call today or visit us at wfis.wellsfargo.com/concussioncare 888-857-9504 | Fax: 916-231-3398

Wells Fargo Insurance Services11017 Cobblerock Drive, Suite 100 Rancho Cordova, CA 95670

Excess insurance coverageThis plan is excess to any other medical or dental insurance the covered person may have. No benefit is payable for any covered expense incurred, which is paid or payable by any other valid and collectible insurance. Covered expenses do not include any amount not covered by the primary carrier due to penalties for failure to comply with policy provisions or requirements. The concussion accident medical insurance policy includes:

• Provider Designation and Certification

• Client Training and Software

• Pre-season Baseline Neurocognitive Testing (ages 10 and over only)

• Medical Maximum (per injury): $25,000

• AD&D Maximum (per injury): $1,000

• AD&D Aggregate Limit: $5,000

• Coinsurance: 100% of allowance per Schedule of Benefits

• Benefit Period: 52 weeks

• Deductible: $0

• Post Injury Neurocognitive testing

• Health and behavior intervention

• Outpatient (Office) Physician Visits/Consultations

• Magnetic Resonance Imaging, brain and spinal canal

• Ultrasound

• Electroencephalogram (EEG)

• Needle electromyography

• Nerve conduction studies

Does not cover emergency services, ambulance services or surgical procedures. This coverage is designed to cover the diagnosis and management of concussion. This is only a brief description of the insurance policy. Please refer to the policy for full details.

ImPACTimpacttest.com

Injury occurs

Athlete referred to providertrained in the evaluation

and managementof concussion

Comparison of post-concussiveperformance and symptoms

to baseline test levels

Re-evaluation, rest,gradual exertion

Safe return to play

Claim form completed by school and parentand taken to a provider trained in the evaluation

and management of concussion

Follow-upsas needed

Pre-season ImPACTbaseline test

Post-injury ImPACT testperformed in

provider’s office

Athlete evaluatedand removed

from play

PUHSD Concussion Management Program

QUICK REFERENCE COLLEGEBOUND STUDENT-ATHLETES

See your Athletic Director for more information So you want to be a college athlete? That’s great! Now, you have to learn the process to actually be a college athlete.

Keep two priorities in mind: College first, sports second. Here are some things to consider about college athletics:

Careers in sports can end abruptly

Starting spots can evaporate after only one year

Practice schedules are hard on grades; college athletes may have problems with eligibility

Some players spend more than four years trying to graduate and eventually their eligibility expires. While athletics may open doors in colleges that might otherwise be just out of reach, the realities above indicate that the college-bound athlete must think ahead to when the cheering stops.

Admissions Eligibility vs. Athletic Eligibility You need to keep in mind that in addition to the minimum academic requirements a college requires for admission, student athletes also need to have at least the minimum academic requirement for athletic eligibility (sometimes very specific coursework is required!). Colleges are members of athletic governing organizations (NCAA or NAIA) which monitor athletic eligibility certification. Admissions requirements are specific to each college campus while athletic eligibility requirements are set by the rules and regulations of the governing organizations that grand athletic eligibility certification. Each entity (college or organization) has its own set of supporting documents and may have slightly different requirements with regard to coursework, grade point averages (and from which years in school) and college-entrance test score minimums, and passing grades.

NCAA

NATIONAL COLLEGIATE ATHLETIC ASSOCIATION

www.ncaa.org

Comprised of over 1000 U.S. institutions, organizations and indi-viduals committed to the best interests, education, and athletics participation of student athletes

Divided into 100 conferences. Has three divisions, each with a specific minimum number ofteams, competitions, and squad sizes and maximum scholarship amounts that can be awarded. Rules differ for each division.

Prospective DI and DII student athletes must register with the Eligi-bility Center (including requesting a transcript and sending official SAT/ACT scores and paying $80), preferably at the beginning of junior year: www.eligibilitycenter.org

NAIA

NATIONAL ASSOCIATION OF INTERCOLLEGIATE ATHLETES

http://naia.cstv.com

Comprised of nearly 300 member institutions (small colleges) in the U.S. and Canada dedicated to developing character and re-spect in both athletics and academics.

Divided into 25 conferences.

Regulated by fewer recruiting restrictions.

Flexibility to transfer to another college within the organization without missing a season of eligibility.

Registration for students is $75. This is a one-time nonrefundable registration fee and includes all services of the NAIA Eligibility Center. Be sure to use code #9876 to have your SAT and ACT test cores sent to NAIA. www.playnaia.org

NCAA DIVISION I Division I schools, on average, enroll the most students, manage the largest athletic budgets, offer a wide array of academic programs and provide the most athletics scholarships

Schools must meet minimum financial aid awards for their athletic program, there are maximum financial aid awards for each sport that each D1 school cannot exceed.

Playing at this most competitive level is a big commitment. Expect to practice ap-proximately 20 hours a week during the season and 6 hours a week in the off-season, plus weight training. Practice may conflict with course offerings.

NCAA DIVISION II Division II provides growth opportunities through academic achievement, high-level athletics competition and community engagement. Many participants are first-generation college students.

There are maximum financial aid awards for each sport that a D2 school must not exceed. D2 teams usually feature a number of local or in-state student-athletes.

Many D2 student-athletes pay for school through a combination of scholarship money, grants, student loans and employ-ment earnings. D2 athletics programs are financed in the institution’s budget like other academic departments on campus. Traditional rivalries with regional institu-tions dominate schedles of many D2 programs.

NCAA DIVISION III The Division III experience provides an integrated environment that focuses on academic success while offering competi-tive athletics and meaningful non-athletic opportunities

D3 athletics features student-athletes who receive no financial aid related to their athletic ability and athletic departments are staffed and funded like any other department in the university.

Athletic departments place special im-portance on the impact of athletics on the participants rather than on the spectators. They also place primary emphasis on regional in-season and conference com-petition.

Athletes are often being recruited by D1 colleges so don’t underestimate the com-petitiveness of a D3 team.

NAIA The NAIA is a governing body of small athletic programs that are dedicated to character-driven intercollegiate athletics. The athletic experience in the NAIA is essentially the same as the NCAA. They have scholarships, conferences, playoffs, and national championships just as the NCAA does. It is not unusual for NAIA and NCAA Division 2 and 3 teams play each other. Usually these games are early in the season before conference play begins.

NAIA schools have no restrictions on holding tryouts. Each coach may deter-mine if they want to hold tryouts or have you tryout when you visit campus. For the NAIA you must meet two of the following to be eligible: 18 ACT or 860 SAT, 2.0 GPA out of 4.0. NAIA member schools are free to offer scholarships. Many schools do, but not all.

  

ATTENTION THE FOLLOWING PAGES INCLUDE 

IMPORTANT INFORMATION ON YOUR  STUDENT’S CLEARANCE.   

 YOU AND YOUR STUDENT  

WILL BE REQUIRED TO SIGN FOR EACH  OF THESE AREAS OF INFORMATION, SO PLEASE READ 

EVERYTHING CAREFULLY.    

IF YOU HAVE ANY QUESTIONS,  PLEASE CONTACT YOUR ATHLETIC DIRECTOR FOR 

CLARIFICATION.    

PARENTS TURN IN 

ONLY PAGE 21/22 (The Last Page) 

 

OF YOUR PACKET 

 

 PURSUING VICTORY WITH HONOR* Code of Conduct for Parents/Guardians 

 Athletic competition of interscholastic‐age children should be fun and should also be a significant part of a sound educational program.  Everyone involved in sports programs has a duty to assure that their programs impart important life skills and promote the development of good character.  Essential elements of character building are embodied in the concept of sportsmanship and six core ethical values:  TRUSTWORTHINESS, RESPECT, RESPONSIBILITY, FAIRNESS, CARING and GOOD CITIZENSHIP (the “Six Pillars of Character”℠).  The highest potential of sports is achieved when all involved consciously TEACH, ENFORCE, ADVOCATE AND MODEL (T.E.A.M.) these values and are committed to the ideal of pursuing victory with honor.  Parents/guardians of student‐athletes can and should play an important role and their good‐faith efforts to honor the words and spirit of this Code can dramatically improve the quality of a child’s sports experience.  

TRUSTWORTHINESS  Trustworthiness.  Be worthy of trust in all you do.  Integrity.  Live up to high ideals of ethics and 

sportsmanship and encourage players to pursue victory with honor.  Do what’s right even when it’s unpopular or personally costly. 

Honesty.  Live honorably.  Don’t lie, cheat, steal or engage in any other dishonest conduct. 

Reliability.  Fulfill commitments.  Do what you say you will do. 

Loyalty.  Be loyal to the school and team; put the interests of the team above your child’s personal glory. 

 RESPECT 

Respect.  Treat all people with respect at all times and require the same of your student‐athletes. 

Class.  Teach your child to live and play with class and be a good sport.  He/she should be gracious in victory and accept defeat with dignity, compliment extraordinary performance, and show sincere respect in pre‐ and post‐game rituals. 

Disrespectful Conduct.  Don’t engage in disrespectful conduct of any sort including profanity, obscene gestures, offensive remarks of a sexual nature, trash‐talking, taunting, boastful celebrations, or other actions that demean individuals or the sport. 

Respect for Officials.  Treat game officials with respect.  Don’t complain or argue about calls or decisions during or after an athletic event. 

 RESPONSIBILITY 

Importance of Education.  Support the concept of “being a student first.”  Commit your child to earning a diploma and getting the best possible education.  Be honest with your child about likelihood of getting an athletic scholarship or playing on a professional level.  Reinforce the notion that many universities will not recruit student‐athletes who do not have a serious commitment to their education.  Be the lead contact for college and university coaches in the recruiting process. 

  Role Modeling.  Remember, participation in sports is 

a privilege, not a right.  Parents/guardians too should respect the school, coach and teammates with honor, on and off the court/field.  Consistently exhibit good character and conduct yourself as a positive role model. 

Self‐Control.  Exercise self‐control.  Don’t fight or show excessive displays of anger or frustration. 

Healthy Lifestyle.  Promote to your child the avoidance of all illegal or unhealthy substances including alcohol, tobacco, drugs and some over‐the‐counter nutritional supplements, as well as of unhealthy techniques to gain, lose or maintain weight. 

Integrity of the Game.  Protect the integrity of the game.  Don’t gamble or associate with gamblers. 

Sexual Conduct.  Sexual or romantic contact of any sort between students and adults involved with interscholastic athletics is improper and strictly forbidden.  Report misconduct to the proper authorities. 

 FAIRNESS 

Fairness and Openness.  Live up to the high standards of fair play.  Be open‐minded, always willing to listen and learn. 

 CARING 

Caring Environment.  Consistently demonstrate concern for student‐athletes as individuals and encourage them to look out for one another and think and act as a team. 

 CITIZENSHIP 

Spirit of the Rules.  Honor the spirit and the letter of rules.  Teach your children to avoid temptations to gain competitive advantage through improper gamesmanship techniques that violate the highest traditions of sportsmanship. 

_____________________ *Our athletic program subscribes to the Pursuing Victory With Honor ArizonaSports Summit Accord.  “Pursuing Victory with Honor” and the “Six Pillars of Character” are service marks of the CHARACTER COUNTS! Coalition, a project of the Josephson Institute of Ethics.  Reproduced with Permission by the CIF. 

 

  

  

STUDENT‐PARENT ACTIVITY AGREEMENT  

1 RELEASE OF LIABILITY  

1.1  As stated  in  the California Education Code  (Section 35330),  I understand  that  I hold the Lake Elsinore Unified School District,  its officers, agents and employees, harmless from any and all  liability or claims which may arise out of, or in connection with, my child’s participation in band, color guard, dance cheer and  sports.    The  Board  of  Education  deems  many  of  the  extracurricular  activities  to  be  worthy  for students,  but  does  not  require  them  of  students.    These  activities  are  voluntary  on  the  part  of  the students,  and  the  Emergency/Medical  Information  Page  with  the  Signature  Consolidation  Page  are necessary  before  participation.    No  penalty  other  than  non‐participation  will  be  assessed  if  the Emergency/Medical Information Page and the Signature Consolidation Page are not signed and initialed where indicated. 

 

1.2 I hereby give my consent for my child to be given medical aid by a physician or athletic trainer during any and all school sponsored activities.  

1.3 I hereby confirm my child:  

1.3.1 Is living with me or a legal guardian and resides in the Lake Elsinore Unified School District;  

1.3.2 Is not nineteen years of age as of June 15; and  

1.3.3 Will not compete on an outside team in the same sport during the high school season.  

1.4 I understand this packet expires, in its entirety, one year from the physical examination date.  

2 CODE OF CONDUCT    

2.1 Student  Responsibilities.    In  order  to meet  these  responsibilities,  participants  agree  to  uphold  their responsibilities and will not, AT ANY TIME, engage in the ILLEGAL USE OF DRUGS, ALCOHOL, VAPING OR TOBACCO OR PARTICIPATE  IN CRIMINIAL BEHAVIOR as defined  in the California State Education Code and/or Penal Code.   Participation  in  the Activity/Athletic programs  is a privilege and a  responsibility.  Students  who  participate  in  these  programs  understand  the  privilege  and  agree  to  uphold  the responsibilities below:  

1.1.1. The Responsibility to self to maintain high standards of health and safety in order to perform at the maximum level of their potential. 

 

1.1.2. The Responsibility to their fellow group/team members to give their best effort at all times.  

1.1.3. The Responsibility to their coaches, advisors and directors to strive for success in every effort they undertake. 

 

1.1.4. The Responsibility to their school and community, whom they represent, to maintain the highest standards of conduct. 

 

1.1.5. The Responsibility to the youth of the community, who  look up to them, to be role models of citizenship and behavior. 

 

1.1.6. The Responsibility to refrain from the use of performance enhancing drugs, cigarettes and/or any other substance deemed inappropriate, a controlled substance, alcohol, and/or drug use. 

  

2.2 Consequences.    Listed  below  are  the  cumulative  penalties  and  regulations  regarding  any  major infractions.  These penalties are cumulative during a student’s tenure in the Lake Elsinore Unified School District.    These  will  be  applied  concurrently  with  the  consequences  of  the  regular  school  discipline program which includes suspension and expulsion.  A student facing expulsion will be suspended from events until a final decision on the expulsion is reached.   Any major infraction of this Code of Conduct shall result in the following consequences: 

2.3  

2.2.1  First Offense  = 15‐Day  Exclusion.   Upon notification by  school  authority,  the  student will be 

excluded from participation in EVERY extra‐curricular activity program or event for 15 calendar 

days from the date of the awareness of the code violation.   If the  infraction occurs during the 

summer break, the exclusion period will begin on the first day students return to school. 

2.2.2 Second Offense = 30‐Day Exclusion.   Upon notification by school authority, the student will be 

excluded from participation in EVERY extra‐curricular activity program or event for 15 calendar 

days from the date of the awareness of the code violation.   If the  infraction occurs during the 

summer break, the exclusion period will begin on the first day students return to school. 

 

2.2.3 Third Offense = 60‐Day Exclusion.   Upon notification by  school authority,  the  student will be 

excluded from participation in EVERY extra‐curricular activity program or event for 15 calendar 

days from the date of the awareness of the code violation.   If the  infraction occurs during the 

summer break, the exclusion period will begin on the first day students return to school. 

 

2.2.4 Fourth Offense = Complete Exclusion.  Upon notification by school authority, the student will be 

excluded from participation in EVERY extra‐curricular activity program or event for the duration 

of his/her attendance in the Lake Elsinore Unified School District. 

 

2.3 Parent Responsibilities.  Besides  the school  s t a f f   and coaches, parents have  a strong  influence  over 

students'  conduct  and  behavior.    Good  citizenship,  behavior,  and  sportsmanship  can  best  be 

emphasized through  a partnership  among  students,  staff, and  parents.   Parents  are  responsible for 

maintaining  the  standards  of  the  CIF's  Pursuing  Victory  with  Honor  Code  of  Conduct  for 

Parents/Guardians (Page 18). 

 

2.4 Staff Responsibilities.     School  personnel will be  responsible  for  assisting  students  in  meeting  their 

responsibilities under  this Code.    Coaches  and advisors play a  key  role  in  educating and  being  role 

models for the students enrolled  in their activity.  Coaches  and advisors are responsible  for educating 

students  and enforcing  all aspects  of  the Activity  Code of Conduct.   It  is essential  that a caring  and 

positive  approach  be  used  to  convey  to  students  their  responsibilities  and  the  consequences  to 

students  if  the Code  is violated.    The  school administration will be  responsible  for  administering all 

consequences to students  for violation of this code. 

 

3 ELIGIBLITY TO PARTICIPATE  

3.1  Academic Eligibility.   Eligibility to compete is based on the most recent report card; LEUSD sends out a 

report card each quarter.   To compete,  students must maintain an un‐weighted Grade Point Average 

(GPA) of 2.0 or higher and must not have more than one “F” on the most recent report card.  At the start 

of a new year, the final grade of the prior year will be used to determine eligibility. 

   

  

4 WARNING AGREEMENT TO OBEY INSTRUCTIONS, RELEASE ASSUMPTION OF RISK AND HOLD HARMLESS.  

4.1  Playing or practicing to play/participate in any school activity can be dangerous involving MANY RISKS OF INJURY.    

4.1.1  I understand  that  the dangers and  risks of playing or practicing  to play/participate  in any activity include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious  injury to virtually all  internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious  injury or  impairment to other aspects of my body, general health and well‐being.  I understand that the dangers and risks of playing or practicing to play/participate in activities may result not only in serious injury, but in serious impairment of my  future abilities  to earn a  living,  to engage  in other business,  social and  recreational activities, and generally to enjoy life. 

 

4.1.2  Because of the dangers of participating in activities, I recognize the importance of following coaches’ instructions regarding playing techniques, training and other team rules, etc. and to obey such instructions 

 

4.1.3  In consideration of the Lake Elsinore Unified School District permitting me to try out for a team and to engage  in all activities related to the team  including but not  limited to, trying out, practice or playing/participating in that activity, I hereby assume all risks associated with participating  and  agree  to  hold  the  Lake  Elsinore  Unified  School  District,  its  employees, agents,  representatives,  coaches,  and  all  volunteers  harmless  from  any  and  all  liability, actions causes or actions, debts, claims, or demands of any kind and nature whatsoever which may arise by or in connection with my release and assumption of risk for my heirs, estate, executor, assignees, and for all members of my family. 

 

4.1.4  If there are any doubts, questions or uncertainty in Section 4, contact the athletic director at your high school for clarity before signing.  

 

5 CONCUSSIONS  

5.1  CIF/CDC Concussion Facts for Parents/Guardians and Students.  

5.1.1      What is a Concussion?    

5.1.1.1 A concussion is a brain injury that is caused by:  a blow to the head or body for contact with another player; hitting a hard surface such as the ground, ice or floor; or being hit by a piece of equipment such as a bat, shot put, or discus.  

5.1.1.2  A concussion is a brain injury that CAN:  change the way your brain normally works; range from mild to severe; present itself differently for each student; occur during practice or competition in ANY sport or activity; and happen even if you do not lose consciousness. 

 

5.1.2 Play it Safer, CIF Bylaw 313.   A student who is suspected of sustaining a concussion or head injury in a practice, game or performance shall be removed from the competition at that time for the remainder of the day.  A student who has been removed from play may not return to play until he/she is evaluated by a licensed health care provider trained in the evaluation and management of concussion; and receives written clearance to return to play from the health care provider.     

 

  

5.1.3 What Are the Symptoms of a Concussion?   You can’t see a concussion, but you might notice some of the symptoms right away.  Other symptoms can show up hours or days after the injury.  

    Concussion symptoms may include:  

• AMNESIA • CONFUSION • HEADACHE • LOSS OF CONSCIOUSNESS • BALANCE PROBLEMS OR DIZZINESS • DOUBLE OR FUZZY VISION • SENSIVITIY TO LIGHT OR NOISE • NAUSEA (feeling that you might vomit) • DON’T FEEL RIGHT • FEELING SLUGGISH, FOGGY OR GROGGY • FEELING UNUSUALLY IRRITABLE • CONCENTRATION OR MEMORY PROBLEMS (forgetting game plays, routines, facts, meeting times) 

• SLOWED REACTION TIME  5.1.4  What Can Trigger Symptoms?  Exercises or activities that involve a lot of concentration such as 

studying, working on  the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. 

 5.1.5 What Can Happen If My Child Keeps Playing with a Concussion or Returns Too Soon?  Students 

with  the  signs  and  symptoms  of  concussion  should  be  removed  from  play  immediately.  Continuing  to  play  with  the  signs  and  symptoms  of  a  concussion  leaves  the  young  student especially vulnerable to greater  injury.   There  is an  increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly  if the student suffers another concussion before completely recovering from the first one.  This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences.   It  is well‐known that the adolescent or teenage student will often under‐report  symptoms of  injuries  and  concussions  are no different.   As  a  result,  the education of administrators, coaches, parents and students is the key for the student’s safety. 

 5.1.6  What  you  Should Do  if  You  Think  Your Child has  Suffered  a Concussion?   Any  student  even 

suspected of suffering a concussion should be removed from the game, practice or performance immediately.   No student may  return  to activity after an apparent head  injury or concussion, regardless  of  how  mild  it  seems  or  how  quickly  symptoms  clear,  without  written  medical clearance.   Close observation of the student should continue for several hours.   This new “CIF Bylaw 313” now requires the consistent and uniform implementation of long and well‐established return‐to‐play concussion guidelines that help ensure and protect the health of students. 

 5.1.6 It’s Better to Miss One Game Than the Whole Season.  When in Doubt, Get Checked Out.  For more 

information and resources, visit www.cifstate.org/health_safety and www.cdc.gov/concussion.      

5.2  LEUSD  Concussion Management  Protocol.    Concussions  and  other  brain  injuries  can  be  serious  and potentially  life  threatening  injuries  in  activities.   Research  indicates  that  these  injuries  can also have serious consequences later in life if not managed properly.  In an effort to combat this injury, the following concussion management protocol will be used for LEUSD students suspected of sustaining a concussion.  A concussion occurs when there is a direct or indirect insult to the brain.  As a result, transient impairment of mental  functions  such  as memory, balance/equilibrium,  and  vision may occur.    It  is  important  to recognize that many activity‐related concussions do not result in loss of consciousness and, therefore, all 

  

suspected head injuries must be taken seriously.  Coaches, advisors, and fellow teammates can be helpful  in  identifying those who may potentially have a concussion, because a concussed student may not be aware  of  their  condition  or  potentially  be  trying  to  hide  the  injury  to  stay  in  the  game,  practice  or performance.   5.2.1  A student suspected of sustaining a concussion will be evaluated by the athletic trainer using the 

LEUSD Concussion Report.  In the case of an athletic trainer not present, the coach/director will use the LEUSD Concussion Report.  The presence of symptoms will dictate that the student is to be evaluated by a doctor (MD or DO). 

 

5.2.2   A  student who  is  suspected of  sustaining a  concussion or head  injury  in a practice, game or performance  shall be  removed  from  the event at  that  time  for  the  remainder of  the day.   A student who has been removed from play may not return to play until the student is evaluated by a licensed health care provider trained in the evaluation and management of concussion and who receives written clearance to return to play from that health care provider. CIF Bylaw 313. 

 

5.3  LEUSD Student Concussion Statement  

5.3.1  I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. 

 

5.3.2  I have read and understand the CIF/CDC CONCUSSION FACTS above.  After reading the CIF/CDC CONCUSSION FACTS, I am aware of the following information: 

 

5.3.2.1  A  concussion  is  a  brain  injury,  which  I  am  responsible  for  reporting  to  my  team physician or athletic trainer. 

 

5.3.2.2  A concussion can affect my ability to perform everyday activities and affect reaction time, balance, sleep, and classroom performance. 

 

5.3.2.3  You cannot see a concussion, but you might notice some of the symptoms right away.  Other symptoms can show up hours or days after the injury. 

 

5.3.2.4  If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. 

 

5.3.2.5  I will not return to play in a game, practice or performance if I have received a blow to the head or body that results in concussion‐related symptoms. 

 

5.3.2.6  Following concussion, the brain needs time to heal.  You are much more likely to have a repeat concussion if you return to play before your symptoms resolve themselves. 

 

5.3.2.7 In rare cases, repeat concussions can cause permanent brain damage and even death.  6  SUDDEN CARDIAC ARREST SYMPTOMS AND WARNING SIGNS.  INFORMATION FOR ATHLETE/PARENT/GUARDIAN 

 

6.1  What is Sudden Cardiac Arrest?   Sudden cardiac arrest (SCA) is when the heart stop beating suddenly and unexpectedly.  When this happens, blood stops flowing to the brain and other vital organs.  SCA doesn’t just happen to adults; it takes the lives of students too; however, the causes of sudden cardiac arrest in students and adults can be different.  A student’s SCA will likely result from an inherited condition, while an adult’s SCA may be caused by either inherited or lifestyle issues. 

  

  

6.2  SCA is NOT a Heart Attack.   A heart attack may cause SCA, but they are not the same.  A heart attack is caused by a blockage  that  stops  the  flow of blood  to  the heart.   SCA  is a malfunction  in  the heart’s electrical system, causing the heart to suddenly stop beating. 

 

6.3  How Common is Sudden Cardiac Arrest in the United States?   SCA is the #1 cause of death for adults in this country.  There are about 300,000 cardiac arrests outside hospitals each year.  About 2,000 students die of SCA each year.  It is the #1 cause of death for student athletes. 

 6.4  What Are  the Warning Signs?     Although SCA happens unexpectedly, some people may have signs or 

symptoms, such as:   • Fainting or Seizures during exercise • Dizziness • Lightheadedness • Unexplained shortness of breath • Difficulty Breathing • Racing or Fluttering heartbeat (palpitations) 

• Syncope (fainting) • Fatigue (extreme tiredness) • Weakness • Nausea • Vomiting • Chest Pains 

    These symptoms can be unclear in athletes since people often confuse these warning signs with physical exhaustion.  SCA can be prevented if the underlying causes can be diagnosed and treated. 

 6.5  What  are  the  Risks  of  Practicing  or  Playing  After  Experiencing  These  Symptoms?      There  are  risks 

associated with continuing to practice or play after experiencing these symptoms.  When the heart stops, so does the blood that flows to the brain and other vital organs.  Death or permanent brain damage can occur in just a few minutes.  Most people who experience SCA die from SCA. 

 6.6.  Eric Paredes Sudden Cardiac Arrest Prevention Act AB-1639.   This Act is intended to keep students safe 

while practicing or playing.  The requirements of the Act are:    6.6.1  Information About SCA Symptoms and Signs. 

• Every student-athlete and their parent or guardian must read and sign this form (Line 6.0 on the Signature Consolidation Page).   This must be understood and acknowledged every year. 

• The  State  Department  of  Education  to  post  guidelines,  videos  and  information  on  SCA symptoms and warning signs on its website. 

• A coach of an activity to complete the SCA training course prior to July 1, 2017 and every other year thereafter.   

 6.6.2  Removal from Play/Return to Play.    

• Any student who has signs or symptoms of SCA must be removed from play.  The symptoms can happen before, during or after an activity.  Play includes all activity. 

Before returning to play, the student must be evaluated.  Clearance to return to play must be in writing.   The evaluation must be performed by a  licensed physician; a certified registered nurse practitioner may consult any other licensed or certified medical professionals

 

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ACTIVITIES ‐ INSTRUCTORS  

Ac vi es Director  Courtney Gonzalez  253‐7300 ext.3608  courtney.gonzalez@leusd.k12.ca.us Cheerleading  Ashely Cas llo  253‐7300 ext.3308  ashely.cas llo@leusd.k12.ca.us   Dance  Stephanie Duhamel  253‐7300 ext.2422  stephanie.duhamel@leusd.k12.ca.us Instrumental Music/Color Guard  Chris Fossmo  253‐7300 ext.2407  chris.fossmo@leusd.k12.ca.us Theatre Arts  Sco  Karlan    253‐7300 ext.3406  sco .karlan@leusd.k12.ca.us 

ATHLETICS DEPARTMENT

Athle c Director  David Drake        253‐7311    david.drake@leusd.k12.ca.us Athle c Clerk  Twila Brand  253‐7300 ext.2012  twila.brand@leusd.k12.ca.us 

ATHLETICS ‐ HEAD COACHES

FALL SPORTS Football  Mark Chandler   253‐7301 Lv Mssg  mark.chandler@leusd.k12.ca.us Cross Country, Girls  Nicole Olson  253‐7300 ext.3305  nicole.olson@leusd.k12.ca.us Cross Country, Boys  Juven no Morfin  253‐7300 ext.3661  juven no.morfin@leusd.k12.ca.us   Golf, Girls  Todd Naylor  253‐7300 ext.3701  todd.naylor@leusd.k12.ca.us Tennis, Girls  Brian Henderson  253‐7300 ext.2403  brian.henderson@leusd.k12.ca.us Volleyball, Girls  Jeff Berkey  253‐7400 ext.2131  jeffrey.berkey@leusd.k12.ca.us Water Polo, Boys  Jason Kaiser  253‐7300 ext.3403  jason.kaiser@leusd.k12.ca.us  

WINTER SPORTS Basketball, Boys  Kenny O’Neal  253‐7301 Lv Mssg  konealfit20@gmail.com Basketball, Girls  Ed Raiford  253‐7301 Lv Mssg  eddie.raiford@leusd.k12.ca.us Soccer, Boys  Juven no Morfin  253‐7300 ext.3661  juven no.morfin@leusd.k12.ca.us Soccer, Girls  Aaron Nessman  253‐7300 ext.2002  aaron.nessman@leusd.k12.ca.us Water Polo, Girls  Israel Morrow  253‐7300 ext.3311  israel.morrow@leusd.k12.ca.us Wrestling  Jed Clark  253‐7300 ext.2403  jed.clark@leusd.k12.ca.us  

SPRING SPORTS Baseball      253‐7311    david.drake@leusd.k12.ca.us Golf, Boys  Rich Smith  253‐7300 ext.3651  rich.smith@leusd.k12.ca.us So ball  Steve Wilson  253‐7301 Lv Mssg  swilson12@roadrunner.com Swimming  Israel Morrow  253‐7300 ext.3353  israel.morrow@leusd.k12.ca.us Tennis, Boys  Jason Kaiser  253‐3700 ext.3403  jason.kaiser@leusd.k12.ca.us Track & Field, Boys  Andrew Penwarden  253‐3700 ext.2403  andrew.penwarden@leusd.k12.ca.us Track & Field, Girls  Ed Raiford  253‐7300 Lv Mssg  eddie.raiford@leusd.k12.ca.us Volleyball, Boys  Ross Wolter  253‐7300 ext.3519  ross.wolter@leusd.k12.ca.us       

27. Date of Tetanus Shot:_______________________________________________________

28. Women Only Date of your first menstrual period?________________________________

29. Women Only Date of last menstrual period? ____________________________________

30. Women Only Longest period of time between periods last year? ____________________

Explain all “Yes” answers here, by question number:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________ Continued on attached, separated piece of paper.

______________________________________________________________________________ _____________ _______________________________

STUDENT INFORMATION

GRADE ______ AGE______ GRAD YEAR____________ GENDER______

ADDRESS___________________________________________________________________ ___________________________________________________________________________ CITY, ZIP ___________________________________________________________________

MOBILE PHONE______________________________________________________________

OTHER PHONE ______________________________________________________________

SCHOOLS ATTENDED LAST 12 MONTHS:__________________________________________

___________________________________________________________________________

DATE OF BIRTH______________________________________________________________

PLACE OF BIRTH _____________________________________________________________

EMERGENCY CONTACT INFORMATION FATHER OR GUARDIAN_______________________________________________________ MOBILE PHONE_____________________________________________________________

OTHER PHONE______________________________________________________________

MOTHER OR GUARDIAN______________________________________________________

MOBILE PHONE_____________________________________________________________

OTHER PHONE______________________________________________________________

EMERGENCY NAME/PHONE___________________________________________________

FAMILY PHYSICIAN __________________________________________________________

PHONE NUMBER____________________________________________________________

REQUIRED FOR FOOTBALL

__________________________________________________________________________ HEALTH INSURANCE COMPANY

__________________________________________________________________________ HEALTH INSURANCE POLICY NUMBER

1. Are you currently under a doctor’s care for any reason?

2. Have you ever been hospitalized?

3. Have you ever had surgery?

4. Are you currently taking any medication or pills?

5. Do you have any allergies? (medicine, bee sting, etc.)

6. Have you ever been dizzy or fainted during or after exercise?

7. Have you ever had chest pains during or after exercises?

8. Have you ever had high blood pressure?

9. Have you ever been told you have a heart murmur?

10. Have you ever had a racing heart or skipped heartbeats?

11. Have you had a head injury?

12. Have you ever been knocked unconscious?

13. Have you ever had a seizure?

14. Have you ever been dizzy or passed out due to the heat?

15. Do you have any trouble breathing before or after exercise?

16. Do you have any problem with your eyes or vision?

17. Do you wear glasses or contacts or protective eye wear?

18. Do you use any special equipment? (splint, neck rolls, mouth guards, etc.)

19. Has anyone in your family died of heart problems or sudden death before age 50?

20. Do you only have one working organ of usually paired organs? (eye, kidney, etc.)

21. Have you ever sprained, broken, dislocated, or had repeated swelling or pain of

any bones or joints?

22. Are any of the following currently bothering you? (circle)

Hand / Wrist / Elbow / Forearm Hip/ Thigh / Knee / Ankle / Shin / Calf / Foot

23. Have you ever had a stinger, burner, or pinched nerve?

24. Have you ever had any medical problems or injuries?

(asthma, mono, diabetes, etc.)

25. Have you had any medical problems since your last evaluation?

26. Were there any special instructions or precautions given by the 27. Medical Practitioner?

ACTIVITY CLEARANCE PACKET EMERGENCY/MEDICAL INFORMATION PAGE

STUDENT ID#_____________________________________________

LAST NAME______________________________________________ FIRST NAME _____________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FALL: Volleyball Girls Water Polo Boys Cross Country Football Tennis Girls Golf Girls _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

WINTER: Soccer Water Polo Girls Basketball Wrestling ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SPRING: Volleyball Boys Swim Track Baseball Softball Tennis Boys Golf Boys __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MULTI: Cheer Dance Band Color Guard Non-Participant/Manager (N-P) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PHYSICIAN STATEMENT MALE FEMALE HEIGHT_______ WEIGHT_______ BP_______/_______ PULSE_______ VISION R:20/_______ L:20/_______ CORRECTED? Y N

While this does not constitute a physical nor replace the need for a periodic health evaluation by a

family physician, this individual appears to be physically capable of participation in interscholastic

sports as of this date except as indicated below.

Cleared for sports without restriction

Cleared for sports with the following restrictions_____________________________

________________________________________________________________________

Not cleared to participate

pending further evaluation

in these sports/activities_________________________________________________

DOCTOR’S OFFICE STAMP/PHONE

____________________________________ ______________ Physician Signature Physical Date

Appearance HEENT Lymph Nodes

Heart Pulse Lungs Abdomen Genitourinary

(males) Skin Back

Shoulder/ Arm

Elbow/ Forearm

Wrist/Hand/ Fingers

Hip/ Thigh Knee Leg/Ankle Foot/Toes Functional

NORMAL ABNORMAL

REMARKS

Y N

MEDICAL HISTORY QUESTIONNAIRE

Parent Initials

Student Initials

PACKET RECEIPT I have received and reviewed the 22-Page Activity Clearance Packet SECTION 1 I understand the information in the Release of Liability section.

SECTION 2 I understand the responsibilities and consequences listed in the Code of Conduct.

SECTION 2.3 I have read and understand the requirements of the Code of Conduct, and acknowledge that I may be disciplined if I violate any of its provisions.

SECTION 3 I understand the information in the Eligibility to Participate section.

SECTION 4 Warning Agreement to Obey Instructions, Release Assumption of Risk or Hold Harmless

SECTION 5.1 CIF/CDC Concussion Facts for Parents/Guardians and Students. SECTION 5.2 LEUSD Concussion Management Protocol SECTION 5.3 LEUSD Student Concussion Statement

SECTION 5.3.1 I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician.

SECTION 5.3.2 I have read and understand the CIF/CDC Concussion Facts in Section 5.1.

SECTION 5.3.2.1 I understand a concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer.

SECTION 5.3.2.2 I understand a concussion can affect my ability to perform every day activities and affect reaction time, balance, sleep, and classroom performance.

SECTION 5.3.2.3 I understand I cannot see a concussion, but I might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

SECTION 5.3.2.4 I understand that if I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer.

SECTION 5.3.2.5 I will not return to play in a game, practice or performance if I have received a blow to the head or body that results in concussion-related symptoms.

SECTION 5.3.2.6 I understand that following concussion, the brain needs time to heal. I am much more likely to have a repeat concussion if I return to play before my symptoms resolve themselves.

SECTION 5.3.2.7 I understand that in rare cases, repeat concussions can cause permanent brain damage and even death.

SECTION 6.0 i have reviewed the Student/Parent/Guardian Sudden Cardiac Arrest Symptoms (SCA) and Warning Signs and understand the symptoms and warning signs of SCA related to participation in activity programs.

Emergency/Medical Information Page

I hereby state that, to the best of my knowledge, my the information submitted on the Emergency/Medical Information Page is complete and correct

I hereby state, to the best of my knowledge, the answers to the questions on the Emergency/Medical Information Page are true. I understand that by performing

the examination, the signing physician does not assume responsibility for medical care of this individual. I verify that I have read and understand all material

presented and all information I have provided is correct, and I give permission for my child or ward to receive a physical exam and to participate in band, color

guard, dance, cheer and sports.

In the event reasonable attempts to contact the parent/guardian at the phone numbers provided on the Emergency/Medical Information Page meets with no

success, full authorization is given for the administration of any treatment deemed necessary by a medical practitioner, and the transfer of son/daughter or

ward to any medical practitioner, and the transfer of my son/daughter or ward to any licensed hospital or emergency clinic reasonably accessible. It is

understood that the authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and

power on the part of the school authorities and aforesaid agent(s) to give reasonable care. Facts are provided on the Emergency/Medical Information Page

concerning the student’s medical history which a medical practitioner should know.

Name of Parent/Guardian (Please Print) _________________________________________________________________________________________

_______________________________________________________________________________________________Date_______________________

Signature of Mother Father Guardian

Name of Student (Please Print) ________________________________________________________________________________________________

_______________________________________________________________________________________________Date_______________________

Student’s Signature

ACTIVITY CLEARANCE PACKET SIGNATURE CONSOLIDATION PAGE