LIMESTONE ATHLETICS

If you are planning on participating in any of the following activities you must

complete the attached packet and turn-in to the athletic table.

FALL WINTER SPRING

BOYS SOCCER BASKETBALL CHEERLEADING BASEBALL

CROSS COUNTRY BOYS BASKETBALL BASS FISHING

FOOTBALL DANCE TEAM BOYS TENNIS

FOOTBALL CHEERLEADING GIRLS BASKETBALL BOYS TRACK

GIRLS/BOYS GOLF WRESTLING GIRLS SOCCER

GIRLS TENNIS GIRLS TRACK

VOLLEYBALL SOFTBALL

LIMESTONE COMMUNITY HIGH SCHOOL EMERGENCY MEDICAL INFORMATION AND AUTHORIZATION

INFORMATION (Please print) Name of Athlete ________________________________________________________________________ Address ________________________________________________________________________ Birthdate __________________________ Birthplace _____________________________ Please list what sport(s) you plan to participate in: _______________________________________________ Phone Number of Parent/Guardian during day: Father _______________________________ Mother _____________________________ Name/Phone Number Name/Phone Number Home Phone Number ____________________________________________________________________ Family Doctor ____________________________________________________________________ Preferred Hospital ____________________________________________________________________ Known Allergies ____________________________________________________________________ Current Medications ____________________________________________________________________ Do you wear glasses or contacts ________ Do you use an inhaler _____Yes _____No In case of an emergency and neither parent/guardian can be reached at home or at work, attempt to contact the alternate listed below: Relationship ___________________________ Alternate Name _______________________ Phone ___________________________

AUTHORIZATION (Please sign) We give our consent for coaches, athletic trainers, or team physicians to use their own best judgment in securing or rendering emergency medical assistance and/or transportation in the case that we cannot be reached or that it would be imprudent to do so under all circumstances. In addition, permission is hereby granted the attending physician or athletic trainer to proceed with any necessary treatment for the above-named student in the event of an injury or illness. I understand an attempt will be made by the coach, athletic trainer, or attending physician to contact me in the most expeditious way possible. ___________________________________ ___________________________________ Father/Guardian Signature Mother/Guardian Signature

Date _______________________________ Date _______________________________

FOR OFFICE USE ONLY

PHYSICAL DATE: ______________________________

REQUIREMENT OF INSURANCE FOR ATHLETES All student athletes must be covered by insurance. You may already have insurance covering

your student’s participation in school athletic programs. If so, you may not desire to purchase

insurance through the school. Even if you have insurance, you should check with your

insurance agent or representative to be certain that you have coverage for athletic

participation.

If you do not desire to purchase school insurance, you must fill out the following form:

INSURANCE VERIFICATION

Date __________________

_______________________________ is insured by ____________________________________ (Student) (Insurance Company) for all injuries that might occur in connection with participation in the District’s athletic

program. I have confirmed this with my insurance provider. I do not desire to purchase

insurance through the school plan. I understand that the District will reasonably rely on this

waiver and I agree that I will not assert any claims against the District on account of this

reliance.

____________________________________ Parent/Guardian

AUTHORIZATION FOR RELEASE OF RECORDS OR INFORMATION Section A: I, (Athlete’s Name) _________________________________, authorize the disclosure of my personal health information as described in Section B below. I understand that this authorization is voluntary and made to confirm my directions. I hereby give my permission to Limestone Community High School District No. 310 to disclose my personal health information in the manner described herein. Section B: Personal Health Information to be Disclosed I am authorizing the following personal health information to be used and/or disclosed: All personal health information that is stated/shared on son/daughter’s physical. Persons/Entities Authorized to Receive and Use I am authorizing Limestone Community High School District No. 310 to disclose or let use the personal health information described above, to: Emergency medical personnel. Purpose of the Disclosure This disclosure is being made for the sole purpose of: Seeking medical help in case of injury during game or practice.

Right to Revoke I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke it, this authorization will expire one (1) year from the date it was signed. To revoke the authorization, I will contact, in writing, Superintendent, Limestone Community High School District No. 310, 4201 S. Airport Rd., Bartonville, IL 61607 SIGNATURE I, (Parent Name) ________________________________, have had full opportunity to read and consider the contents of this authorization, and I confirm that the contents are consistent with my direction to the Limestone Community High School District No. 310. I understand that, by signing this form, I am confirming my authorization that Limestone Community High School District No. 310 may use and/or disclose to the persons and/or organizations named in this form the nonpublic personal health information described in this form. Signature of Parent/Guardian: __________________________________________ Date: __________________________

IHSA Sports Medicine Acknowledgement & Consent Form

Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump,

blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the

head. They can range from mild to severe and can disrupt the way the brain normally works.

Even though most concussions are mild, all concussions are potentially serious and may

result in complications including prolonged brain damage and death if not recognized

and managed properly. In other words, even a “ding” or a bump on the head can be serious.

You can’t see a concussion and most sports concussions occur without loss of consciousness.

Signs and symptoms of concussion may show up right after the injury or can take hours or days

to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms

or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

Headaches

“Pressure in head”

Nausea or vomiting

Neck pain

Balance problems or dizziness

Blurred, double, or fuzzy vision

Sensitivity to light or noise

Feeling sluggish or slowed down

Feeling foggy or groggy

Drowsiness

Change in sleep patterns

Amnesia

“Don’t feel right”

Fatigue or low energy

Sadness

Nervousness or anxiety

Irritability

More emotional

Confusion

Concentration or memory problems (forgetting game plays)

Repeating the same question/comment

Signs observed by teammates, parents and coaches include:

Appears dazed

Vacant facial expression

Confused about assignment

Forgets plays

Is unsure of game, score, or opponent

Moves clumsily or displays incoordination

Answers questions slowly

Slurred speech

Shows behavior or personality changes

Can’t recall events prior to hit

Can’t recall events after hit

Seizures or convulsions

Any change in typical behavior or personality

Loses consciousness

IHSA Sports Medicine Acknowledgement & Consent Form

Concussion Information Sheet (Cont.)

What can happen if my child keeps on playing with a concussion or returns too soon?

Athletes 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 athlete 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 athlete 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 adolescent or teenage athletes will often fail to report symptoms of injuries. Concussions are no different. As a result, education of administrators, coaches, parents and students is the key to student-athlete’s safety.

If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. IHSA Policy requires athletes to provide their school with written clearance from either a physician licensed to practice medicine in all its branches or a certified athletic trainer working in conjunction with a physician licensed to practice medicine in all its branches prior to returning to play or practice following a concussion or after being removed from an interscholastic contest due to a possible head injury or concussion and not cleared to return to that same contest. In accordance with state law, all IHSA member schools are required to follow this policy. You should also inform your child’s coach if you think that your child may have a concussion. Remember it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to:

http://www.cdc.gov/ConcussionInYouthSports/

Adapted from the CDC and the 3rd

International Conference on Concussion in Sport Document created 7/1/2011 Reviewed 4/24/2013

IHSA Sports Medicine Acknowledgement & Consent Form

IHSA Performance-Enhancing Substance Testing Policy

In 2008, the IHSA Board of Directors established the association’s Performance-Enhancing Substance (PES) Testing Program. Any student who participates in an IHSA-approved or sanctioned athletic event is subject to PES testing. A full copy of the testing program and other related resources can be accessed on the IHSA Sports Medicine website. Additionally, links to the PES Policy and the association’s Banned Drug classes are listed below. School administrators are able to access the necessary resources used for program implementation in the IHSA Schools Center. IHSA PES Testing Program http://www.ihsa.org/documents/sportsMedicine/2013-14/2013-14%20PES%20policy%20final.pdf IHSA Banned Drug Classes http://www.ihsa.org/documents/sportsMedicine/2013-14/2013-14%20IHSA%20Banned%20Drugs.pdf

IHSA Steroid Testing Policy Consent to Random Testing As a prerequisite to participation in IHSA athletic activities, we agree that I/our student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have reviewed the policy and understand that I/our student may be asked to submit to testing for the presence of performance-enhancing substances in my/our student’s body either during IHSA state series events or during the school day, and I/our student do/does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the results of the performance-enhancing substance testing may be provided to certain individuals in my/our student’s high school as specified in the IHSA Performance-Enhancing Substance Testing Program Protocol which is available on the IHSA website at www.IHSA.org. We understand and agree that the results of the performance-enhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject me/our student to penalties as determined by IHSA. A complete list of the current IHSA Banned Substance Classes can be accessed at http://www.ihsa.org/initiatives/sportsMedicine/files/IHSA_banned_substance_classes.pdf

IHSA Sports Medicine Acknowledgement & Consent Form

Acknowledgement and Consent

Student/Parent Consent and Acknowledgements By signing this form, we acknowledge we have been provided information regarding concussions and the IHSA Performance-Enhancing Testing Policy. We also acknowledge that we are providing consent to be tested in accordance with the procedures outlined in the IHSA Performance-Enhancing Testing Policy.

STUDENT Student Name (Print): Grade (9-12) Student Signature: Date: PARENT or LEGAL GUARDIAN Name (Print): Signature: Date: Relationship to student:

Each year IHSA member schools are required to keep a signed Acknowledgement and Consent form and a current Pre-participation Physical Examination on file for all student athletes.

Consent to Self Administer Asthma Medication

As a patient under my care, , is prescribed to self-administer the following asthma medication.

Medication

Purpose

Dosage

Time/Special Circumstances

Printed Name of Physician Signature of Physician Date I, , do hereby give my son/daughter, , Permission to self-administer his/her asthma medication as prescribed by his/her physician during athletic competition. Printed Name of Parent/Guardian Signature of Parent/Guardian Date

2013-14

Path

to the

Stu

den

t-Ath

lete Exp

erience

P.O. Box 7136 Indianapolis, IN 46207-7136

317/223-0700877/262-1492

www.eligibilitycenter.orgwww.2point3.org

The NCA

A salutes

more than

450,000

student-athletes

participating in

23 sports

at more than 1,100

colleges/universities

Checklist for C

ollege-B

ound Student-Athletes

Register at the beginning of your sophom

ore year at w

ww

.eligibilitycen

ter.org.

Ask your high school counselor to send your

transcript to the NC

AA

Eligibility C

enter at the end of your junior year.

Take the AC

T or SAT and use the code

“9999” to have your official scores sent directly to the N

CA

A E

ligibility Center.

Check w

ith your high school counselor to m

ake sure you are on track to graduate on tim

e with your class and are taking the

required amount of N

CA

A-approved core

courses.

Request

final am

ateurism

certification during your senior year (beginning A

pril 1).

Ask

your high

school counselor

to subm

it your final transcript with proof of

graduation.

If you

wish

to participate

in N

CA

A

Division

I or

II athletics,

you need

to be

certified by

the N

CA

A

Eligibility

Center. You need to qualify academ

ically and you w

ill also need to be cleared as an am

ateur student-athlete.

You are responsible for achieving and protecting your eligibility status!

For a Com

plete List of NC

AA C

oursesV

isit w

ww

.eligibilitycenter.org

and enter

the site

as an

NC

AA

C

ollege-Bound

Student-Athlete.

Navigate to the “R

esources” tab, click “U.S. Students”

and then “List of NC

AA

Courses.” Follow

the prompts

to search for your high school’s list by name.

Division I

(16 Core C

ourses)

4 years of English.

3 years of m

athematics

(Algebra I or higher).

2 years of natural/physical science (1 year of lab if offered by high school).

1 year of additional E

nglish, m

athematics or

natural/physical science.

2 years of social science.

4 years of additional courses (from

any area above, foreign language or com

parative religion/philosophy).

Division II

(16 Core C

ourses)

3 years of English.

2 years of m

athematics

(Algebra I or higher).

2 years of natural/physical science (1 year of lab if offered by high school).

3 years of additional E

nglish, m

athematics or

natural/physical science.

2 years of social science.

4 years of additional courses (from

any area above, foreign language or com

parative religion/philosophy).

Core C

ourses• N

CA

A D

ivisions I and II require 16 core courses. • For students enrolling on or after A

ugu

st 1, 20

16, N

CA

A D

ivision I will require 10 core

courses to be completed prior to the seventh

semester (seven of the 10 core courses m

ust be a com

bination of English, m

ath or natural or physical science that m

eet the distribution requirem

ents to the right). These 10 courses becom

e “locked in” at the start of the seventh sem

ester and

cannot be

retaken for

grade im

provement. Divisions I and II Initial-Eligibility Requirem

ents

Test Scores• D

ivision I uses a Sliding Scale to match test

scores and core GPA

. • D

ivision II requires a minim

um SA

T score of 820 or an A

CT sum

score of 68.• The SA

T score used for NC

AA

purposes includes only the critical reading and m

ath sections. The w

riting section of the SAT is not used.

• The AC

T sum score used for N

CA

A purposes is

a sum of the follow

ing four sections: English,

mathem

atics, reading and science.

To view

the

Division

I Sliding

Scale, visit

ww

w.2p

oint3.org.

When you register for the SA

T or AC

T, use the N

CA

A E

ligibility Center code of 9999

to ensure all SA

T and AC

T scores are reported directly to the N

CA

A E

ligibility Center from

the testing agency. Test scores that appear on transcripts w

ill not be used.

Grade-Point Average

• Only courses that appear on your high school’s List

of NC

AA

Courses w

ill be used in the calculation of your core G

PA. For a com

plete list of your school’s courses, follow

the instructions on the right side of this brochure.

Division

I• A

Sliding Scale is used to match test scores and

core GPA

s. The Sliding Scale can be found at w

ww

.2poin

t3.org or on Page No. 10 of the G

uide for the C

ollege-Bound Student-A

thlete found at w

ww

.eligibilitycenter.org.

• For students enrolling on or after Au

gust 1, 20

16,

the Division I G

PA required to be eligible for

competition is 2.300.

• For students enrolling on or after Au

gust 1, 20

16,

the Division I G

PA required to receive athletics aid

and practice is 2.000-2.299.

Division

II• The D

ivision II core GPA

requirement is a m

inimum

of 2.000.