Have you attended another high school IN THE PAST 12 MONTHS?
UKIAH HIGH SCHOOL
2019-20 SPORTS PARTICIPATION CHECKLIST
RETURN TO Attendance Office or Athletic Director
(Do not give to a coach)
______________________ ______ __________________ ________
Student’s Name Grade Sport(s) I.D. #
I have received, read and signed the following documents (PLEASE INITIAL NEXT TO EACH DOCUMENT or you will not be eligible to practice):
Athlete Parent / Guardian
_______ ________ Physician Statement of Student Certification
_______ ________ Acknowledgement/Assumption of Potential Risk
_______ ________ Authorization & Consent for Medical Treatment and Health Insurance Verification
_______ ________ Concussion Information Sheet
_______ ________ NCS Ejection Policy
_______ ________ UUSD Extra-Curricular Rules & Regs/Student Contract
_______ ________ CIF Code of Conduct
_______ ________ Statements re: Hazing and Anabolic/Illegal Drug Use
_______ ________ Sudden Cardiac Arrest Notification Form
_______ ________ Complaint Procedure & Playing Time
_______ ________ I have watched the Video Clip “Positive Sport Parenting” online: Nfhslearn.com
________ Parent Code of Conduct
Signature of Parent/Guardian ________________________________________ Date __________________
Signature of Athlete ________________________________________________ Date __________________
Physical Examination Information
The physical examination must be dated June 1st or later for the current school year. The physical examination is good until July 1 of the same school year. (i.e a physical exam for the 2019-20 school year is good until July 1, 2020).
It is very important that the above requested documents are turned in to the Attendance Office or A.D. at least a week or two before the beginning of the sport season. With the number of student-athletes and sports provided each season, it will normally take at least a week to process all the information. If you turn in the information on the first day of practice/tryouts, you will more than likely miss at least the first few days of practice/tryouts.
_____ 1. There were no history or physical findings on this exam which would prohibit this student from participating in competitive athletics.
_____ 2. This student should have the following health problems evaluated or treated prior to participating in competitive athletics. (list below)
_____ 3. This student has health problems which would prohibit him or her from participating in competitive athletics.
PHYSICIAN’S STATEMENT CERTIFICATION
Are there apparent cavities in teeth? _____ Yes _____ No
Is there a bridge or false teeth? _____ Yes _____ No
Has the above had any injury or physical condition that should be watched? _____
If yes, please list ______________________________________________________________________________________
I hereby certify that__________________________________________was examined by me on ____________ 20______ and found physically fit to participate in sports in the school year 2019-20.
Physician’s Signature __________________________________________________Date________________________
Please Print Name _____________________________________________________________
ATHLETICS / SPORTS VOLUNTARY ACTIVITIES PARTICIPATION FORM
ACKNOWLEDGMENT AND ASSUMPTION OF POTENTIAL RISK
I authorize my son/daughter, to participate in the Ukiah Unified School District sponsored activities: (list all sports planning to participate)
A.) I understand and acknowledge that these activities, by their very nature, pose the potential risk of serious injury/illness to individuals who participate in such activities.
E.) I acknowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATION FORM and that I understand and agree to its terms.
Student Signature Date
A signed VOLUNTARY ACTIVITIES PARTICIPATION FORM and AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT AND HEALTH INSURANCE VERIFICATION FORM must be on file with the Ukiah Unified School District before a student will be allowed to participate in the above extra-curricular activities.
TRANSPORTATION AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT AND HEALTH INSURANCE VERIFICATION
I do hereby give my permission for ___________________________________ to be transported to and from athletic events in UUSD provided transportation OR by UUSD approved parent/guardian drivers when necessary.
Pursuant to Education Code 32221, the insurance shall provide the following coverage: At least one thousand five hundred dollars ($1,500) for all medical and hospital expenses.
I have health insurance that meets the requirements under the California Education Code Section 32221.
I do not have health insurance that meets the requirements under the California Education Code Section 32221.
Athletic Team/Sport: _________________________________________
Student's Name: _________________________________________
Insured (Subscribers) Name: _________________________________________
Insurance Company: _________________________________________
Policy/I.D. Number: _________________________________________
|California Education Code 32221.5:|
Some students may qualify to enroll in no-cost or low-cost local, state, or federally sponsored health insurance programs. Information about these programs may be obtained by calling Medi-Cal at 800-541-5555 or Healthy Families Program at 800-880-5305.
|AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT|
In the event of an injury or illness to _______________________________(son/daughter) while participating on the athletic team, I do hereby authorize the Ukiah Unified School District, as agent for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under, the general or special supervision of any physician and/or surgeon, whether such diagnosis or treatment is rendered at the office of said physician or at any medical facility.
UKIAH HIGH SCHOOL
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:
Signs observed by teammates, parents and coaches include:
|What can happen if my child keeps on playing with a concussion or returns to soon?|
Athletes with the signs and symptoms of concussion will 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 athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.
|If you think your child has suffered a concussion|
Any athlete even suspected of suffering a concussion will 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. The new CIF Bylaw 313 now requires implementation of long and well-established return to play concussion guidelines that have been recommended for several years:
“A student-athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time and for the remainder of the day.”;
“A student-athlete who has been removed may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.
You should also inform your child’s coach if you think that your child may have a concussion Remember its 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:
_____________________________ _______________________________ _____________
Student-athlete Name Printed Student-athlete Signature Date
_____________________________ _________________________________ _____________
Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date
Adapted from the CDC and the 3rd International Conference on Concussion in Sport
Document created 5/20/2010
ATHLETE EJECTION POLICY NOTIFICATION FORM*
(North Coast Section Ejection Policy)
Ukiah High School
The following rules and minimum penalties are applicable to all players as adopted by the NCS Board of Managers on April 21, 1995. This policy is in effect and will include non-league, league, invitational tournaments/events, post-season; league, section or state playoffs, etc.
I have read and understand the rules and regulations of the Ejection Policy. Athletes may not participate in any contest until this document is filed with the school.
Student's Signature (Date)
SPORT(s) ___________________________________________ VAR JV FR
UKIAH UNIFIED SCHOOL DISTRICT
EXTRACURRICULAR ACTIVITIES RULES / REGULATIONS
Students who participate in extracurricular activities serve in the capacity of role models, ambassadors of goodwill, and assume a posture of high expectations as representatives of Ukiah High School, Pomolita Middle School, or Eagle Peak Middle School and are subject to the rules and regulations outlined in this section and Board Policy. Participation in extracurricular activities is defined as athletics, after-school band, after-school drama, and other activities in which the student represents the school.
Violation of the rules and regulations outlined below will result in exclusions from such activities as specified.
Any student who commits a violation of Education Code 48900 and/or 48915 that results in the assignment of a Behavioral Contract or recommendation for expulsion is automatically removed from participation in athletic competition and extracurricular activities for a minimum period of 14 calendar days beginning on the date of the issuance of the Behavioral Contract. All school rules are in effect during school hours, travel to and from school, and during extracurricular activities.
A student who is suspended from school is also suspended from all extracurricular activities during the period of suspension.
Students participating in extracurricular programs are subject to meeting the academic eligibility standards included in the Ukiah Unified School District board policy.
Students participating in athletic programs are subject to all bylaws of the California Interscholastic Federation (CIF), North Coast Section (NCS) and North Bay League (NBL).
A student must be in attendance all day on event days and practice days. Waivers may be given for unusual causes by principal or designee.
Continued or persistent violation of any of these procedures will result in disciplinary action including conferences with parents/guardians, suspension and/or dismissal from an activity. All activity sponsors shall have the final authority for setting criteria for selection, participation, and activity rules other than listed. A copy of these rules will be given to each participant. Any student who is officially dropped from an activity or quits an activity forfeits his/her right for any award.
Ukiah High School
Code of Conduct for Interscholastic Student-Athletes
Interscholastic athletic competition should demonstrate high standards of ethics and sportsmanship and promote the development of good character and other important life skills. The highest potential of sports is achieved when participants are committed to pursuing victory with honor according to six core principles: trustworthiness, respect, responsibility, fairness, caring, and good citizenship (the "Six Pillars of Charactersm").
This Code applies to all student-athletes involved in interscholastic sports in California. I understand that, in order to participate in high school athletics, I must act in accord with the following.
Trustworthiness — be worthy of trust in all I do.
Integrity — live up to high ideals of ethics and sportsmanship and always pursue victory with honor; do what’s right even when it’s unpopular or personally costly.
Honesty — live and compete honorably; don’t lie, cheat, steal or engage in any other dishonest or unsportsmanlike conduct.
Reliability — fulfill commitments; do what I say I will do; be on time to practices and games.
Loyalty — be loyal to my school and team; put the team above personal glory.
Respect — treat all people with respect all the time and require the same of other student-athletes.
Class — live and play with class; be a good sport; be gracious in victory and accept defeat with dignity; give fallen opponents help, compliment extraordinary performance, 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 or racial nature, trash-talking, taunting, boastful celebrations or other actions that demean individuals or the sport.
Respect Officials — treat contest officials with respect; don’t complain about or argue with official calls or decisions during or after an athletic event.
Importance of Education — be a student first and commit to getting the best education I can. Be honest with myself about the likelihood of getting an athletic scholarship or playing on a professional level and remember that many universities will not recruit student-athletes that do not have a serious commitment to their education, the ability to succeed academically or the character to represent their institution honorably.
Role-Modeling — Remember, participation in sports is a privilege, not a right and that I am expected to represent my school, coach and teammates with honor, on and off the field. Consistently exhibit good character and conduct yourself as a positive role model.
Suspension or termination of the participation privilege is within the sole discretion of the school administration.
Self-Control — exercise self-control; don’t fight or show excessive displays of anger or frustration; have the strength to overcome the temptation to retaliate.
Healthy Lifestyle — safeguard your health; don’t use any illegal or unhealthy substances including alcohol, tobacco and drugs or engage in any unhealthy techniques to gain, lose or maintain weight.
Integrity of the Game — protect the integrity of the game; don’t gamble. Play the game according to the rules.
Be Fair — live up to high standards of fair play; be open-minded; always be willing to listen and learn.
Concern for Others — demonstrate concern for others; never intentionally injure any player or engage in reckless behavior that might cause injury to myself or others.
Teammates — help promote the well being of teammates by positive counseling and encouragement or by reporting any unhealthy or dangerous conduct to coaches.
Play by the Rules — maintain a thorough knowledge of and abide by all applicable game and competition rules.
Spirit of rules — honor the spirit and the letter of rules; avoid temptations to gain competitive advantage through improper gamesmanship techniques that violate the highest traditions of sportsmanship.
I have read and understand the requirements of this Code of Conduct. I understand that I’m expected to perform according to this code and I understand that there may be sanctions or penalties if I do not.
Student-Athlete Signature Date
Education Code 32050
As used in this article, “hazing” includes any initiation or pre-initiation into a student organization or any pastime or amusement engaged in with respect to such an organization, which causes, or is likely to cause, bodily danger, physical harm, or personal degradation or disgrace resulting in physical or mental harm, to any student or other person attending any school, community college, college, university, or other educational institution in this state; but the term “hazing” does not include customary athletic events, or other similar contests or competitions.
Education code 32051
No student, or other person in attendance at any public, private, parochial, or military school, community college, college, or other educational institution, shall conspire to engage in hazing, participate in hazing, or commit any act that causes or is likely to cause bodily danger, physical harm, or personal degradation or disgrace resulting in physical or mental harm to any fellow student, or person attending the institution. The violation of this section is a misdemeanor, punishable by a fine of not less than one hundred dollars ($100), nor more than five thousand dollars ($5000), or imprisonment in the county jail for not more than one year, or both.
Ukiah Unified School District Board Policy AR 6145.5
Any student who engages in hazing may be subject to discipline including, but not limited to, suspension or expulsion. Hazing means a method of initiation or pre-initiation into a student organization or body, whether or not the organization or body is officially recognized by the district, which is likely to cause serious bodily injury or personal degradation or disgrace resulting in physical or mental harm to a former, current, or prospective student.
|ANABOLIC STEROIDS AND ILLEGAL DRUGS|
As a condition of membership in the California Interscholastic Federation (CIF) and the governing board of the Ukiah Unified School District Board Policy 5131.63 prohibiting the use of anabolic steroids and illegal drugs has been established. CIF Bylaw 524 requires that all participating students and their parents/guardians sign an agreement.
Before participating in interscholastic athletics, a student athlete and his/her parent/guardian shall sign a statement that the student athlete pledges not to use androgenic/anabolic steroids and dietary supplements banned by the U.S. Anti-Doping Agency and the substance synephrine, unless the student has a written prescription from a licensed health care practitioner to treat a medical condition.
Student-athletes must also recognize that under CIF Bylaw 200.D the student may be subject to penalties including not being eligible for participation in CIF sports. We understand that the Ukiah Unified School District policy regarding the use of illegal drugs will be enforced for any violation of these rules. A student who is found to have violated the agreement or this policy shall be restricted from participating in athletics and shall be subject to disciplinary procedures including, but not limited to, suspension or expulsion in accordance with law, Board policy, and administrative regulation.
Athletic Complaint Procedure 2019-20
In the event that there is a concern or complaint (other than that of a criminal nature) with a coach, the following procedure must be followed:
Please keep in mind that high school sports have no minimum required playing time. Generally, you can expect the following:
Freshman Sports – All members showing up to practice daily will get playing time. While all team members may not play in each and every game, it would be expected that team members will play in the majority of games. Naturally, the better players will get more playing time. Freshman sports are for skills development and preparation for J.V. and Varsity.
J.V. Sports- All members practicing daily will get playing time. The better players will play the most, but every effort will be made to allow all players to participate.
Varsity Sports- There is no guaranteed playing time. Starters will play the majority of the time in an effort to put the very best team on the field.
Parent Signature _________________________________ Date __________________
Athlete Signature ________________________________ Date __________________
CODE OF CONDUCT FOR PARENTS/GUARDIANS
The role of the parent in the education of a student is vital. The support shown in the home is often manifested in the ability of the student to accept the opportunities presented at school and in life. There is a value system– established in the home, nurtured in the school –that young people are developing. Their involvement in classroom and other activities contributes to that development. Trustworthiness, citizenship, caring, fairness and respect are lifetime values taught through athletics. These are the principles of good sportsmanship and character. With them, the spirit of competition thrives, fueled by honest rivalry, courteous relations and graceful acceptance of the results.
As a parent/guardian of a student-athlete at our school, your goals should include:
The leadership role you take will help influence your child, and our community, for years to come.
Violation of the above code of conduct may result in one or more of the following consequences: a warning, removal from the venue, suspension from attending home events, or further discipline to be determined by the administration.
The majority of fans come to events to watch the athletes. They deserve to do so in an atmosphere that is free from the distraction of others yelling at the coaches, other team’s players or the officials.
Whenever the attention is diverted from the athletes playing the contest we are doing a disservice to our student athletes and ruining the experience of other fans.
As parent/guardian I understand my role and expected conduct at all contests. I understand that the consequences of conduct or behavior that is in violation of these expectations may result in my removal from the venue.
Parent Signature __________________________________________________________________________ Date ________________________
Keep Their Heart in the Game
Sudden Cardiac Arrest Information for Athletes & Parents/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. SCA is a malfunction in the heart’s electrical system, causing the victim to collapse. The malfunction is caused by a congenital or genetic defect in the heart’s structure.
|Recognize the Signs & Risk Factors|
|Potential indicators that SCA may occur||Factors That Increase the Risk of SCA|
|Fainting or seizure, especially during or right after exercise||Family history of known heart abnormalities or sudden death before age 50|
|Fainting repeatedly or with excitement or being startled||Specific family history of Long QT Syndrome, Brugada Syndrome, Hypertrophic Cardiomyopathy, or Arrhythmogenic Right Ventricular Dysplasia (ARVD)|
|Excessive shortness of breath during exercise||Family members with unexplained fainting, seizures, drowning or near drowning or car accidents|
|Racing or fluttering heart palpitations or irregular heartbeat||Known structural heart abnormality, repaired or unrepaired|
|Repeated dizziness or lightheaded||Use of drugs, such as cocaine, inhalants, “recreational” drugs, excessive energy drinks, diet pills or performance-enhancing supplements|
|Chest pain or discomfort with exercise|
|Excessive, unexpected fatigue during or after exercise|
|Cardiac Chain of Survival|
Recognition of Sudden Cardiac Arrest
Victim is collapsed, unresponsive and not breathing, even if gasping, gurgling, exhibiting breathing noises or seizure-like activity.
Follow emergency dispatcher's instructions. Call any on-site Emergency Responders.
Begin CPR immediately. Hands only CPR involves fast and continual two-inch chest compressions - about 100 per minute.
Immediately retrieve and use an automated external defibrillator to restore the heart to its normal rhythm. Follow step-by-step audio instructions from the AED.
Designate a bystander to direct EMS to the victim for quick transfer to the hospital.
|What is an AED?|
|An automated external defibrillator (AED) is the only way to save a sudden cardiac arrest victim. An AED is a portable, user-friendly device that automatically diagnoses potentially life-threatening heart rhythms and delivers an electric shock to restore normal rhythm. Anyone can operate an AED, regardless of training. Simple audio direction instructs the rescuer when to press a button to deliver the shock, while other AEDs provide an automatic shock if a fatal heart rhythm is detected. A rescuer cannot accidentally hurt a victim with an AED - quick action can only help. AEDs are designed to only shock victims whose hearts need to be restored to a healthy rhythm. Check with your school for locations of on-campus AEDs.|
|What are we doing to help protect student athletes?|