Athletic Packet Requirements · 2017. 8. 8. · Athletic Packet Requirements All players are...

Athletic Packet Requirements

All players are required to turn in the completed Athletic Packet completely filled

out (including all signatures) prior to tryouts. All Athletic Packets must be either

stapled or paper-clipped in numerical order with page 1 being on top and page 10

being on the bottom:

: Athletic Emergency Information Form

Pages 2-5: Annual Pre-participation Physical Evaluation Form (4-pages including doctor’s signature)

Page 6: Athletic Informed Consent Form

Page 7: (MTBI) / Concussion Statement and Acknowledgement Form

Page 8: Athletic Code of Conduct (signature page only)

Page 9: Family and Coach Agreement

Page 10: Certificate of Completion of AIA Brainbook Academy Concussion

Course

ARIZONA INTERSCHOLASTIC ASSOCIATION7007 North 18th Street, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

2016-2017 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION (The Parent or Guardian should fill out this form with assistance from the student athlete.)

Name: Name:

Name:

Relationship:

Relationship:

Phone (Home):

Phone (Home):

(Work):

(Work):

(Cell):

(Cell):

Y N

Sex: Age: Date of Birth:Grade:School:Sport(s):Address:Phone:Personal Physician: Hospital Preference:

In case of emergency, contact:

Exam Date:

Explain "Yes" answers on following page. Circle questions you don’t know the answers to.

1) Has a doctor ever denied or restricted your participation in sports for any reason?

2) Do you have an ongoing medical condition (like diabetes or asthma)?

3) Are you currently taking any prescription or nonprescription (over-the-counter) medicines or supplements?(Please specify):

4) Do you have allergies to medicines, pollens, foods, or stinging insects?(Please specify):

5) Does your heart race or skip beats during exercise?6) Has a doctor ever told you that you have (check all that apply):

High Blood Pressure A Heart Murmur High Cholesterol A Heart Infection

7) Have you ever spent the night in the hospital?

8) Have you ever had surgery?

* 9) Have you ever had an injury (sprain, muscle/ligament tear, tendinitis, etc.) that caused you to miss a practice orgame? (If yes, circle affected area in the box below):

*10) Have you had any broken/fractured bones or dislocated joints? (If yes, circle affected area in the box below):

* 11) Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physicaltherapy, a brace, a cast, or crutches? (If yes, circle affected area in the box below):

□ Head Neck Shoulder Upper Arm Elbow Forearm

Hand/Fingers Chest Upper Back Low Back Hip Thigh

Knee Calf/Shin Ankle Foot/Toes

The Preferred Health Care Partner of the Arizona Interscholastic Association

1NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

Y N12) Have you ever had a stress fracture?

13) Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?

14) Do you regularly use a brace or assistive device?

15) Has a doctor told you that you have asthma or allergies?16) Do you cough, wheeze, or have difficulty breathing during or after exercise?17) Is there anyone in your family who has asthma?18) Have you ever used an inhaler or taken asthma medicine?19) Were you born without, are you missing, or do you have a nonfunctioning kidney,eye, testicle or any other organ?

20) Have you had infectious mononucleosis (mono) within the last month?

21) Do you have any rashes, pressure sores, or other skin problems?

22) Have you had a herpes skin infection?23) Have you ever had an injury to your face, head, skull or brain (including a concussion, confusion, memory lossor headache from a hit to your head, having your “bell rung” or getting “dinged”)?

24) Have you ever had a seizure?

25) Do you have headaches with exercise?26) Have you ever had numbness, tingling, or weakness in your arms or legs after being hit, falling, stingers or burners?

27) When exercising in the heat, do you have severe muscle cramps or become ill?

28) Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?

29) Have you ever been tested for sickle cell trait?

30) Have you had any problems with your eyes or vision?

31) Do you wear glasses or contact lenses?

32) Do you wear protective eyewear, such as goggles or a face shield?

33) Are you happy with your weight?

34) Are you trying to gain or lose weight?

35) Has anyone recommended you change your weight or eating habits?

36) Do you limit or carefully control what you eat?

37) Do you have any concerns that you would like to discuss with a doctor?

Females Only Explain “Yes” Answers Here

38) Have you ever had a menstrual period?

39) How old were you when you had your firstmenstrual period?

40) How many periods have you had in thelast year?

Y N


Phone: (602) 385-3810


2NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

Y

Y

N

N

2016-2017 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION (The Physician should fill out this form with assistance from the Parent or Guardian.)

Student Name: Date of Birth:

Patient History Questions: Please tell me about your child...

Family History Questions: Please tell me about any of the following in your family...

1) Has your child fainted or passed out DURING or AFTER exercise, emotion or startle?

3) Has your child had extreme fatigue associated with exercise (different from other children)?

2) Has your child ever had extreme shortness of breath during exercise?

4) Has your child ever had discomfort, pain or pressure in his/her chest during exercise?

5) Has a doctor ever ordered a test for your child's heart?

6) Has your child ever been diagnosed with an unexplained seizure disorder?

7) Has your child ever been diagnosed with exercise-induced asthma not well controlled with medication?

8) Are there any family members who had sudden, unexpected, unexplained death before age 50? (including SIDS, car accidents, drowning, ornear drowning)

9) Are there any family members who died suddenly of "heart problems" before age 50?

10) Are there any family members who have unexplained fainting or seizures?

11) Are there any relatives with certain conditions, such as:

Enlarged Heart

Hypertrophic Cardiomyopathy (HCM)

Dilated Cardiomyopathy (DCM)

Heart Rhythm problems:

Long QT Syndrome (LQTS)

Short QT Syndrome

Brugada Syndrome

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

Marfan Syndrome (Aortic Rupture)

Heart Attack, age 50 or younger

Pacemaker or Implanted Defibrillator

Deaf at Birth (Congenital Deafness)

Explain “Yes” Answers Here

I hereby state that, to the best of my knowledge, my answers to all of the above questions are complete and correct. Furthermore, I acknowledge and understand that my eligibility may be revoked if I have not given truthful and accurate information in response to the above questions.

Signature of athlete Signature of parent/guardian Date

Signature of MD/DO/ND/NMD/NP/PA-C/CCSP Date:

FORM 15.7-A 02/14

Y N


Phone: (602) 385-3810


3 NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

1-888-364-7502NextCareAZ.com

Apache Junction • 851202080 West Southern Ave., Suite #A1

Broadway Road

Mer

idia

n Ro

ad

Ironw

ood

Driv

e

Southern Avenue

60

Walgreens

Avondale • 8539213075 W. McDowell Rd., Suite #D106

W. McDowell Rd.

W. Van Buren St.

W. Indian School Rd.

N. D

ysart Rd.

N. Litch�eld Rd.

Fry’s

Casa Grande • 851221683 E. Florence Blvd., Suite #7

10

E. Florence Blvd.

E. Cottonwood Ln.

N. A

rizola Rd.

County Rd.

N. Verbena H

enness Rd.

99¢ Store

Bank ofAmerica

Walmart Chandler • 85224600 S. Dobson Road, Suite #C-26

Pecos Road Dob

son

Roa

dFrye Road

Chandler Blvd.

Glendale • 853065410 W. Thunderbird Road, Suite #101

W. Greenway Rd

N. 5

9th

Ave

N. 5

1st A

ve

N. 4

3rd

Ave

W. Thunderbird RdASU West Campus

Thunderbird Paseo Park

N. 3

5th

Ave

17N. 5

5th

Ave

H

Glendale • 8530210240 N. 43rd Ave., Suite #310240 North 43rd Avenue, Ste #3 Glendale, AZ 85302

W. Cactus Rd.

Peoria Ave.

N. 5

1st A

ve.

N. 4

3rd

Ave.

W. Dunlap Ave.

17

17

Glendale • 853059494 W. Northern Ave., Suite #101Peoria/Glendale9494 W. Northern Ave.

W. Olive Ave.

W. Northern Ave.N. 9

9th

Ave.

N. 9

1st A

ve.

W. Glendale Ave.

101

101

Target

Mesa • 852051066 N. Power Road, Suite #101

E. Brown Rd

Red MountainHigh School

N. P

ower

Rd

202

N. R

ecke

r Rd

E. McKellips Rd

Mesa • 852043130 E. Baseline Road, Suite #105

60

Baseline Road

N. L

inds

ay R

d.

N. V

al V

ista

Dr.

S. 3

2nd

St.

Dan

a Pa

rk

Mesa • 85203535 E. McKellips Road, Suite #101

McKellips Dr.

N. M

esa

Dr.

N. H

orne

LOOP202

Walmart

Cottonwood • 86326450 S. Willard Street, Suite #120

89AS. Calv

ary W

ayS.

Willa

rd St

.

W. Cottonwood St.

Airpark Rd.

89A

Glendale • 8530818589 N. 59th Ave., Suite #101

N. 59th Ave

W. Union Hills Dr

Honeywell

101

N. 51st Ave

N. 67th Ave

Starbucks

Chino Valley • 86323474 State Highway 89

Safeway

89

89

W. Rd 1 N E. Rd 1 N

W. Rd 2 N

N. R

d 1

E

Walgreens

Center St.

Chino ValleyHigh School

Flagstaff • 860011000 N. Humphreys St., Suite #104

180

180

N. F ort Valley Road

N. H

umph

reys

St

reet

W. Columbus Avenue

W. Desilva Avenue

Basha’sN

. Bea

ver S

tree

t

Flagstaff MedicalCenter

Lake Havasu City • 864031810 Mesquite Ave., Suite B

Kmart95 Mesqu

ite A

ve.

N. McC

ulloch

Blvd.

Rivi

era

Blv

d

Capri Blvd.Library Ln

Civic Center Ln

95

Swanso

n Ave.

WheelerPark

Havasu RegionalMedical Center


LOOP202

McKellipsVal V

ista

Gre

en�e

ld

McDowell

Walmart

Peoria • 8538220470 N. Lake Pleasant Rd., Suite #102

Rose Garden Ln.

Beardsley Rd.

Lake

Ple

asan

t Roa

d(9

9th

Ave.

)

(91s

t Av

e.)

101

20470 N. Lake Pleasant Rd.Suite 102Peoria, AZ 85382

LakePleasant Pkwy

Bashas

Walgreens

Phoenix • 850161701 E. Thomas Road, Suite #A104

51

E. Oak St.

E. Thomas Rd.

E. Osborn Rd.

N. 16th St.

N. 21st St.

N. 20 th St.

PhoenixChildren’sHospital

Phoenix • 850184730 E. Indian School Rd., Suite #211

N. A

rcad

ia Dr.

Indian School

N. 4

4th

St.

48th

St.

Arcadia H.S.

Safeway

Phoenix • 850218101 N. 19th Ave., Suite #A

8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021

W. Northern Ave.

W. Orangewood Ave.N. 1

9th

Ave.

N. 7

th A

ve.

17

Albertson’s


Phoenix • 8505020950 N. Tatum Blvd., Suite #19020950 N Tatum Blvd, Suite 190, Phoenix, AZ 85050

E. Deer Valley Rd.

N. T

atum

Blv

d.

E. Rose Garden Ln.DESERT RIDGEMARKET PLACE

101101

Scottsdale • 852607425 E. Shea Blvd., Suite #108

N. S

cott

sdal

e Rd

E. Shea Blvd

Harkins Theaters

N. H

ayden Rd

E. Mountain View Rd

N. 7

0th

St

101

N. 7

4th

St

Sun City • 853519745 W. Bell Road, Suite #1059745 W. Bell Road, Suite 105

Sun City, 85351

W. Union Hills Dr.

W Bell Rd.N. 9

9th

Ave

N. 9

8th

Ave

.

N. 9

1st

Ave.

W. Thunderbird Rd.

101

101

Tempe • 85281914 N. Scottsdale Rd., Suite #104

Curry Road

Scot

tsda

le R

oad

LOOP202

Jack inthe Box

Rura

l

Tucson • 857126238 E. Pima Street

Pima

SpeedwayW

ilmot10

6238 E. Pima St. Tucson

Circle K

Tucson • 857489525 E. Old Spanish Trail, Suite #101

E. Old Spanish Trail

E 22nd St

S Ha

rriso

n Rd

9525 E. Old Spanish Trail Tucson

Target

Starbucks

Tucson • 857054280 North Oracle Rd., Suite #100

W. Wetmore Rd.

W. Prince Rd.

W. Miracle Mile

N. O

racl

e Rd

.

N. F

low

ing

Wel

ls R

d.

10

4280 N. Oracle Rd. Ste. 100Tucson, AZ 85705

77

Walgreens

W. Limberlast Dr.

Tucson • 857065369 S. Calle Santa Cruz, Suite #145

W. Ajo Way

W. Valencia Rd.

W. Drexel Rd.

W. Irvington Rd.

S. M

idva

le P

ark

Rd.

S. C

alle

San

ta C

ruz R

d.

10

86 86

5369 S. Calle Santa Cruz Suite 145, Tucson, 85706

Harkins

19

Tucson • 85719501 North Park Ave., Suite #110

E. 6th St.

Speedway Blvd.

University Blvd.

N. E

uclid

Ave

.

10

N.P

ark

Ave.

TUCSON

501 N. Park Ave., Ste. 110

MetroWildcat

Sedona • 863362530 W. SR 89A, Suite #A

89A

yaW nor e

H eul B

.rD t acr aeB zt ut S

. d R ybgi R

Anda

nte

Dr.

SEDONA

.t Sdr alli

W. S

. nLydna

C. S

S. C

alvar

y Way

COTTONWOOD

PRESCOTT PRESCOTT VALLEY

89A

89A

Green Ln.

Miller Valley Rd.

Willow

Creek R

d.

N. G

lass

ford

Hill

Rd.

N. N

avaj

o D

r.

N. R

ober

t Rd.

N. W

inds

ong

Dr.

450 S. Willard Street, Suite 120 Cottonwood, AZ 86326(Arizona 89A at Willard Street)

2530 W. SR 89ASedona, AZ 86336(Arizona 89A & Andante Dr.)

2062 Willow Creek Rd.Prescott, AZ 86301(Green Ln. & Willow Creek Rd.)

3051 N. Windsong Dr.Prescott Valley, AZ 86314(E. Florentine Rd & Windsong Dr.)

69

E. Florentine Rd.

Prescott • 863012062 Willow Creek Road

89A

yaW

noreH

eul B

.rDt acr aeB

zt ut S

. d Rybgi R

Anda

nte

Dr.

SEDONA

.t Sdr alli

W. S

. nLydna

C. S

S. C

alvar

y Way

COTTONWOOD


89A

89A

Green Ln.

Miller Valley Rd.

Willow

Creek R

d.

N. G

lass

ford

Hill

Rd.

N. N

avaj

o D

r.

N. R

ober

t Rd.

N. W

inds

ong

Dr.





69

E. Florentine Rd.

Prescott Valley • 863143051 N. Windsong Drive

N. W

inds

ong

Dr.

N. R

ober

t Rd.

69

E. Florentine Dr.

E. Lakeshore Dr.

Phoenix • 850323229 E. Greenway Rd., Suite #102

51

E. Thunderbird Rd.

Greenway Rd.

E. Bell Rd.

N. 32nd St.

N. 40th St.

Food City

Phoenix • 850355920 W. McDowell Road

W. McDowell Rd.

W. Coronado Rd.

N. 59th Ave.

5920 W. McDowell Rd, Phoenix, AZ 85035

7-11

Walgreens

Surprise • 8537414800 W. Mtn. View Blvd., Suite #100

60

N. Reem

s Road

W. Mountain View Boulevard

Hampton Inn & Suites

Albertson’sMarket

W. Grand Ave

Colon n ade Way




Phone: (602) 385-3810

2016-2017 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION


Name: Sex: Age: Date of Birth:

Height: Weight:% Body fat (optional):

Pupils:

Pulse:

BP:____/____ (____ /____,____/____)

Corrected: Y___ N___Vision: R20/_____ L20/_____

Normal Abnormal Findings Initials*

Medical

Musculoskeletal

Appearance

Lymph Nodes

Back

Pulses

Wrist/Hand/Fingers

Eyes/Ears/ Throat/Nose

Heart

Shoulder/Arm

Lungs

Hip/Thigh

Genitourinary †

Leg/Ankle

Hearing

Neck

Murmurs

Elbow/Forearm

Abdomen

Knee

Skin

Foot/Toes* Multi-examiner set-up only.† Having a third party present is recommended for the genitourinary examination.

NOTES:

Recommendations:

Name of Physician(Print/Type):

Address:

Signature of Physician:

FORM 15.7-B 03/12

Exam Date:

Phone:

, MD/DO/ND/NMD/NP/PA-C/CCSP

Cleared Without RestrictionNot Cleared For: All Sports Certain Sports Reason:

Equal_____ Unequal____

NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.


Apache Junction • 851202080 West Southern Ave., Suite #A1

Broadway Road

Mer

idia

n Ro

ad

Ironw

ood

Driv

e

Southern Avenue

60

Walgreens

Avondale • 8539213075 W. McDowell Rd., Suite #D106

W. McDowell Rd.

W. Van Buren St.

W. Indian School Rd.

N. D

ysart Rd.

N. Litch�eld Rd.

Fry’s

Casa Grande • 851221683 E. Florence Blvd., Suite #7

10

E. Florence Blvd.

E. Cottonwood Ln.

N. A

rizola Rd.

County Rd.

N. Verbena H

enness Rd.

99¢ Store

Bank ofAmerica

Walmart Chandler • 85224600 S. Dobson Road, Suite #C-26

Pecos Road Dob

son

Roa

dFrye Road

Chandler Blvd.

Glendale • 853065410 W. Thunderbird Road, Suite #101

W. Greenway Rd

N. 5

9th

Ave

N. 5

1st A

ve

N. 4

3rd

Ave

W. Thunderbird RdASU West Campus

Thunderbird Paseo Park

N. 3

5th

Ave

17N. 5

5th

Ave

H

Glendale • 8530210240 N. 43rd Ave., Suite #310240 North 43rd Avenue, Ste #3 Glendale, AZ 85302

W. Cactus Rd.

Peoria Ave.

N. 5

1st A

ve.

N. 4

3rd

Ave.

W. Dunlap Ave.

17

17

Glendale • 853059494 W. Northern Ave., Suite #101Peoria/Glendale9494 W. Northern Ave.

W. Olive Ave.

W. Northern Ave.N. 9

9th

Ave.

N. 9

1st A

ve.

W. Glendale Ave.

101

101

Target

Mesa • 852051066 N. Power Road, Suite #101

E. Brown Rd

Red MountainHigh School

N. P

ower

Rd

202

N. R

ecke

r Rd

E. McKellips Rd

Mesa • 852043130 E. Baseline Road, Suite #105

60

Baseline Road

N. L

inds

ay R

d.

N. V

al V

ista

Dr.

S. 3

2nd

St.

Dan

a Pa

rk


McKellips Dr.

N. M

esa

Dr.

N. H

orne

LOOP202

Walmart

Cottonwood • 86326450 S. Willard Street, Suite #120

89AS. Calv

ary W

ayS.

Willa

rd St

.

W. Cottonwood St.

Airpark Rd.

89A

Glendale • 8530818589 N. 59th Ave., Suite #101

N. 59th Ave

W. Union Hills Dr

Honeywell

101

N. 51st Ave

N. 67th Ave

Starbucks

Chino Valley • 86323474 State Highway 89

Safeway

89

89

W. Rd 1 N E. Rd 1 N

W. Rd 2 N

N. R

d 1

E

Walgreens

Center St.

Chino ValleyHigh School

Flagstaff • 860011000 N. Humphreys St., Suite #104

180

180

N. F ort Valley Road

N. H

umph

reys

St

reet

W. Columbus Avenue

W. Desilva Avenue

Basha’sN

. Bea

ver S

tree

t

Flagstaff MedicalCenter

Lake Havasu City • 864031810 Mesquite Ave., Suite B

Kmart95 Mesqu

ite A

ve.

N. McC

ulloch

Blvd.

Rivi

era

Blv

d

Capri Blvd.Library Ln

Civic Center Ln

95

Swanso

n Ave.

WheelerPark

Havasu RegionalMedical Center


LOOP202

McKellipsVal V

ista

Gre

en�e

ld

McDowell

Walmart

Peoria • 8538220470 N. Lake Pleasant Rd., Suite #102

Rose Garden Ln.

Beardsley Rd.

Lake

Ple

asan

t Roa

d(9

9th

Ave.

)

(91s

t Av

e.)

101

20470 N. Lake Pleasant Rd.Suite 102Peoria, AZ 85382

LakePleasant Pkwy

Bashas

Walgreens

Phoenix • 850161701 E. Thomas Road, Suite #A104

51

E. Oak St.

E. Thomas Rd.

E. Osborn Rd.

N. 16th St.

N. 21st St.

N. 20 th St.

PhoenixChildren’sHospital

Phoenix • 850184730 E. Indian School Rd., Suite #211

N. A

rcad

ia Dr.

Indian School

N. 4

4th

St.

48th

St.

Arcadia H.S.

Safeway

Phoenix • 850218101 N. 19th Ave., Suite #A

8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021

W. Northern Ave.

W. Orangewood Ave.N. 1

9th

Ave.

N. 7

th A

ve.

17

Albertson’s


Phoenix • 8505020950 N. Tatum Blvd., Suite #19020950 N Tatum Blvd, Suite 190, Phoenix, AZ 85050

E. Deer Valley Rd.

N. T

atum

Blv

d.

E. Rose Garden Ln.DESERT RIDGEMARKET PLACE

101101

Scottsdale • 852607425 E. Shea Blvd., Suite #108

N. S

cott

sdal

e Rd

E. Shea Blvd

Harkins Theaters

N. H

ayden Rd

E. Mountain View Rd

N. 7

0th

St

101

N. 7

4th

St

Sun City • 853519745 W. Bell Road, Suite #1059745 W. Bell Road, Suite 105

Sun City, 85351

W. Union Hills Dr.

W Bell Rd.N. 9

9th

Ave

N. 9

8th

Ave

.

N. 9

1st

Ave.

W. Thunderbird Rd.

101

101

Tempe • 85281914 N. Scottsdale Rd., Suite #104

Curry Road

Scot

tsda

le R

oad

LOOP202

Jack inthe Box

Rura

l

Tucson • 857126238 E. Pima Street

Pima

SpeedwayW

ilmot10

6238 E. Pima St. Tucson

Circle K

Tucson • 857489525 E. Old Spanish Trail, Suite #101

E. Old Spanish Trail

E 22nd St

S Ha

rriso

n Rd

9525 E. Old Spanish Trail Tucson

Target

Starbucks

Tucson • 857054280 North Oracle Rd., Suite #100

W. Wetmore Rd.

W. Prince Rd.

W. Miracle Mile

N. O

racl

e Rd

.

N. F

low

ing

Wel

ls R

d.

10

4280 N. Oracle Rd. Ste. 100Tucson, AZ 85705

77

Walgreens

W. Limberlast Dr.

Tucson • 857065369 S. Calle Santa Cruz, Suite #145

W. Ajo Way

W. Valencia Rd.

W. Drexel Rd.

W. Irvington Rd.

S. M

idva

le P

ark

Rd.

S. C

alle

San

ta C

ruz R

d.

10

86 86

5369 S. Calle Santa Cruz Suite 145, Tucson, 85706

Harkins

19

Tucson • 85719501 North Park Ave., Suite #110

E. 6th St.

Speedway Blvd.

University Blvd.

N. E

uclid

Ave

.

10

N.P

ark

Ave.

TUCSON

501 N. Park Ave., Ste. 110

MetroWildcat

Sedona • 863362530 W. SR 89A, Suite #A

89A

yaW nor e

H eul B

.rD t acr aeB zt ut S

. d R ybgi R

Anda

nte

Dr.

SEDONA

.t Sdr alli

W. S

. nLydna

C. S

S. C

alvar

y Way

COTTONWOOD


89A

89A

Green Ln.

Miller Valley Rd.

Willow

Creek R

d.

N. G

lass

ford

Hill

Rd.

N. N

avaj

o D

r.

N. R

ober

t Rd.

N. W

inds

ong

Dr.





69

E. Florentine Rd.

Prescott • 863012062 Willow Creek Road

89A

yaW

noreH

eul B

.rDt acr aeB

zt ut S

. d Rybgi R

Anda

nte

Dr.

SEDONA

.t Sdr alli

W. S

. nLydna

C. S

S. C

alvar

y Way

COTTONWOOD


89A

89A

Green Ln.

Miller Valley Rd.

Willow

Creek R

d.

N. G

lass

ford

Hill

Rd.

N. N

avaj

o D

r.

N. R

ober

t Rd.

N. W

inds

ong

Dr.





69

E. Florentine Rd.

Prescott Valley • 863143051 N. Windsong Drive

N. W

inds

ong

Dr.

N. R

ober

t Rd.

69

E. Florentine Dr.

E. Lakeshore Dr.

Phoenix • 850323229 E. Greenway Rd., Suite #102

51

E. Thunderbird Rd.

Greenway Rd.

E. Bell Rd.

N. 32nd St.

N. 40th St.

Food City

Phoenix • 850355920 W. McDowell Road

W. McDowell Rd.

W. Coronado Rd.

N. 59th Ave.

5920 W. McDowell Rd, Phoenix, AZ 85035

7-11

Walgreens

Surprise • 8537414800 W. Mtn. View Blvd., Suite #100

60

N. Reem

s Road

W. Mountain View Boulevard

Hampton Inn & Suites

Albertson’sMarket

W. Grand Ave

Colon n ade Way



TEAMDeer Valley Unified Scltool DistrictCONSENT FOR PARTICIPANON GRADE

.{LL STUDENTS PARTICiPATING IN THE DEER VAIIEY SCHOOL DISTRiCT EXTRAMURAL PRoGRAMMUST BE COVERED BY INSURANCE

We give consent.for our child to participate in:

Student's Name: Birth Date: _Age:

Parent (s) / Guardian Name: Home phone: area code #

Address: Cell phone:_Pager:

Phone Number of Parent during day: Father: Mother:

IN CASE OF EMERGENCY. IF PARENTS CANNOT BE CONTACTED

Please Notify: Phone Number;

Phone Number:Family Doctor:

Preferred Hospital: Known Allergies:

Yes, we understand and agree that the coach may apply first aid treaknent until the family doctor can be contacted.Yes, we give our consent for coaches to us€ their own judgment in seiuring medical aid and ambulance service in case theParents cannot be reached. Nurses are not in attendance at after school games or practices.

Date: Parent's Signature:

GRADE:

STATEMENT OF INSURANCE COYERAGE

We will be participating in the school insurance program

We will not be participating in the school insurance program, but will provide our own insurance coverageIf this statement is checked, please complete the following:

A. IAVe affirm that VWe are the parent(s) or legal guardian(s) --ofI/We request that the fore-mentioned snrdent be exempt from the school insurance program and that he/she iscurrently covered and will be covered during the present school year by an accident policy, insured by:(Company): . This policy provides protection at least in theequivalent sums and coverage's as the policy offered by the school. This includes coverage during a schoolsupervised game or activity.

B. NOTIFICATION - WARNING: VWe give our permission for our sonldaughter to participate in organizedInterscholastic athle[ics, realizing that such activity involves the potential for injury which is inherent in all sports.i/We acknowledge that even with the best coaching use of the most advanced protective equipment and strictobservance of rules, injuries are still a possibility. On rare occasions, these injuries can be so severe as to result in '

total disability, paralysis. quadriplegia or even death.

I have read and understand parts A and B, and hereby give my consent for my son/daughter to participare in theDeer Valley Extramural Program. I also consent for him/her.to accompany the team as a member on trips. Iverifv the information contained in this document is accurate.

DATE: SICNATURE OF STUDENT:

uSIGNATURE OF PARENT OR LEGAL GUARDIAN:

Arizona Interscholastic Association, Inc.

Mild Traumatic Brain Injury (MTBI) / Concussion

Annual Statement and Acknowledgement Form

I, _________________________ (student), acknowledge that I have to be an active participant in my own health

and have the direct responsibility for reporting all of my injuries and illnesses to the school staff (e.g., coaches,

team physicians, athletic training staff). I further recognize that my physical condition is dependent upon

providing an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or

disabilities experienced before, during or after athletic activities.

By signing below, I acknowledge:

My institution has provided me with specific educational materials including the CDC Concussion fact

sheet (http://www.cdc.gov/concussion/HeadsUp/youth.html) on what a concussion is and has given me

an opportunity to ask questions.

I have fully disclosed to the staff any prior medical conditions and will also disclose any future conditions.

There is a possibility that participation in my sport may result in a head injury and/or concussion. In rare

cases, these concussions can cause permanent brain damage, and even death.

A concussion is a brain injury, which I am responsible for reporting to the team physician or athletic

trainer.

A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance,

sleep, and classroom performance.

Some of the symptoms of concussion may be noticed right away while other symptoms can show up

hours or days after the injury.

If I suspect a teammate has a concussion, I am responsible for reporting the injury to the school staff.

I will not return to play in a game or practice if I have received a blow to the head or body that results in

concussion related symptoms.

I will not return to play in a game or practice until my symptoms have resolved AND I have written

clearance to do so by a qualified health care professional.

Following concussion the brain needs time to heal and you are much more likely to have a repeat

concussion or further damage if you return to play before your symptoms resolve.

Based on the incidence of concussion as published by the CDC the following sports have been identified as high risk

for concussion; baseball, basketball, diving, football, pole vaulting, soccer, softball, spiritline and wrestling.

I represent and certify that I and my parent/guardian have read the entirety of this document and fully understand

the contents, consequences and implications of signing this document and that I agree to be bound by this

document.

Student Athlete:

Print Name: _________________________ Signature: __________________________

Date: ___________

Parent or legal guardian must print and sign name below and indicate date signed.

Print Name: _________________________ Signature: __________________________

Date: ___________

FORM 15.7‐C 06/14

ATHLETIC CODE OF CONDUCT

DEER VALLEY UNIFIED SCHOOL DISTRICT #97 ATHLETIC CODE OF CONDUCT

The interscholastic athletic program is an extension of the regular offerings of the high school, and as such, the student-athlete must be considered an individual who has freely chosen to participate in a program extending beyond the regular classroom routine. The student-athlete must recognize that participation in athletics requires a code of conduct, which goes beyond that of the non-athlete. Once signed, the student is subject to all rules and regulations of the Code of Conduct for the remainder of his/her high school career. All guidelines outlined in the district Student Rights and Responsibilities Handbook as related to the ARS, will be enforced with school consequences. The Code of Conduct includes, but is not limited to, behaviors during public appearances where the athlete is representing his/her school, behaviors during transportation to such an event, behaviors during training or practice, and behaviors during any time on campus. The athlete found in violation of these guidelines, through discovery by school staff, public official, or student-athlete admission, he/she will be subject to additional consequences listed below.

FIRST INFRACTION LEVEL

• Use or possession of all tobacco or alcohol products requires a suspension of 20% of the next athletic opportunities from the day the infraction is discovered.

• Use or possession of a controlled substance requires athlete to be

suspended from athletics for the remainder of that school year and may face long-term suspension if infraction occurred on campus, at an off campus activity, or in school vehicle.

• Athletes involved in an infraction of the Student Rights and

Responsibilities as related to the ARS will be subject to a suspension of 20% of the next athletic opportunities from the day of the infraction is discovered.

*An athletic opportunity is any single athletic contest under the Arizona Interscholastic Association.

SECOND INFRACTION LEVEL

• If the infraction occurs in the same season, the athlete will be dismissed from the squad AND receive a suspension of 40% of the next athletic opportunities from the day the infraction is discovered.

• If an infraction occurs after the original season, the athlete will be

subject to a 40% suspension of the next athletic opportunities.

• Athletes involved in an infraction of the Student Rights and Responsibilities as related to the ARS will be subject to a suspension of 40% of the next athletic opportunities from the day of the infraction is discovered.

THIRD INFRACTION LEVEL

• If a third infraction occurs, the athlete will incur a 365-day suspension from all athletic opportunities from the day the infraction is discovered.

There is an expectation that the athlete needs to complete an educational awareness program on substance abuse within one year at the expense of the individual. Failure will result in the athlete not being able to move back to the previous level or to the grace period with no level. Athletes will not fulfill their consequence by missed athletic opportunities with another sport unless they complete the season with that sport. Failure to complete the season requires that athletes complete consequences back to the original infraction. If the athlete is infraction free for a period of one year, the athlete shall revert back to the previous level.

We understand the above rules and will abide by them.

Parent/Guardian Signature: _____________________Print Name _______________ Athlete Signature: ________________________ Print Name ____________ Date______________________ This Code of Conduct will be part of the Athletic Clearance Procedure for all High School athletes in the Deer Valley Unified School District. This will be filed in the school athletic office.

khughes

Highlight

khughes

Highlight

khughes

Highlight

khughes

Highlight

khughes

Highlight

JJIB Interscholastic Sports Concussion Policy: In order for the DVUSD 7-8 Athletics to be in compliance with new State Law A.R.S. 15-341 (August, 2011) in regards to concussion education and the JJIB Interscholastic Sports Concussion Policy, all students who either tryout and/or participate on a DVUSD athletic team must complete the following course:

1. Go to this site http://aiaacademy.org/ 2. Select Concussion - Brainbook picture 3. Register as a Student 4. Enter Demographic information – (Select the high school you

would attend according to where you live now) 5. Select sport for this season and any season in the future 6. Complete course

7. Print certificate of completion and turn in with the Athletic

Clearance Packet

Athletic Packet Requirements · 2017. 8. 8. · Athletic Packet Requirements All players are...

Documents

Transcript of Athletic Packet Requirements · 2017. 8. 8. · Athletic Packet Requirements All players are...