Littleton Elementary School District #65...Littleton Elementary School District No. 65 Littleton...

Littleton Elementary School District #65

Athletic Handbook

2019-2020

Dear Parents/Guardians and Athletes,

Welcome to the Littleton Elementary School Athletic Program. We believe our athletic program

is an extension of the classroom. As such, athletics offers students an opportunity to develop

and grow physically, intellectually, emotionally, and socially. The positive benefits participation

in athletics offers include, but are not limited to, self-esteem, self-discipline, self-confidence,

and the development of team spirit. Further, participants learn the values associated with

competition and benefit from the experience of both winning and losing.

Included in this handbook are the rules and regulations necessary to provide a fair and orderly

opportunity for all participants. This handbook contains information regarding the general

operations and regulations of the Littleton Elementary School District Athletic Department.

Please read this content carefully with your athlete.

We look forward to working with you,

Michelle Smith

LESD Athletic Director

[email protected]

mailto:[email protected]

School Information ........................................................................................................................................... 1

2019-2020 Athletic Schedule ............................................................................................................................ 2

Accident Insurance .................................................................................................................................... 5

Athletic Fee ............................................................................................................................................... 5

Athletic Seasons ........................................................................................................................................ 5

Eligibility ................................................................................................................................................... 5

Formation of Teams .................................................................................................................................. 6

Game Day Eligibility Requirements.......................................................................................................... 6

Parent/Guardian Involvement .................................................................................................................... 6

Participation Requirements ....................................................................................................................... 6

Playing Time ............................................................................................................................................. 7

Practices ..................................................................................................................................................... 7

Spectator/Fan Expectation ......................................................................................................................... 7

Student Athlete Responsibilities and Code of Conduct ............................................................................. 7

Student Athlete Supervision ...................................................................................................................... 7

Suspension and Removal from the Team .................................................................................................. 8

Transportation............................................................................................................................................ 8

Sports Tryout Permission Slip ............................................................................................................................. 9

Consent for Emergency Care Form .................................................................................................................. 10

Parent/Student Agreement Form ...................................................................................................................... 11

Annual Pre-Participation Physical Form ......................................................................................................... 12

Concussion Acknowledgement Form ................................................................................................................ 13

Concussion Fact Sheets ...................................................................................................................................... 14

Interscholastic Sports Statement ....................................................................................................................... 16

Athletic Fee/Tax Credit Form ........................................................................................................................... 17

TABLE OF CONTENTS

Page 1

Littleton Elementary School District No. 65

Littleton Elementary School District No. 65 Mailing Address: P.O. Box 280, Cashion, AZ 85329

Physical Address: 1600 South 107th Avenue, Avondale, AZ 85323 Office Hours: 7:30 a.m. - 4:30 p.m.

Main Line: (623) 478-5600 [email protected]

Collier Elementary 350 South 118th Ave. Avondale, AZ 85323 Office Hours: 7:30 a.m. - 3:30 p.m. (regular day) 7:30 a.m. - 2:30 p.m. (early release) School Hours: 8:05 a.m. - 3:00 p.m. (regular day) 8:05 a.m. -12:40 p.m. (early release) Attendance Line: (623) 478-5901 Main Line: (623) 478-5900 [email protected]

Littleton Elementary STEM Academy 1252 South Avondale Blvd, Avondale, AZ 85323 Office Hours: 7:00 a.m. - 3:00 p.m. (regular day)

7:00 a.m. - 2:00 p.m. (early release) School Hours: 7:30 a.m. - 2:25 p.m. (regular day) 7:30 a.m. -12:05 p.m. (early release) Attendance Line: (623) 478-5702 Main Line: (623) 478-5700 [email protected]

Country Place Leadership Academy 10207 W. Country Place Blvd, Tolleson, AZ 85353 Office Hours: 7:00 a.m. - 3:00 p.m. (regular day)

7:00 a.m. - 2:00 p.m. (early release) School Hours: 7:30 a.m. - 2:25 p.m. (regular day) 7:30 a.m. -12:05 p.m. (early release) Attendance Line: (623) 478-6103 Main Line: (623) 478-6100 [email protected]

Quentin STEM Academy 11050 West Whyman Avenue, Avondale, AZ 85323 Office Hours: 8:10 a.m. - 4:10 p.m. (regular day) 8:10 a.m. - 3:10 p.m. (early release) School Hours: 8:40 a.m. - 3:35 p.m. (regular day) 8:40 a.m. - 1:15 p.m. (early release) Attendance Line: (623) 478-6001 Main Line: (623) 478-6000 [email protected]

Estrella Vista STEM Academy 11905 W. Cocopah Circle N., Avondale, AZ 85323 Office Hours: 8:10 a.m. - 4:10 p.m. (regular day) 8:10 a.m. - 3:10 p.m. (early release) School Hours: 8:40 a.m. - 3:35 p.m. (regular day) 8:40 a.m. - 1:15 p.m. (early release) Attendance Line: (623) 478-6290 Main Line: (623) 478-6200 [email protected]

Tres Rios Service Academy 5025 South 103rd Avenue, Tolleson, AZ 85353 Office Hours: 7:30 a.m. - 3:30 p.m. (regular day) 7:30 a.m. - 2:30 p.m (early release) School Hours: 8:05 a.m. - 3:00 p.m. (regular day) 8:05 a.m. - 12:40 p.m. (early release) Attendance Line: (623) 478-6301 Main Line: (623) 478-6300 [email protected]

Fine Arts Academy 1700 S. 103rd, Avenue, Tolleson, AZ 85353 Office Hours: 8:10 a.m. - 4:10 p.m. (regular day) 8:10 a.m. - 3:10 p.m. (early release) School Hours: 8:40 a.m. - 3:35 p.m. (regular day) 8:40 a.m. - 1:15 p.m. (early release) Attendance Line: (623) 478-6401 Main Line: (623) 478-6400 [email protected]

Family Welcome Center P.O. Box 280, Cashion, AZ 85329 1642 South 107th Avenue, Avondale, AZ 85323 Office Hours: 7:30 a.m. - 4:00 p.m. (regular day) 7:30 a.m. - 2:30 p.m. (early release) Attendance Line: (623) 478-5890 Main Line: (623) 478-5800 [email protected]

Page 1

2019-2020 ATHLETIC SCHEDULE

BOYS BASKETBALL SCHEDULE Games start at 4:45pm

Date Tres Rios Gymnasium Fine Arts Gymnasium Estrella Vista Gymnasium

8/22/2019 Tres Rios vs. Littleton County Place vs. Quentin Collier vs. Fine Arts

8/27/2019 Estrella Vista vs. Fine Arts Quentin vs. Tres Rios Littleton vs. Collier

9/5/2019 Tres Rios vs. Collier Fine Arts vs. County Place Littleton vs. Estrella Vista

9/10/2019 Estrella Vista vs. Country Place Littleton vs. Quentin Fine Arts vs. Tres Rios

9/13/2019 Collier vs. Country Place Littleton vs. Fine Arts Quentin vs. Estrella Vista

9/17/2019 Quentin vs. Collier Estrella Vista vs. Tres Rios Country Place vs. Littleton

9/19/2019 Quentin vs Fine Arts Collier vs. Estrella Vista Tres Rios vs. Country Place

9/24/2019 Playoffs Playoffs Playoffs



GIRLS SOCCER SCHEDULE Games start at 4:45pm

Date Tres Rios Field Quentin Field Collier Field











FLAG FOOTBALL SCHEDULE Games start at 4:45pm

Date Tres Rios Field Quentin Field Estrella Vista Field











Page 2


SOFTBALL SCHEDULE Games start at 4:45pm

Date Tres Rios Field Littleton Fields

10/29/2019 Tres Rios vs. Littleton County Place vs. Quentin

10/31/2019 Collier vs. Fine Arts Estrella Vista vs. Tres Rios

11/1/2019 Quentin vs. Tres Rios Littleton vs. Collier

11/5/2019 Tres Rios vs. Collier Fine Arts vs. County Place

11/7/2019 Littleton vs. Estrella Vista Quentin vs. Collier

11/8/2019 Littleton vs. Quentin Fine Arts vs. Tres Rios

11/12/2019 Collier vs. Country Place Littleton vs. Fine Arts

11/14/2019 Quentin vs. Estrella Vista Tres Rios vs. Country Place

11/15/2019 Estrella Vista vs. Fine Arts Country Place vs. Littleton

11/18/2019 Quentin vs Fine Arts Collier vs. Estrella Vista

11/19/2019 Estrella Vista vs. Country Place

12/3/2019 Playoffs Playoffs



BOYS SOCCER SCHEDULE Games start at 4:45pm

Date Tres Rios Field Quentin Field Collier Field











VOLLEYBALL SCHEDULE Games start at 4:45pm

Date Tres Rios Gymnasium Quentin Gymnasium Estrella Vista Gymnasium










2/25/2020 Playoffs Playoffs Playoffs Page 3


BASEBALL SCHEDULE Games start at 4:45pm

Date Tres Rios Field Littleton Fields

3/24/2020 Tres Rios vs. Littleton County Place vs. Quentin

3/26/2020 Collier vs. Fine Arts Estrella Vista vs. Tres Rios

3/30/2020 Quentin vs. Tres Rios Littleton vs. Collier

3/31/2020 Tres Rios vs. Collier Fine Arts vs. County Place

4/3/2020 Littleton vs. Estrella Vista Quentin vs. Collier

4/6/2020 Littleton vs. Quentin Fine Arts vs. Tres Rios

4/7/2020 Collier vs. Country Place Littleton vs. Fine Arts

4/9/2020 Quentin vs. Estrella Vista Tres Rios vs. Country Place

4/16/2020 Estrella Vista vs. Fine Arts Country Place vs. Littleton

4/17/2020 Quentin vs Fine Arts Collier vs. Estrella Vista

4/21/2020 Estrella Vista vs. Country Place




GIRLS BASKETBALL SCHEDULE Games start at 4:45pm

Date Tres Rios Gymnasium Fine Arts Gymnasium Estrella Vista Gymnasium











Page 4

ATHLETICS

Accident Insurance The District’s insurance carrier only covers incidents when our staff is involved such as a collision in a District vehicle so we encourage families to get their own insurance for things like falling on the playground. We realize there are many student accident insurance providers serving the market, and families should choose coverage with whom ever they are most comfortable. Markel Insurance Company is recommended for student accident insurance. Markel has received an “A” rating from A.M. Best, signifying excellent financial health. They offer higher insurance limits while maintaining comparable rates with around-the-clock, school time-only, football, and extended dental program options. They have an on-line open enrollment option available throughout the year. For more information about Markel’s student accident insurance program, including rates, applications, and claims, please visit http://markelaz.sevencorners.com. Athletic Fee Student-athletes are required to pay a fee of $25.00 per sport, $60.00 per student annual maximum, or $90.00 per family annual maximum. Student-athletes may receive a waiver from the principal if they meet specific criteria. Parents can request a waiver form from the school’s front office. Students who qualify for free lunch may receive a full waiver; students who receive reduced lunch may have an 80% waiver. This fee is non-refundable to those who drop out of the program, are suspended, or ineligible due to grades/conduct. The athletic fee or payment arrangement is due a day before the scheduled game day. The athletes are responsible for the uniforms and maintaining the condition in which they were given. Uniforms must be cleaned before they are returned. If a uniform is lost or damaged, the student will be charged to replace it. The fees can be applied to the tax credit on your state income tax return. Athletic Seasons

Fall - Boys Basketball and Gir ls Soccer

Winter—Flag Football and Softball

Spring-Boys Soccer and Volleyball

Summer-Baseball and Girls Basketball

Cheerleading is not offered at every campus. Please check with your school office for more information. Eligibility Each athlete’s academic & behavior progress will be monitored throughout the season of competition by the Assistant Principal. A student-athlete must be both academically and behaviorally eligible to participate in LESD athletics. A student who has two or more out-of-school suspensions during the current academic school year or has been long-term suspended, will be required to petition for eligibility. The administrator, teacher, and coach will determine if the athlete is eligible to participate. ACADEMIC eligibility:

During the season, the Assistant Principal will verify the student-athlete’s grade in Synergy.

Should a student athlete earn a failing grade in any class s/he are ineligible until the following eligibility review. During academic ineligibility athletes may practice, but they may not participate in any games. They may travel on the bus with their team to/from competition however, they are benched from competing.

The following procedure will be used for BEHAVIOR eligibility:

Assistant Principal will review student-athlete meeting expectations on a daily basis. Step 4(s) / In-School Suspensions will result in the athlete not being eligible to participate in either practice or competition. Closed Make Your Day Step 4(s) / Completed In-School Suspension(s) allow for an athlete to participate with his/her teammates; however, it is at the Coach’s discretion if there is an impact to participation in practice or competition.

The Assistant Principal will verify each athlete’s academic eligibility and notify the coach via email on/before 8:00AM on Friday of the same week;

The Assistant Principal or his/her designee will notify the coach of any Step 4(s) / In-School Suspension(s) on the same day. Should it be discovered that an ineligible player participated in a competition:

the competition will be forfeited;

the said player will serve a one-game suspension; and

the coach will serve a one-game suspension.

Page 5

ATHLETICS

During behavior ineligibility athletes may practice, but they may not participate in any games. They may travel on the bus with their team to/from competition however they are benched from competing. If an athlete is ineligible academically and/or behaviorally three times during the season, the athlete will be dismissed from the team. Formation of Teams Teams will be comprised of 6th, 7th, and 8th grade students. Teams will be determined after an evaluation by the coaches. Because of limited resources and supervision it may be necessary for some coaches to “cut” interested athletes to keep the team sizes manageable. Athletes must attend all tryouts to be considered for a team. After the tryouts, athletes with the highest scores based on the assessment will be selected and placed on the team. Game Day Eligibility Requirements

Student must attend a full day of school on the day of the game to participate.

Students may provide verification of attending medical, dental, or court-ordered appointments if not present for a full school day.

Student must meet academic and behavioral eligibility

Parent/Guardian Involvement

Should you have any concern do not approach the coach immediately at the conclusion of a game or practice. At this time, coaches have other responsibilities, and it isn’t an optimal time to discuss concerns. Should you have concerns, contact the coach and arrange for a mutually agreed upon means of addressing the matter. Should this not resolve the concern, please seek the support of the Athletic Director via the email link on the Littleton School District website to discuss your concern.

Should a parent/guardian’s action involve confronting a coach, official, or school staff outside of these protocols, possible removal/trespass notification from the site and/or attending any future school activities in the District may result. A. Common concerns of parents appropriate to

discuss with a coach are:

Unhealthy mental or physical strain you detect in your child at home;

How you can contribute to your child’s skill improvement and development; and/or

Any dramatic change you detect in your child’s behavior.

B. Common parent concerns inappropriate to

discuss with a coach are: Coaching strategy/decisions;

Distribution of student-athlete participation allocation; and/or

Other student athletes.

Participation Requirements The health and welfare of our athletes is the most important concern. Every effort will be made to ensure a healthy environment and safe training conditions for our athletes. Before athletes may participate in any aspect of school sports, they must:

1. Completed Consent for Emergency Care form with insurance coverage information provided.

2. Completed Physical form with doctor’s signature; To participate a physical is needed within one week after the student is placed on the team. Physicals must be dated after May 1st.

3. AIA Mild Traumatic Brain Injury/Concussion Statement and Acknowledgement Form.

4. Completed Parent/Student Agreement Form.

5. Completed Sports Tryout Permission Form.

6. Athletic fee paid to school or scholarship received prior to participation (must have waiver form completed and signed by the principal).

7. Complete Coaches Training Certificate.

Please go to our website, www.littletonaz.org, under the School Info Tab, for information about our athletic program, applications to participate in after school sports programs, and the electronic version of the Littleton Athletic Handbook.

Page 6

Playing Time The athlete’s attendance at practice, participation in practice, grades, classroom behavior, as well as the number of students on the team are factors considered by the coach when determining playing time. Every effort shall be made by the coach to maximize each participant’s playing time. Our athletic program is a hybrid of competitive and non-competitive. We provide the opportunity for student athletes to gain skills; all students may try out, and each student athlete will have a minimum amount of playing time during each competition. Coaches will plan for each eligible player to play at least 1/8th to 1/9th of the competition.

Basketball – Minimum of ½ of one quarter during the first half. Second half open substitutions are permitted.

Flag Football – each player must have the opportunity to play in at least ½ of one quarter during the first half. Second half open substitutions .

Volleyball – each player must have the opportunity to play for at least 10 points of one game.

Soccer – each player must have the opportunity to play for at least the equivalent of ½ of the minutes in the first half. Second half open substitutions are permitted.

Baseball – 3 outs or one time at bat.

Softball – 3 outs or one time at bat.

Practices Practice schedules are determined by the coaches. Practices may be held after school until 5:00PM on Mondays, Tuesdays, Thursdays, and Fridays. There are no practices or competitions on Wednesdays or any other early release days. Siblings or friends of athletes are not allowed to stay at practices. Spectator/Fan Expectations

Proper clothing and shirts must be worn at all times.

Refrain from derogatory or obscene cheers or signs, including shouting profanities towards officials, coaches or spectators.

Display only positive banners or posters.

Use of any noise makers of any type (air horns, bullhorns, whistles, etc) at sporting event are prohibited.

The throwing of any objects including confetti, torn paper scraps, crepe paper, toilet tissue, mini-balls, Frisbees, etc., by spectators will not be allowed at athletic events.

Spectators are not allowed on the playing field or court at any time, including half time, before, after and between games. After a competition, no one will be allowed onto the competition area until team members are released by their coaches, and the officials have exited safely.

Student spectators must be accompanied by an adult at all times.

Students spectators who are wandering around and distracting other fans/players will be asked to leave and further school consequences may apply.

Violation of any of these rules may result in the removal from the activity; permission to future events may be denied, up to and including possible trespassing notification. This determination will be made by the Office of School Leadership of Littleton Elementary Schools.

Student Athlete Responsibilities and Code of Conduct Student Athletes must abide by the academic and behavior guidelines of the school.

1. Athletes must maintain passing grades in all classes (including specials).

2. Athletes must have good behavior in all classes.

3. Athletes must treat all coaches, opposing teams, school staff members, and referees with respect.

4. Athletes are responsible for displaying good sportsmanship at all games.

Student Athlete Supervision 1. Athletes should report to the coach or

designated area when they are dismissed from their class.

2. Athletes should not leave a site or designated area without permission.

ATHLETICS

Page 7

3. Athletes must remain with their coaches at all times.

4. Coaches will be responsible for the supervision of their players. Coaches will remain with their players until all have been picked up after practice.

Suspension and Removal from the Team Players must follow certain guidelines while participating and representing their school. An athlete who violates the rules listed below shall be suspended or removed from their team.

ONE GAME SUSPENSION

Players suspended from the team may not participate in practice/competition. They can travel on the bus to/from any competition however they are benched from competition.

1. Two (2) unexcused tardies from a practice or game

2. One (1) unexcused absence from a practice or game

3. Misconduct during practices or games 4. Violation of the Student Athlete’s Code of

Conduct 5. If an athlete earns an out-of-school suspension

they will be benched for their next game (with the exception of a suspension resulting in a parent not attending a step 4 conference). In addition, during their out-of-school suspension, they are not allowed to be on any LESD campus and they will not travel with their team.

REMOVAL FROM THE TEAM

1. Athlete becomes academically or behaviorally ineligible for a third time during a season.

2. Upon earning a third one-game suspension. 3. If an athlete earns a second out of school

suspension during course of the academic year,

the athlete will be required to petition the current coach, teacher, and an administrator for permission to rejoin the team. In addition, the athlete may be ineligible to participate in sports for the remainder of the academic year. The decision is final and at the discretion of the current coach and Administration.

Transportation Littleton Elementary School District will provide transportation after school on practice days. The athletic bus will be available for student-athletes who stay for the team’s athletic practice. The buses will leave the campus at approximately 5:00PM for practice days and will drop off students at bus stops within walking distance of their homes. Transportation will be provided by the Littleton Elementary School District to all athletic games for student athletes only. Transportation will be provided back from athletic games for students who reside within the attendance area of Littleton Elementary School District. All athletes are required to use school transportation. Ineligible or suspended athletes may not ride the bus to/from games. Parents need to be at school no later than 15 minutes after the conclusion of practice or the arrival of the bus after a sporting event. The safety of our student-athletes is paramount. If a parent/guardian wishes to take their student athlete home after a sporting event, the parent/guardian taking custody of the student-athlete must meet with the coach and provide to the coach an electronic or hard copy of the driver’s license. Parents/Guardians are required to provide this electronic/written notification to the coach prior to the competition beginning.

ATHLETICS

The Littleton Elementary School District is a Kids at Hope district which means we are committed to the belief, principles and practices

that support the success of all children — No Exceptions! Page 8

LITTLETON ELEMENTARY SCHOOL DISTRICT SPORTS TRY-OUTS PERMISSION FORM

Date: Homeroom Teacher: Parents/Guardians: ______________________________________ Your child would like to try out for ___________________. Try-outs will run from _____________________________________________________________________ (dates and times). In order for your child to try out, we will need to have this permission slip and the Medical Release form (on back) completed and returned to the coach. If your student is chosen for the team we would like you to be aware of the following information:

The student will need a current school physical;

Before playing, parents and students must return the completed Athletic Handbook form;

There is a $25 sports participation fee ($60 individual cap/$90 family cap) that must be paid before the first game in order for your child to participate. A payment plan is available to pay the fee if needed. Please call ______________ to set up a payment plan.

All students will be transported back to their home school after games.

Bussing will be available after tryouts, practices, and games for those students who currently ride a bus. Busses will drop students off at their regular bus stop only.

Sincerely, The _______________ Coaching Staff

I give my consent to have try-out for ___________________. (Students Name)

I understand I will be responsible for my child getting home after try-outs for non-bus

riders.

If your student will need bus transportation, please complete the following: Bus Color/Number ____________ Bus Stop Location ___________________________

MEDICAL RELEASE ON NEXT PAGE

Page 9

CONSENT FOR EMERGENCY CARE FORM 201ω-20ςπ

Name of Student: (Please Print)

Grade: School:

In case of illness or injury, I request the staff member contact me at the number listed below. If I cannot be reached, I authorize a school representative to obtain emergency treatment for my child at the closest medical facility unless instructed otherwise by paramedics or emergency medical personnel. I understand the school assumes no responsibility other than the exercise of prudent supervision. All medical expenses will be covered by my own medical carrier. I have legal custody of my child and grant permission for any emergency treatment or hospital services be rendered to said minor under the general or specific direction of: Dr. Phone: (Please Print) Medical Insurance Provider: Policy Number:

Student Information Student’s Parent/Legal Guardian Name (Please Print) Home or Cell Phone: Work Phone/Ext: Home Address: Other emergency contact name: Phone: Relationship to student: List any Medication(s) the student takes on a daily/as needed basis: List any medical condition the student has: Signature of Parent/Legal Guardian: Date: _________________

Page 10

PARENT/STUDENT AGREEMENT

2019-2020

Name of Student (print)

Grade

School

I allow my child (student named above) to participate in the Littleton Elementary School District

Athletic program.

I am aware my child is to return the issued uniform in the same condition as received at the end of their season. I will be held responsible for the cost of replacing the uniform.

I have read the Athletic Handbook which includes Littleton Elementary School District Athletic Program’s policies and procedures and Athletic Code of Conduct. I, as a LESD65 student-athlete, and parent/guardian understand the expectations outlined in the Athletic Code of Conduct.

____________________________________________ ______________________________ Student Athlete Signature Date ____________________________________________ ______________________________ Parent Signature Date

Please check the sport your child will be participating in:

Fall Winter Spring Late Spring

(B) Basketball Flag Football (B) Soccer (B) Baseball

(G) Soccer Softball Volleyball (G) Basketball

Cheerleading [not all schools]




Emergency Contact Information:

Name:

Address:

Home Phone: Cell Phone: Emergency Phone:

Doctor’s Name:

Address:

Doctor’s Phone:

Page 11

ANNUAL PRE-PARTICIPATION PHYSICAL

Littleton Elementary School District

*ANNUAL PHYSICAL EXAMINATION: Must be dated after May 1 of the current year.

Name: _______________________________________________________________ Date: _________________________ Height: _____________ Weight; ______________ Pulse: __________ BP: __________________________ Vision: R 20/ ________ L 20/ ________ Glasses/Contacts; YES NO Pupils: Equal _______ Unequal _______

Normal Abnormal Findings Initials*

Medical

Appearance

Skin

Eyes/Ears/Nose

Throat/ Oropharynx

Lymph Nodes

Heart

Pulses

Lungs

Abdomen

Genitalia/ Hernia

Musculoskeletal

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand

Hip/thigh

Knee

Leg/ankle

Foot

*Station-based examination only CLEARANCE

Cleared Cleared after completing evaluation/rehabilitation for:

Not Cleared for: Reason: Recommendations:

Name of physician (print/type) Date Address Phone

Signature of physician MD/DO/NP/PA-C

Page 12

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 06/15 Page 13

Revised: 9/8/16

ARIZONA TAX CREDIT CONTRIBUTION Reduce Your Arizona Tax Bill & Support Your School

Couples filing joint taxes may donate up to $400; Individuals up to $200

Mail Your Contributions To: LITTLETON ELEMENTARY SCHOOL DISTRICT NO. 65

ATTN: BUSINESS RESOURCES P.O. BOX 280 CASHION, AZ 85329

I would like my contribution to support the following school (choose only one):

Littleton Quentin Estrella Vista

Collier Country Place Tres Rios

Date Parent (Guardian)/Community Member Address

City Zip Phone Number

STUDENT FEES: PAY‐TO‐PARTICIPATE STUDENT CLUBS

EXTRA CURRICULAR ACTIVITY

Student Name $25/activity

$60/student cap

$90/family cap

Activity

$1/student club $1/extra‐curricular activity

Total Amount Paid

Cash

Check # CONTRIBUTIONS ARE NON‐REFUNDABLE

I want to support:

School May Designate (0446)

Fine Arts (0448)

Athletics (0447) Enrichment/Clubs/Field Trips/Character Programs (0449)

Fine Arts Academy

Page 14

Concussions affect each child and teen differently. While most children and teens with a concussion feel better within a couple of weeks, some will have symptoms for months or longer. Talk with your children’s or teens’ health care provider if their concussion symptoms do not go away or if they get worse after they return to their regular activities.

Plan ahead. What do you want your child or teen to know about concussion?

What Are Some More Serious Danger Signs to Look Out For?In rare cases, a dangerous collection of blood (hematoma) may form on the brain after a bump, blow, or jolt to the head or body and can squeeze the brain against the skull. Call 9-1-1 or take your child or teen to the emergency department right away if, after a bump, blow, or jolt to the head or body, he or she has one or more of these danger signs:

• One pupil larger than the other.

• Drowsiness or inability to wake up.

• A headache that gets worse and does not go away.

• Slurred speech, weakness, numbness, or decreased coordination.

• Repeated vomiting or nausea, convulsions or seizures (shaking or twitching).

• Unusual behavior, increased confusion, restlessness, or agitation.

• Loss of consciousness (passed out/knocked out). Even a brief loss of consciousness should be taken seriously.

You can also download the CDC HEADS UP app to get concussion information at your fingertips. Just scan the QR code pictured at left with your smartphone.

What Should I Do If My Child or Teen Has a Possible Concussion?As a parent, if you think your child or teen may have a concussion, you should:

1. Remove your child or teen from play.

2. Keep your child or teen out of play the day of the injury. Your child or teen should be seen by a health care provider and only return to play with permission from a health care provider who is experienced in evaluating for concussion.

3. Ask your child’s or teen’s health care provider for written instructions on helping your child or teen return to school. You can give the instructions to your child’s or teen’s school nurse and teacher(s) and return-to-play instructions to the coach and/or athletic trainer.

Do not try to judge the severity of the injury yourself. Only a health care provider should assess a child or teen for a possible concussion. You may not know how serious the concussion is at first, and some symptoms may not show up for hours or days. A child’s or teen’s return to school and sports should be a gradual process that is carefully managed and monitored by a health care provider.

Children and teens who continue to play while having concussion symptoms or who return to play too soon—while the brain is still healing—have a greater chance of getting another concussion. A repeat concussion that occurs while the brain is still healing from the first injury can be very serious and can affect a child or teen for a lifetime. It can even be fatal.

Revised 12/2015

To learn more, go to www.cdc.gov/HEADSUP Page 15

http://www.cdc.gov/HEADSUP

A Fact Sheet for YOUTH SPORTS PARENTSThis sheet has information to help protect your children or teens from concussion or other serious brain injury.

What Is a Concussion?A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move quickly back and forth. This fast movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging the brain cells.

How Can I Help Keep My Children or Teens Safe?Sports are a great way for children and teens to stay healthy and can help them do well in school. To help lower your children’s or teens’ chances of getting a concussion or other serious brain injury, you should:

• Help create a culture of safety for the team.

› Work with their coach to teach ways to lower the chances of getting a concussion.

› Emphasize the importance of reporting concussions and taking time to recover from one.

› Ensure that they follow their coach’s rules for safety and the rules of the sport.

› Tell your children or teens that you expect them to practice good sportsmanship at all times.

• When appropriate for the sport or activity, teach your children or teens that they must wear a helmet to lower the chances of the most serious types of brain or head injury. There is no “concussion-proof” helmet. Even with a helmet, it is important for children and teens to avoid hits to the head.

How Can I Spot a Possible Concussion?Children and teens who show or report one or more of the signs and symptoms listed below—or simply say they just “don’t feel right” after a bump, blow, or jolt to the head or body—may have a concussion or other serious brain injury.

Signs Observed by Parents• Appears dazed or stunned.

• Forgets an instruction, is confused about an assignment or position, or is unsure of the game, score, or opponent.

• Moves clumsily.

• Answers questions slowly.

• Loses consciousness (even briefly).

• Shows mood, behavior, or personality changes.

• Can’t recall events prior to or after a hit or fall.

Symptoms Reported by Children and Teens• Headache or “pressure” in head.

• Nausea or vomiting.

• Balance problems or dizziness, or double or blurry vision.

• Bothered by light or noise.

• Feeling sluggish, hazy, foggy, or groggy.

• Confusion, or concentration or memory problems.

• Just not “feeling right,” or “feeling down.”

Talk with your children and teens about concussion. Tell them to report their concussion symptoms to you and their coach right away. Some children and teens think concussions aren’t serious or worry that if they report a concussion they will lose their position on the team or look weak. Remind them that it’s better to miss one game than the whole season.

GOOD TEAMMATES KNOW: IT’S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON.

Page 16

fong.vianey

Typewritten Text

Littleton ESD #65

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

fong.vianey

Typewritten Text

INTERSCHOLASTIC SPORTS

In accordance with Policy JJIB-Interscholastic Sports, the Littleton ESD#65 Board shall develop, in

consultation with the Arizona Interscholastic Association (AIA) Guidelines, Information and Forms to

inform and educate coaches, pupils and parents of the dangers of Heat-Related Illnesses, Sudden Cardiac

Death and Prescription Opioid use. Before a pupil participates in any District-Sponsored practice

session, game or other Interscholastic Athletic Activity, the pupil and the pupil’s parent must be provided

with the information at least once each school year on the risks of Heat-Related Illnesses, Sudden

Cardiac Death and Prescription Opioid Addiction.

Parents & Students,

We are asking that you please review the following information related to Heat-Related Illnesses, Sudden

Cardiac Death and Prescription Opioid Addiction. In alignment with our Governing Board Policy the

information we are providing is from Arizona Interscholastic Association (AIA).

Heat Related Illnesses

http://www.nfhs.org/articles/dangers-of-heat-illness-reduced-by-following-proper-guidelines/ (Heat

Related Illness Policy) Sudden Cardiac Death

https://nfhslearn.com/courses/61032/sudden-cardiac-arrest (Sudden Cardiac Death) Prescription Opioid Use

http://aiaonline.org/files/16347/high-school-athletes-and-the-risks-associated-with-opioid-use.pdf (Opioid

Use) http://www.nfhs.org/articles/the-opioid-epidemic-and-high-school-sports-why-it-matters/ (Opioid Use)

Page 17

http://www.nfhs.org/articles/dangers-of-heat-illness-reduced-by-following-proper-guidelines/

https://nfhslearn.com/courses/61032/sudden-cardiac-arrest

http://aiaonline.org/files/16347/high-school-athletes-and-the-risks-associated-with-opioid-use.pdf

http://www.nfhs.org/articles/the-opioid-epidemic-and-high-school-sports-why-it-matters/

Littleton Elementary School District #65...Littleton Elementary School District No. 65 Littleton...

Documents

Transcript of Littleton Elementary School District #65...Littleton Elementary School District No. 65 Littleton...