Orcutt Academy High Schoolorcuttacademyhigh.ss11.sharpschool.com/UserFiles... · 2 | Page Updated...

1 | Page Updated 4/25/2016

Orcutt Academy High School Pre-Participation Physical Evaluation

Student Health History Form

Medicines and Allergies: Please list the prescription and over-the-counter medicines and supplements (herbal and nutritional-including energy drinks/ protein supplements) that you are currently taking: ______________________________________________________________________ Do you have any allergies? Yes No

If yes, please identify specific allergies below: Medicines Pollens Foods Stinging Insects

Please mark an "X" in "Yes" or "No" box to all questions, if you do not know the answer, please circle the number. GENERAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in any sport for any reason?

2. Do you have any ongoing medical conditions? If so, please identify below: Asthma / Anemia / Diabetes / Infections / Other: ____________

3. Have you ever spent the night in the hospital? 4. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU Yes No 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during exercise? 8. Has a doctor ever told you that you have any heart problems? If yes, circle all that apply.

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected during exercise?

11. Have you ever had an unexplained seizure? 12. Do you get more tired or short of breath, quicker than your friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arryhthmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or game?

18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture? 21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability?

22. Do you regularly use a brace, orthotics, or other assistive device? 23. Do you have a bone, muscle, or joint injury that bothers you? 24. Do any of your joints become painful, swollen, feel warm, or look red? 25. Do you have any history of juvenile arthritis or connective tissue disease?

MEDICAL QUESTIONS Yes No 26. Do you cough, wheeze, or have difficulty breathing during or after exercise?

27. Have you ever used an inhaler or taken asthma medicine? 28. Is there anyone in your family who has asthma? 29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

30. Do you have groin pain or a painful bulge or hernia in the groin area? 31. Have you had infectious mononucleosis (mono) within the past month? 32. Do you have any rashes, pressure sores, or other skin issues? 33. Have you had a herpes (cold sores) or MRSA (staph) skin infection? 34. Have you ever had a head injury or concussion? 35. Have you ever had a hit or blow to the head that caused confusion, prolonged headaches or memory problems?

36. Do you have a history of seizure disorder or epilepsy? 37. Do you have headaches with exercise? 38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

39. Have you ever been unable to move your arms or legs after being hit or falling?

40. Have you ever become ill while exercising in the heat? 41. Do you get frequent muscle cramps when exercising? 42. Do you or someone in your family have sickle cell trait or disease? 43. Have you had any problems with your eyes or vision? 44. Have you had an eye injury? 45. Do you wear glasses or contact lenses? 46. Do you wear protective eyewear, such as goggles or a face shield? 47. Do you worry about your weight? 48. Are you trying to gain or lose weight? Has anyone recommended that you do?

49. Are you on a special diet or do you avoid certain types of foods? 50. Have you ever had an eating disorder? 51. Do you have any concerns that you would like to discuss with a doctor? 52. Do you have or someone in your family with Down Syndrome or Dwarfism?

FEMALES ONLY Yes No 52. Have you ever had a menstrual period? 53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months? Explain "yes" answers below or on the backside of the paper:

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Student Signature: ________________________________ Parent/Guardian Signature: __________________________________ Date: ____________

(Note: This form is to be filled out by the student and the parent prior to seeing the medical examiner. The medical examiner may keep a copy of this form in the chart).

Exam Date: Name: Birth Date: Age: Email: Gender: Grade: Address: City: Phone (H): (Work) (Cell) Sport(s): Emergency Contact: Phone: Relationship:

High Blood Pressure High Cholesterol

A Heart Murmur A Heart Infection Other: _____________________________


Orcutt Academy High School Parent / Student Athlete Authorization Form

THE STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN INTERSCHOLASTIC ATHLETICS

UNTIL THIS FORM HAS BEEN SIGNED AND RETURNED TO THE SCHOOL I hereby authorize the release and disclosure of the pre-participation physical evaluation clearance form of: ("Student") _________________________________, as described below, to ("School") ___________________________. The information described below may be released to the School Principal or Assistant Principal, Athletic Director, Coach, Athletic Trainer, Physical Education Teacher, School Nurse and/or other members of the School's administrative staff as necessary to evaluate the student's eligibility to participate in school sponsored activities. Including, but not limited to interscholastic sports programs, physical education classes, or other classroom activities. The personal health information of a student, other than the clearance form; may be released and disclosed. It includes the records of the evaluation, diagnosis, and treatment of injuries, which the Student incurred while engaging in school sponsored activities, including but not limited to practice sessions, training and competition; and other records as necessary to determine the Student's physical fitness to participate in school sponsored activities. The personal health information described above may be released or disclosed to the school by the student's personal physician or physicians. A physician or other health care professional maybe retained by the school to perform physical examinations. This to determine the student's eligibility to participate in certain school sponsored activities. In addition, to provide treatment to students injured while participating in such activities. Whether or not such physician, other health care professionals are paid for their services, volunteer their time to the school, any other EMT, hospital, physician or other health care professional who evaluates, diagnoses, treats an injury or other condition incurred by the student while participating in school sponsored activities. I understand that the school has requested this authorization to release or disclose the personal health information described above to make certain decisions about the student's health and ability to participate in certain school sponsored and classroom activities, and that the school is a not a health care provider or health plan covered by federal HIPAA privacy regulations, and the information described below may be re-disclosed and may not continue to be protected by the federal HIPAA privacy regulations. I also understand that the school is covered under the federal regulations that govern the privacy of educational records, and that the personal health information disclosed under this authorization may be protected by those regulations. I also understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of this authorization; however, the student's participation in certain school-sponsored activities may be conditioned on the signing of this authorization. I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by a health care provider in reliance on this authorization, by sending a written revocation to the school principal (or designee) whose name and address appears below. Name of Principal: Rhett Carter School Address: 610 Pinal Ave, Orcutt, CA 93455 This authorization will expire when the student is no longer enrolled as a student at the School. NOTE: IF THE STUDENT IS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN TO BE VALID. IF THE STUDENT IS 18 YEARS OF AGE OR OVER, THE STUDENT MUST SIGN THIS AUTHORIZATION PERSONALLY. Student’s Signature: ____________________________________________________ Student’s Birth Date: ________________

Parent/Guardian’s Name (please print): ________________________________________

Parent/Guardian Signature: ____________________________________________________ Date: _________________________

I am the Student's (check one): Parent ________ Legal Guardian________

The original is kept with the school and a copy is given to student’s parent/guardian if requested



Physical Examination Form to be completed by the Doctor

Athlete’s Name Date of Birth ________________

PHYSICIAN REMINDERS 1. Consider additional questions on more sensitive issues

• Do you feel stressed out or under a lot of pressure? • Do you ever feel sad, hopeless, depressed, or anxious? • Do you feel safe at your home or residence? • Have you ever tried cigarettes, chewing tobacco, snuff, or dip? • During the past 30 days, did you use chewing tobacco, snuff, or dip? • Do you drink alcohol or use any other drugs? • Have you ever taken anabolic steroids or used any other performance supplement? • Have you ever taken any supplements to help you gain or lose weight or improve your performance? • Do you wear a seat belt, use a helmet, or use condoms? • Do you consume energy drinks?

2. Consider reviewing questions on cardiovascular symptoms (questions 5-14). EXAMINATION Height Weight □ Male □ Female

BP ( / ) Pulse ( / ) Vision: R 20/ L 20/ Corrected □ Y □ N MEDICAL NORMAL ABNORMAL

Appearance

Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyper laxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat Pupils equal Hearing

Lymph nodes

Heart Murmurs (auscultation standing, supine, +/- Valsalva) Location of the point of maximal impulse (PMI)

Pulses Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)

Skin HSV, lesions suggestive of MRSA, tinea corporis

Neurologic

MUSCULOSKELETAL

Neck

Back

Shoulder / Arm

Elbow / Forearm

Wrist / Hand / Fingers

Hip / Thigh

Knee

Leg / Ankle

Foot / Toes

Functional Duck walk, single leg hop

*Consider ECG, echocardiogram, or referral to cardiology for abnormal cardiac history or exam *Consider GU exam if in private setting. Having third part present is recommended *Consider cognitive or baseline neuropsychiatric testing if a history of significant concussion



Clearance Form to be completed by the Doctor

Name Sex Age Date of Birth (Please print)

Cleared without restriction

Cleared, with recommendations for further evaluation or treatment for:

Not Cleared for:

All Sports

Certain Sports:

Reason:

Recommendations:

____ I have examined the above-named student and completed the pre-participation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences explained to the athlete (and parents/guardians). Name of physician (print) Date

Address Phone

Signature of physician MD or DO

2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.


Orcutt Academy High School Athletic Department

Athlete’s Code of Discipline

The goal of athletic participation is to provide a rewarding co-curricular experience for all students. All participants must commit to exemplary conduct and behavior as a representative of the school, district, and community. As a participant in Orcutt Academy High School Athletics, I agree to the following:

1. To recognize that athletes involved in activities which reflect negatively upon themselves, the team or the school is subject to suspension from athletics;

2. To understand that hazing is defined as any act of forcibly involving fellow students in inappropriate, demeaning, or potentially dangerous acts (as in an initiation rite). Hazing is a form of intentional harassment and is considered a serious violation of our Code of Conduct;

3. To meet the minimum academic requirements established by the Board of Directors of the Orcutt Academy High School and California Interscholastic Federations (CIF) for eligibility;

4. To recognize that suspension for offenses to Education Code 48900 will result in competition ineligibility during the time of suspension;

5. To recognize that sport specific standards of behavior and appropriate consequences may be set by the head coach of each individual sport;

6. To recognize that a student/athlete who has unlawfully possessed, used, offered to sell, sold, or otherwise furnished, or been under the influence of, any controlled substance, alcoholic beverage, or an intoxicant of any kind, including androgenic/anabolic steroids, or unlawfully possessed, offered, arranged, or negotiated to sell any drug paraphernalia, while on school grounds, during school, or during or while going to, coming from or attending a school sponsored event, while going to or coming from school, during the lunch period whether on or off school grounds, shall receive the consequences listed below; First Offense: *6 months or more suspension from athletic competition Second Offense: Suspended from athletics for one calendar year, regardless of the substance Third Offense: Lifetime suspension from the athletic program, regardless of the substance

*Any offense occurring outside the student’s athletic season, including summer will result in the suspension being applied to the next sport he/she participates in. Any offense occurring during the student’s athletic season may result in suspension for the balance of the season. Any time left on the suspension will be applied to the student’s next season of sport. If a suspended athlete so chooses, he/she may have his/her suspension reviewed, and possibly have the time of the suspension cut in half upon enrollment and completion of an acceptable substance abuse counseling program. 7. To recognize a student/athlete involved in any activity during the time school is not in session, which

results in an arrest and/or conviction, shall receive the consequences listed above. Any athletic suspension may be subject to a review by the principal, athletic director, head-coach and/or coaches’ council.



Athlete’s Code of Discipline Parent Grievance Procedure The grievance procedure is intended to be a process whereby concerns of alleged mistreatment of student-athlete can be addressed professionally and in a timely manner. Legitimate grievance issues: 1. Failure to provide due process in disciplinary actions 2. Failure to provide an equitable opportunity to compete for a position/team 3. Mistreatment of athletes (verbal and/or physical) 4. Any violation of an adopted code/policy

Non-legitimate grievances “Out of bounds” for discussion:

1. Playing time 2. Position of athlete 3. Game strategy 4. Win/loss record 5. Other athletes, coaches, parents, or teachers

It is the school’s intent that problems be resolved before coming to a formal grievance procedure. 1. Parent shall make contact with the coach in question to discuss a grievance. Please make an

appointment that is outside of school, practice, or game time. Parents should not make contact during class time, scheduled practices, or games.

2. If necessary, the student athlete in question shall be present. 3. If a grievance cannot be resolved in initial meeting, the following steps may be necessary: a. A meeting with the Athletic Director or Principal and other involved parties.

My parent(s)/guardian(s) and I have read the above and fully understand the regulations. We understand the responsibilities being taken on by being a member of the team. We agree to abide by the policies and rules described therein. We realize failure to comply may result in suspension and / or expulsion from the team. As parent(s) / guardian(s), we understand that the school district and coach(s) will take all means necessary to create a safe environment in which to play, however we understand there is some risk involved for accident or injury, and therefore hold them harmless should such an incident arise.

I/we agree to allow my/our child to participate in the OAHS Sports Program and will support my/our child in this sports endeavor. By signing this agreement, we agree to the policies and rules.

Athlete (print name, sign, & date): ________________________________________________________

Parent (print name, sign, & date): _________________________________________________________

This Code of Discipline must be signed and be on file before a student participates in an athletic event in the Orcutt Academy High School. A copy of this signed form is kept on file in the Athletic Director’s office at Orcutt Academy High School on an annual basis.



Athlete’s Code of Ethics

Athletics is an integral part of the school’s total education program. All school activities, curricular and

extracurricular, in the classroom and on the playing field, must be congruent with the school’s stated goals

and objectives established for the intellectual, physical, social, and moral development of the students. It is

within this context that the following Code of Ethics is presented.

As an athlete, I understand that it is my responsibility to:

1. Place academic achievement as the highest priority.

2. Show respect for teammates, opponents, officials, and coaches.

3. Respect the integrity and judgment of game officials.

4. Exhibit fair play, sportsmanship, and proper conduct on and off the playing field.

5. Maintain a high level of safety awareness.

6. Refrain from the use of profanity, vulgarity and other offensive language and gestures.

7. Adhere to the established rules and standards of the game to be played.

8. Respect all equipment and use it safely and appropriately.

9. Refrain from the use of alcohol, tobacco, illegal and non-prescriptive drugs, anabolic steroids or

any substance to increase physical development or performance that is not approved by the

United States Food and Drug Administration, Surgeon General of the United States or American

Medical Association. (See…Athletic Code of Discipline).

10. Know and follow all state, section and school athletic rules and regulations as they pertain to

eligibility and sports participation.

11. Win with character, lose with dignity.

12. Agree not to use androgenic/anabolic steroid without the written prescription of a fully licensed

physician (as recognized by the AMA) to treat a medical condition.

13. Show good sportsmanship and understand that the highest potential of sports is achieved when

competition reflects the six pillars of character: trustworthiness, respect, responsibility, fairness,

caring, and good citizenship.

14. Consistently demonstrate integrity, observe, and enforce the spirit as well as the letter of the

rules.

15. Understand that participation in the school sports program is a privilege, not a right. To earn that

privilege, student-athletes must abide by the rules and conduct themselves, on and off the

field, as positive role models who exemplify good character.



Athlete’s Code of Ethics

Athlete’s Bill of Rights pursuant to Education Code 271 The following list of rights, which are based on the relevant provisions of the federal regulations implementing Title IX of the Education Amendments of 1972 (20 U.S.C. Sec. 1681 et seq.), may be used by the department for purposes of Section 270:

a) You have the right to fair and equitable treatment and you shall not be discriminated against based on your sex.

b) You have the right to be provided with an equitable opportunity to participate in all academic extracurricular activities, including athletics.

c) You have the right to inquire of the athletic director of your school as to the athletic opportunities offered by the school.

d) You have the right to apply for athletic scholarships. e) You have the right to receive equitable treatment and benefits in the provision of all of the following:

1) Equipment and supplies 2) Scheduling of games and practices 3) Transportation and daily allowances 4) Access to tutoring 5) Coaching 6) Locker rooms 7) Practice and competitive facilities 8) Medical and training facilities and services 9) Publicity

f) You have the right to have access to a gender equity coordinator to answer questions regarding gender equity laws.

g) You have the right to contact the State Department of Education and the California Interscholastic Federation to access information on gender equity laws.

h) You have the right to file a confidential discrimination complaint with the United States Office of Civil Rights or the State Department of Education if you believe you have been discriminated against or if you believe, you have received unequal treatment based on your sex.

i) You have the right to pursue civil remedies if you have been discriminated against. j) You have the right to be protected against retaliation if you file a discrimination complaint.

My parent(s) / guardian(s) and I have read the above and fully understand the contents. We understand the responsibilities being taken on by being a member of the team. We agree to abide by the policies and rules described therein. We realize failure to comply may result in suspension and / or expulsion from the team. As parent(s) / guardian(s), we understand that the school district and coach(s) will take all means necessary to create a safe environment in which to play, however we understand there is some risk involved for accident or injury, and therefore hold them harmless should such an incident arise.

I/we agree to allow my/our child to participate in the OAHS Sports Program and will support my/our child in this sports endeavor. By signing this agreement, we agree to the policies and rules.

Athlete (print name, sign & date): _________________________________________________________

Parent (print name, sign, & date): _________________________________________________________

A copy of this signed form is kept on file in the Athletic Director’s office at Orcutt Academy High School on an annual basis.


Orcutt Academy High School Delta PT Athletic Training Program by San Luis Sports Therapy

Athlete’s Concussion Injury Management Protocol

Based on recommendations of CDC, NATA, NFHSS, CIF, 3rd International Consensus Statement

1. ImPACT testing will be utilized to establish baseline cognitive scores, and again in the event of a

concussion; procedures are reviewed annually with AT staff by Program Director. a. Baseline testing will be done prior to contact practices at the beginning of the athletic season.

Baseline testing is good for two years.

b. Per the ImPACT’s company guidelines, post-concussion testing is recommended within 48-72 hours after injury. Test is repeated once the athlete is asymptomatic, or at weekly intervals. If case is mild and return to play is eminent, test may be performed twice in a week, but never more than this.

c. Results may be interpreted by team physician, family physician, neurologist or neuropsychologist

d. If the athlete does not have a baseline on record, they may still be given a post-injury test, as results can be compared to ImPACT’s large normative database

e. Parents will be provided contact information for neurologists and neuropsychologists in the area

f. Final return-to-play clearance must come from an MD and/or neuropsychologist.

2. Any athlete suspected of having a concussion will be removed from play immediately, and not allowed to return to play the same day.

3. All athletes sustaining any type of head injury, regardless of severity, must be evaluated and the SCAT3 Evaluation form must be completed (see document #5, Appendix A).

4. Each athlete with suspected concussion also must be released to a parent or adult who will sign the Home Care Instruction form (see document #6, Appendix A)

5. Testing and Return to play guidelines will follow the fourth International Conference on Concussion in Sport Consensus Statement. In order to be returned to play, the athlete must have no physical symptoms, no cognitive symptoms, and a written MD clearance.

6. Athletic Trainer will follow up daily with injured athlete, utilizing the Graded Symptom Checklist

7. Graded Return To Play Guidelines will be followed in all cases of confirmed head injury: a. One day at each phase b. If no return of symptoms during, or day after, may progress to next phase c. If any physical or cognitive symptoms, during or day after, go back to previous phase d. Minimum time to return to full contact = 5 days

Bike: Introducing movement, without jarring of brain Run: Movement, with addition of brain ‘bounce’ Agility: Adds element of decision-making to movement In Red: In drills, no contact (‘in-red jersey’); processing information, while moving No Restrictions: Pre-practice exam, watch during practice, post-practice exam



Athlete’s Concussion Home Care Instructions Your student athlete may have sustained a concussion on __________________. To help ensure that his/her injury is managed appropriately, please follow these important recommendations:

1. Please remind athlete to report to the Athletic Training Room on ________________for a follow-up evaluation.

2. Athlete must obtain physician evaluation & written clearance. Be sure to discuss ANY medication use with physician.

3. Please review the items outlined on the following Symptom Checklist. If any of these problems develop prior to his/her follow-up evaluation, please call the Athletic Trainer, your family physician, or the local emergency medical system. Otherwise, you may follow these instructions:

If the athlete experienced loss of consciousness (LOC), prolonged periods of amnesia, or was still experiencing significant symptoms at bedtime; awaken the athlete during the night to check on deteriorating signs and/or symptoms: such as, decreased level of consciousness or increasing headache. These may indicate a more serious head injury or late-onset complication, and require immediate medical attention. In accordance with CA State Law, athlete’s MUST provide a copy of physician’s written clearance to the Athletic Trainer in order to return to any physical activity!

Recommendations provided to: ______________________________ Athlete: ______________________________

_____In person _____By phone#: ___________________ Date: _______________ Time: ________

Athletic Trainer: ______________________________________ Athletic Trainer phone #: _______________________

Symptoms may include: Symptoms not readily apparent: ● Blurred vision ● Abnormal vision, hearing, smell and/or taste ● Dazed or vacant expression ● Difficulty concentrating ● Difficulty with balance/coordination ● Excessive fatigue ● Dizziness ● Hypersensitivity to light and/or noise ● Inability to recognize people or places ● Increasing irritability ● Increasing confusion ● Numbness in the arms or legs ● Intense headache ● Pupils becoming unequal in size ● Nausea or repeated vomiting ● Academic and/or Cognitive difficulties,

(memory, recall, concentration, learning, etc.) ● Slurred speech or inability to speak

SYMPTOMS THAT REQUIRE IMMEDIATE MEDICAL ATTENTION: ● Intense Headache ● Nausea or repeated vomiting ● Loss of, fluctuating or decreasing level of consciousness ● Seizures ● Post-concussion symptoms that worsen, do not improve,

increase in number, or begin to interfere with athlete’s daily activities (i.e. sleep, cognition, behavioral change)

It is OK to: There is NO NEED to: ● Use Tylenol for headache ● Check eyes with a flashlight ● Use icepack on head/neck as needed for comfort ● Wake up frequently (unless instructed) ● Eat a carbohydrate-rich diet ● Stay in bed ● Go to sleep ● Test reflexes ● Rest from mental activity (no strenuous activity or sports)

DO NOT: ● Drink Alcohol ● Drive a car or operate machinery ● Engage in physical activity that makes symptoms worse

(ex: exercise, weight lifting, PE, sports)

● Engage in mental activity that makes symptoms worse (ex: school, job, homework, computer games)

● Return to strenuous/contact activity until symptom free, & with a written MD or DO clearance



Athlete’s Consent for Medical Treatment

I hereby authorize the Orcutt Academy High School athletic training/medical staff, contracted by San Luis Physical Therapy, to evaluate and/or treat said athlete/minor, including use of electrical modalities, for the purpose, of attempting to manage any injuries received while he/she is a participant at Orcutt Academy High School. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk on behalf of myself and said minor. I acknowledge that no warranty is being made as to the results of any treatment.

_________________________________________________________________________ Athlete Name (PRINT) _____________________________________________________ _______________ Athlete Signature Date _____________________________________________________ _______________ Parent Signature Date

SAN LUIS PHYSICAL THERAPY & ORTHOPEDIC REHABILITATION PRIVACY & SECURITY COMPLIANCE NOTICE

San Luis Physical Therapy and Orthopedic Rehabilitation, in compliance with certain laws, have taken reasonable and comprehensive steps towards the protection of the privacy and security of your personal health information. Such information may include oral, written, telephone, facsimile and/or other electronic communication of protected health information (PHI). Complete information regarding Privacy and Security Practices is available to all patients upon individual request and such information is entitled “Statement of Privacy and Security Practices”. Individual Patient Rights: You have rights with respect to the following: To read and understand this privacy and security notice prior to treatment To request a copy of “Statement of Privacy and Security Practices” To expect that all protected health information be utilized only for the following purposes:

- Treatment (including contacting you with regards to appointment and other treatment related communication)

- Payment - Health Care operations - Mailing or other communication with you in the form of announcements and/or newsletters

To request a copy of your personal health information To request revision of inaccuracies in your personal health information To restrict how your personal health information is used and disclosed except as noted above

Further Information/Concerns: Please express any concerns you may have regarding any violation of your privacy rights, and other privacy and security issues to the San Luis Physical Therapy and Orthopedic Rehabilitation Compliance Officer. Any concerns reported will not result in retaliation or retribution. Compliance Officer: Kelly Sanders 805 Aerovista, Suite # 201 San Luis Obispo, CA 93401 Email: [email protected] Phone: (805) 788-0805, Ext#216

You also have the right to report any concerns regarding your privacy rights to the Secretary of the US Health and Human Services Department.

The Department can be contacted at http://www.hhs.gov/ocr/hipaa or by calling (415) 437-8310.



Parent’s Contract

We recognize that a healthy athletic experience requires support from parents. We have agreed to honor these core principles and support our student-athletes in this process.

We will give consistent encouragement and support to our children regardless of the degree of success, the level of skill or time on the field.

We will stress the importance of respect for coaches through discussions with our children and highlight the critical nature of being a team player and contributing to the team success.

We will attempt to attend school and parent meetings outside of sports seasons to meet coaches and school officials and learn firsthand about expectations of participation in interscholastic sports.

We will agree to abide by the rules governing the conduct of athletes while modeling these principles for our children.

We will ensure balance in our children by encouraging excellence in the classroom and excellence in the sport.

We will leave coaching to coaches and will NOT criticize the coaches, the strategies, or the team performance. We will agree to avoid putting pressure on our children about playing time or performance.

We will allow our children to participate in the athletic program, and if appropriate, be transported by the district to and from competitions.

We understand that there is an element of risk associated with all athletic competitions and that the district cannot guarantee that students will not be injured, despite a commitment to provide for every participant’s health and welfare.

California Education Code Section 32221.5 32221.5. A School district that elects to operate an interscholastic athletic team or teams shall include the following statements, printed in boldface of prominent size, in offers of insurance coverage that are sent to members of school athletic teams:

“Under state law, school districts are required to ensure that all members of school athletic teams have accidental injury insurance that covers medical and hospital expenses. This insurance requirement can be met by the school district offering insurance or other health benefits that cover medical and hospital expenses. Some Pupils 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 call the toll-free telephone number.”

We know that school athletic experiences can contribute greatly to the values and ethics of each player and those positive athletic experiences teach important life skills, encourage teamwork, help shape character, and improve citizenship. Parent (print name, date, & signature): _______________________________________________________________

Parent (print name, date, & signature): _______________________________________________________________

1

D Ostca Inrecam DthLaSwCusm Thneexota ThThalis Si AASaa(8 PEFo I hIm PR Si Si

| Page

Dear Parent/G

Orcutt Acadetudent-athleomputerizedt the school

n the event tepeated, anonditions as tool to assis

monitoring re

Developed bhroughout pacrosse, Profwedish Socc

Clinical Centesing the ImP

managing he

he exam takeurocognitivxample, in one second e

ake it enjoy t

his program herapy Athlethletes remasted below.

ncerely,

Andrew BoortAthletic Trainean Luis Sportndrew.boort

805)305-4409

ERMISSION SLIor use of the Im

have read anmPACT Concu

RINT Name of

gnature of At

gnature of Pa

Guardian,

emy High Sctes. ImPACT

d exam that , supervised

hat the athlend the data i the baselinet the athleticcovery, and

y doctors atrofessional afessional Hoc

cer, Canadiaers, 350+ CoACT system.

ead injuries. A

kes approximve informatioone part of theach. The atthe challeng

has been metic Training ains a top pr

tz, ATC er, OAHS ts Therapy tz@slsportsth9

IP mmediate Po

d understoodussion Manag

Athlete _____

thlete ________

arent _________

San L

hool will be (Immediate each athlet by the athle

ete is believeis comparede: at the schc training sta

d in making s

t the Universiand amateuckey, Major/an Hockey; Slleges & Univ As a result, Additional in

mately 25 minon such as mhe exam, a dthlete is laterge of the test

ade possibleProgram, in iority. If you h

herapy.com

ost-Concussion

d the above inement Progra

______________

_____________

_____________

Luis SpParent

utilizing an ine Post Concute takes prioetic trainer.

ed to have sd to the basehool, supervisaff and treatsafe return to

ity of Pittsburr sports. 28 N/Minor LeaguSouth Africanversities, andit has quickly

nformation c

nutes, and ismemory, reacdozen commr asked whict.

e by Sierra V an on-goinghave any qu

n Assessment

nformation anam.

_____________

______________

______________www.sierr

www.slswww.

Sports ImPACT

nnovative coussion Assessr to the athle

suffered a coeline test. Posed by the ating physiciao play decisi

rgh MedicalNFL teams, 18ue Baseball n, New Zealad over 1200 Hy become th

can be found

s set up as a ction time, bmon words ach words we

Vista Regionag effort to asuestions, plea

S D S st (8

and Cognitiv

nd give permis

_ Sport(s) ____

_ Date ____

_ Date ____ravistaregionasportstherapy.impacttest.co

TherLetter

oncussion msment and Cetic season.

oncussion dost-concussioathletic traine

ns in determions.

Center, this8 MLB teams Umpires, USAand and USAHigh Schoolshe ‘gold stand at www.im

‘video gambrain procesappear one re displayed

al Medical Cssure that thease feel free

tacey J. RittDirector of Span Luis Sportacey.ritter@805) 788-080

ve Testing (ImP

ssion for my so

_____________

______________

______________al.com .com om

Upd

rapy

managementCognitive Tes Baseline tes

uring compeon tests are ter. The inform

mining the ex

s software sys, Major LeaA Olympic HA Rugby, US s across the ndard’ in rec

mpacttest.co

me’ type formsing speed a at a time on

d. It is a simp

Center, and te health ande to use the c

er, MS, ATC ports Medicirts Therapy @slsportsthera05 x235

PACT)

on/daughter

_____

_____

_____ Tel #:___

dated 4/25/201

t program fosting) is an osting will be p

etition, the etaken under mation is thextent of the i

ystem is utilizegue Soccer,

Hockey, USA Armed Forccountry are cognizing an

om.

mat. It tracks and concenn the screenle exam and

the San Luis d safety of hcontact info

ne & Athletic

apy.com

to participate

______________

6

or our nline, performed

exam is the same

en used as njury,

ed , US Ski Team,

ces, 350+ currently nd

ntration. For for about

d most who

Sports igh school

ormation

c Training

e in the

__



Press Release Authorization I give my permission for Orcutt Academy to post my/my student’s name, photograph, and where applicable, athletic statistics on the Orcutt Academy website and MaxPrep. In addition, I also release this information for publication in school newsletters and/or general media press releases or features. I release Orcutt Academy from any legal liability rising from this action and give permission without reservation or limitation. _______________________________ _______________________________ ___________ Print Student Name Student Signature Date _______________________________________ _______________________________________ ______________ Print Parent/Guardian Name Parent/Guardian Signature Date

Last FirstName Name

Cheer All Year Eckenrode Katey 805-714-0760 [email protected] Assistant All Year Moore Megan 805-478-5798 [email protected] All Year Lane Jennifer 805-598-2312 [email protected] Fall May Doug 805-878-7634 [email protected] Football Fall Lyon Ted 805-868-3131 [email protected] Football Fall Lyon ShaneGirls Golf Spring McManus James 805-458-2901 [email protected] Golf Spring Birch Raul 805-268-4561 [email protected] Varsity Tennis Fall Lopez Art 805-448-3947 [email protected] Varsity Tennis Fall Hull Stephanie [email protected] Varsity Tennis Fall Childs Tara 805-714-8886 [email protected] JV Tennis Fall Herrera Michele [email protected] JV Tennis Fall Stitt Jennie [email protected] Var Volleyball FallGirls JV Volleyball FallBoys Cross Country Fall Fabing Roger 805-315-3786 [email protected] Cross Country Fall

Girls Var Basketball Winter Avila Danny 805-878-1523 [email protected] Var Basketball Asst Winter Fierros Gilbert 805-896-3936 [email protected] JV Coach Winter Loera Fernando 805-878-2783 [email protected] Var Basketball Winter Black Darrell 805-406-3250 [email protected] Basketball Asst Winter Dell'Armo John 805-938-8550 [email protected] JV Basketball Winter Smalley Ryan 805-345-0838Boys Varsity Soccer Winter Bennett Josh 805-623-2158 [email protected] Var Soccer Winter Dyson Kevin 805-268-4932Boys JV Soccer Winter Ruiz Francisco 805-720-4333Girls Varsity Soccer Winter Speer Brian 805-698-6905 [email protected] Varsity Soccer Winter Justice Larry 805-588-0010 [email protected] Varsity Soccer Winter Ryan Shawn 805-720-0717 [email protected] JV Soccer Winter

Boys Golf Spring White Lincoln 805-403-2498 [email protected] Golf Spring Birch Raul 805-268-4561 [email protected] Volleyball Spring Milton James 603-799-6406 [email protected] Volleyball Spring Papworth Tim 805-863-7452 [email protected] Coach Spring Tosches Marc 805-714-4566 [email protected]

Track Assistant Spring Krouse Stephanie 805-714-5798 [email protected] Assistant Spring Fabing Roger 805-315-3786 [email protected] Varsity Tennis Spring Cartwright John 805-478-2011 [email protected] Spring Ayers Deanna 805-287-0917 [email protected] Assistant Spring Brown Bailey 805-878-8295Swim Assistant Spring Lougee Sara 805-896-4920 [email protected] Coach Spring Roux Kailey 805-598-5495Varsity Baseball Spring Rose Jim 805-406-6906 [email protected] Softball Spring Krasner John 805-714-5159 [email protected] Softball Assistant Spring Santiago Paul [email protected] Softball Assistant Spring Dutra Deedra 805-245-7083 [email protected] Softball Spring

Season Cell Email

Orcutt Academy High School

Sport

2016 - 2017 Coaches Contact Information

1 I Page Updated 4/25/2016


Orcutt Academy High School

Dear Business Owners:

As our 2016-2017 Sports Season rapidly approaches, our athletes have been working very hard and our expectations are very high. In order for our athletes to compete and have an opportunity for a meaningful sports experience, our students rely heavily on fundraising efforts and donations from local businesses.

The high school does receive a small athletic budget that covers the cost of coaches' stipends, CIF dues, CIF travel expenses, and official fees. This leaves facility costs, competition/tournament fees, transportation, equipment, team awards/banquets, and uniforms to be paid for by students out of funds raised or from donations received from local businesses.

As part of our fundraising efforts, we are asking local businesses to help support our sports programs. If your business would be able to help out, it would be greatly appreciated. If you have any questions, please contact our Business Office as listed below.

Thank you in advance for your generous donation and support our sports program.

GO SPARTANS!

Chad McKenzie Athletic Director

Please make check payable to OAHS. Please indicate which sport or you may donate to the General Athletic fund, which is used by all sports. Please mail check and form to the address below.

Name of Business/Sponsor:

I am enclosing a check/money order for Check Amount $ _________ Check # _________ Sport Team(s):

___________________ $___________ / ___________________ $___________ / ___________________ $___________

___________________ $___________ / ___________________ $___________ / ___________________ $___________

The Orcutt Academy High School is fully affiliated with the Orcutt Union School District (OUSD). The OUSD is a publicly funded local educational agency within the County of Santa Barbara. OUSD is a tax-exempt organization, as defined in the IRS Code Section 501(c)(3), organized and operates exclusively for educational purposes. Federal Tax ID #77-0074164

Attn: OAHS Business Office 610 Pinal Ave, Orcutt, CA 93455 (805) 938-8594 Office / (805) 938-8599 Fax

Attn: OA

Dear Orcutt

The successfundraising bPadres Athle

The Generato our sports

The School’sOfficial feescan pop up

Last year, dothese costs. If you wouldand which sOAHS (the sdo not specfor all sports

Thank you in

Sincerely,

Chad McKeAthletic Dire

Please makeAthletic fund

Name of Pa

Name of Stu

I am enclosI would like

Sp

Sp

The Orcutt Acadagency within thoperates exclusivFederal Tax ID #7

AHS Business O

t Academy H

and breadtby teams, paetic League

l Charter cos program.

s Athletic Bu. This leaves

p during a se

onations from We are onc

d like to donasport(s). Pleaport you wa

cify a sport, t.

n advance f

enzie ector

e check payd, which is u

rent/Guardia

udent: ______

ing a check the following

port ________

port ________

emy High School e County of Sant

vely for education77-0074164

Office: 610

High School

th of our Spoarent drivers had an ama

overs the cos

dget covers uniforms, traason.

m parents, sce again askate to a part

ase return theant it to go tohen the mon

or your gene

yable to OAsed by all sp

an: ________

____________

k/money ordg funds to go

___________ $

___________ $

is fully affiliated wa Barbara. OUSD nal purposes.

Pinal Avenue

Parent/Gua

orts programs, and the Atazing year, w

st of a Certifi

s the cost of ansportation

ponsors, andking for donaticular sport(e filled out foo, EX: OAHS ney will go in

erous donati

HS. Please inports. Please

_____________

_____________

der for $_____o to the spor

$___________

$___________

with the Orcutt Un is a tax-exempt o

Orcutt, CA

ardian:

is in large pthletic Boostewith some of

cated Athle

coaches’ st, equipment

d fundraisingations from a(s), please inorm along wFootball), annto the gene

ion and supp

ndicate whic mail check

____________

____________

____________ rt(s) fundraisi

__, Spor

__, Spor

nion School Districorganization, as d

A 93455 (805

part due to ders Club. Thef the sports m

etic Trainer, w

tipend, CIF dt, facility cos

g by teams hanyone who ndicate the awith your chend send it toeral athletic

porting our s

ch sport or yo and form to

_____________

_____________

_ ck/ming account

rt __________

rt __________

ct (OUSD). The OUdefined in the IRS

5) 938-8594

donations froe Academy making it into

which has be

dues, CIF Travsts, and host

helped to as is in a positioamount that

eck or money the OAHS B fundraising a

sports progra

ou may dono the addres

_________

_________

mo #_______t in the follow

_________ $__

_________ $__

USD is a publicly fuCode Section 50

Fax (805) 938

om parents, s now in the Lo the CIF pla

een a great

vel (some), at of other thin

sist with somon to help. t you will be y order paya

Business Officaccount to

am.

nate to the Gs below.

________ wing amoun

___________,

___________,

unded local educ1(c)(3), organized

8-8599

sponsors, Los ayoffs.

addition

and ngs that

me of

donating able to ce. If you be used

General

ts:

cational d, and

c:\documents and settings\office.000\my documents\transportation\transportation volunteer\volunteer safety information.doc

Orcutt Union School District

SAFETY RULES FOR DRIVERS OF VEHICLES USED TO TRANSPORT STUDENTS

It is well for all of us to recognize that while driving students, increased safety precautions should be taken. The district would appreciate your reviewing this list to insure the safest possible trip. 1. Be sure your vehicle, including brakes, lights and tires, is in good operating condition before you

leave. 2. Do not allow more passengers than the vehicle is designed to accommodate. Drivers cannot legally

transport more than 9 students and the vehicle cannot be designed for seating more than 10 people, including the driver.

3. Use of safety belts is required by the State of California. Each passenger must have a seat belt and belts must be used at all times when the vehicle is in motion.

4. Obey all traffic rules. Be alert. Never exceed the posted legal speed limit. Do not allow passengers to

distract you while driving. Do not text or make cell phone calls while driving. 5. All doors should be locked when the vehicle is in motion. 6. Accidents, unusual incidents, or disciplinary problems shall be reported to the school Principal. 7. Accidents, claims resulting from an accident, and supporting documentation shall be reported and

submitted to the Assistant Superintendent of Business at the District Office at (805) 938-8916.

WORKERS' COMPENSATION INSURANCE FOR VOLUNTEERS Thank you for your interest in performing volunteer services for the Orcutt Union School District. Your services are welcome and appreciated. You will be covered by the district's workers' compensation insurance while performing services for the district, providing you have submitted a completed Trip Volunteer Authorization Form. This form must be approved by the Principal/Director and the Assistant Superintendent of Business before a volunteer is authorized to receive coverage for an accident or illness which may result from volunteer service. The coverage will be in effect only for the length of service shown on the authorization form. If you will be performing services beyond the date(s) shown on the form, please notify the Principal/Director immediately. If you should have an accident or illness due to voluntary service, report it immediately to the Principal/Director. If medical services are needed, please contact: Workers’ Compensation Administrators 265 E. Donovan Road Santa Maria, CA 93454 (805) 922-9157 If you will be transporting students as part of your volunteer services, please make sure that the Pupil Transportation section of the Volunteer Authorization form has been completed and requirements met. Again, thank you for your willingness to help in our schools.

c:\documents and settings\office.000\my documents\transportation\transportation volunteer\vehicle safety form.docx

Orcutt Union School District VEHICLE SAFETY FORM

This form is to be completed by the school volunteer using his/her personal vehicle to transport students to a school-sponsored event.

Name of Driver(s): ____________________________________

____________________________________

VEHICLE NO. ___________

License No. _________________ Make/Model _________________

CHECK LIST _____Brake Lights _____ Head Lights _____ Seat Belts _____ Tires

VEHICLE NO. ___________



VEHICLE NO. ___________



I verify that the vehicle(s) noted above are/is in working order and can safely transport students. ______________________ _______________________________ _______________ Print Name Signature Date ______________________ _______________________________ _______________ Print Name Signature Date Please return this completed form to your school principal or athletic director.

c:\documents and settings\office.000\my documents\transportation\transportation volunteer\trip parent volunteer authorization 9-2009.doc REVISED 9/15/09

Orcutt Union School District TRIP VOLUNTEER AUTHORIZATION FORM

A completed form must be submitted to the Principal or Athletic Director at least 5 days prior to services being performed. Name:__________________________________ Phone:____________________ Cell Phone: ____________________

Address: ______________________________________________________________________________________________

Volunteer Services to be Performed: _______________________________________________________________________

Teacher/Coach:_____________Activity:___________________ Teacher/Coach:_____________Activity:__________________

Have you ever been convicted of: Any crime other than minor traffic violations ____Yes ____No Felony ____Yes ____No Child Abuse ____Yes ____No

If so, please explain in detail. Use an extra sheet of paper if necessary.______________________________________________ _____________________________________________________________________________________________________ Education Code 35021 prohibits registered sex offenders from serving as volunteer aides. In accordance with Penal Code 290.4, the Department of Justice operates a “900” telephone number that the district may call to ask if an individual is a registered sex offender.

PUPIL TRANSPORTATION (Complete this section if you will be transporting students.) The district appreciates your contribution in providing pupil transportation. However, please be advised that the school district's liability policies do not protect you. The district strongly urges you to check with your insurance carrier to determine that you have sufficient liability and personal injury coverage prior to driving and/or using any vehicle to transport students. Your insurance is primary and the district’s is secondary. In addition to this completed form, proof of insurance and a current DMV printout must be attached. A DMV printout can be obtained from the Department of Motor Vehicles, 523 South McClelland, 1-800-777-0133. Drivers cannot legally transport more than 9 students and the vehicle cannot be designed for seating more than 10 people, including the driver. A driver must have a seatbelt for each passenger. Date of Trip(s) ___________________ Destination ________________________________________________________

Purpose of Trip(s) ____________________________________________________________________________________

Driver's License # _____________________ (NEED COPY) Issued by (state) ___________ Expiration Date _____________

Auto Insurance Carrier Name ___________________________________________________________________________

Auto Insurance Agent Name & Phone ____________________________________________________________________

I will be driving: _______ my own vehicle _______ a rented vehicle

I certify that I have not been convicted of reckless driving or driving under the influence of drugs or alcohol within the past five years. I understand that if an accident occurs, my insurance coverage shall bear primary responsibility for any losses or claims for damages.

MY SIGNATURE CONSTITUTES AWARENESS OF THE SAFETY RULES AND THE COMPLETENESS AND ACCURACY OF THE STATEMENTS ON THIS FORM

Signature of Volunteer: _________________________________________________ Date: ________________________

_____________________________________ ____ Safety Rules ____ Vehicle Inspection ____ DMV Print-out Approved by: Principal/Athletic Director ____Pull Notice ____ Proof of Ins. __ID Copy ____ DOJ (if non parent)

Megan’s Law Check by__________ on ________ (Business Ofc ______) Pull Notice to Trans_____ Added to DBase______

Student Name:___________________

School Year:__________________

Last First

Orcutt Academy High Schoolorcuttacademyhigh.ss11.sharpschool.com/UserFiles... · 2 | Page Updated...

Documents

Transcript of Orcutt Academy High Schoolorcuttacademyhigh.ss11.sharpschool.com/UserFiles... · 2 | Page Updated...