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AVERY COUNTY SCHOOL ATHLETIC FORMS Please complete the following forms: North Carolina High School Athletic Association Eligibility and Authorization Statement (Parent/ Student) ______ Gfeller-Waller Concussion Statement (Student/Parent) Permission to Travel for Athletics (Parents/All Schools) Photographic/ Videotaping Option (Parents/All Schools) ARIS/ Emergency Treatment Permission Form (Parents/All Schools) Travel Release Form (Optional if needed/All schools) Random Drug Testing Consent Form (Parent / Student) _____ Reminder: All athletes must have a current physical on file to participate in athletics. Physicals are valid for 395 days from the date of the examination. Photographic/Videotaping Permission The Avery County public school system uses photographs, slides, videos, and illustrations of students for many purposes. Such photographs, videos and other illustrating material may be used in newsletters or publications produced by the school system, in slide presentations and/or videos about the schools, by the news media in school-related news coverage, in video productions aired on television produced by the school system or in other similar forms of communication. I do not give permission for my child to be included in presentations by the Avery County Schools or the news media. Parent/Guardian Student Name Date ****ONLY SIGN IF YOU DO NOT GIVE PERMISSION FOR CHILD TO BE PHOTOGRAPHED. **** TRAVEL RELEASE FORM SCHOOL YEAR SPORT STUDENT-ATHLETE I, , the parent or legal (Print full name) Guardian of the student listed above does hereby give permission for my son or daughter to ride home from away athletic events for the sport listed with the individuals listed below. I understand that this release also releases the school from any responsibility or liability in the event of an accident and that my son/daughter is not covered by any school insurance once released from the school’s responsibility. (Signature of Parent or Legal Guardian) (Date) Parents of other athletes who accept responsibility for return travel for the athlete listed above: (Print Name) (Signature) (Print Name) (Signature) (Print Name) (Signature) *It is required that the accepting party personally notify the coach after the contest that he/she will be accepting responsibility for the return travel of the athlete listed above. NOTARY STATEMENT AND SEAL State of ___________________ County of__________________ Sworn to and subscribed before me, this the ____ day of ________, ______. My commission expires ___________________________________________________ Notary Public Signature SEAL Acknowledgement of Risk and Insurance Statement Emergency Treatment Permission Form Athlete’s Name Sport Address City Grade , State Zip Date of Birth / / Home Phone Parent(s)/Guardian Name Work Phone I give permission for (name of child/ward) to participate in the above listed sport. I have reviewed the individual eligibility rules and I am aware that with the participation in sports comes the risk of injury to my child/ward. I understand that the degree of danger and seriousness of the risk vary significantly from one sport to another with contact sports carrying the higher risks. I have had an opportunity to understand the risk inherent in sports through meetings, written handouts, or some other means. He/ She has athletic participation insurance through the school: YES NO OR is insured by our family policy with: Name of Company Policy Number Name of Policy Holder I am aware that participation in sports will involve travel with the team. I acknowledge and accept risks inherent in the sport and with the travel involved and with this knowledge in mind, grant permission for my child/ward to participate in the sport and travel with the team. EMERGENCY AUTHORIZATION In the event that I cannot be reached in an emergency, I hereby give permission to the physicians selected by the coaches and staff of Avery High School to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the person named above. Signature of Parent or Guardian Date / / Alternate Emergency Contacts Name 1. Relationship to Athlete Phone Number 2. Please list any significant health problems that might be important to a physician evaluating your child in case of an emergency: Please list any allergies to medications, et. Has the student been prescribed an inhaler or Epipen? YES Is the student presently taking any medication? YES NO Does the student wear contact lenses? YES NO I certify that all of the above information is true and correct Date NO For what reason? If so, please list: Date of last tetanus shot: Please advise the trainer 2016-2017 North Carolina High School Athletic Association Eligibility and Authorization Statement This document is to be signed by the participant of an NCHSAA member school and by the participant’s parent. I have read, understand and acknowledge receipt of the eligibility rules of the North Carolina High School Athletic Association. I understand that a copy of the NCHSAA Handbook is on file with the principal and athletic administrator and that I may review it, in its entirety, if I so choose. All NCHSAA bylaws and regulations from the Handbook are also posted on the NCHSAA web site at www.nchsaa.org I understand that an NCHSAA member school must adhere to all rules and regulations that pertain to the interscholastic athletics programs that the school sponsors, but that local rules may be more stringent than NCHSAA rules. I understand that participation in interscholastic athletics is a privilege not a right. Student Code of Responsibility As a student athlete, I understand and accept the following responsibilities: I will respect the rights and beliefs of others and will treat others with courtesy and consideration. I will be fully responsible for my own actions and the consequences of my actions. I will respect the property of others. I will respect and obey the rules of my school and laws of my community, state and country. I will show respect to those who are responsible for enforcing the rules of my school and the laws of my community, state and country. I understand that a student whose character or conduct violates the school’s Athletic Code or School Code of Responsibility could be deemed ineligible for a period of time as determined by the principal or school system Administration I understand that if I drop a class, take course work through Post Secondary Enrollment Option, or other educational options, this action could affect compliance with NCHSAA academic standards and my eligibility. Informed Consent – By its nature, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily. PARENTS, LEGAL CUSTODIAN’S OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN AN NCHSAA- SPONSORED SPORT WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN’S SIGNATURE. I understand that in the case of injury or illness requiring treatment by medical personnel and transportation to a health care facility, that a reasonable attempt will be made to contact the parent/legal custodian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be treated and transported via ambulance to the nearest hospital. I consent to medical treatment for the student following an injury or illness suffered during practice and/or a contest. I understand all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. Further I understand that if my student is removed from a practice or competition due to a suspected concussion, he or she will be unable to return to participation that day. After that day, written authorization from a physician (M.D. or D.O.) or an athletic trainer working under the supervision of a physician will be required in order for the student to return to participation. I have received, read and signed the Gfeller-Waller Concussion Information Sheet. I consent to the NCHSAA use of the herein named student’s name, likeness, and athletic-related information in reports of contests, promotional literature of the Association and other materials and releases related to interscholastic athletics. By signing this document, we acknowledge that we have read the above information and that we consent to the herein named student’s participation. Must Be Signed Before Participation _________________________________________________________________________________ ______________________________________________________ Student’s Signature Birth Date Grade in School Date _________________________________________________________________________________ ______________________________________________________ Signature of Parent or Legal Custodian Date r and coaching staff of any changes to the above information as soon as possible. AVERY COUNTY SCHOOLS STUDENT ATHLETE, CHEERLEADER, STUDENT DRIVER, EXTRA-CURRICULUAR PARTICIPANT AND PARENT PERMISSION AND CONSENT FOR RANDOM DRUG AND ALCOHOL TESTING Student’s Consent Student’s Name (Please print.)___________________ Date I have read and understand the Avery County School System’s Random Drug and Alcohol testing procedures. My signature verifies that I will consent to random drug/alcohol testing while I am involved in athletics, cheerleading, or during any time in which I register, operate or park on Avery County School campus. This consent is good for this school year only. Failure to return this form will result in loss of driving privileges and/or participation in athletics and/or cheerleading. Student’s Signature Date ___________________ Parent’s Permission I have read and understand the Avery County School System’s Random Drug and Alcohol testing procedures and give permission for my son/daughter to participate in the random drug/alcohol testing program at any time during this school year when he/she is involved in athletics, cheerleading, or when he/she is registering, operating or parking a motor vehicle on Avery County School campus. Failure to return this form will result in loss of driving privileges and/or athletic eligibility of my child. Parent/Legal Guardian’s Signature __________________Date RDT FORM 1