Download Athletic Forms 16/17 - Avery County Schools

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