Download Pomperaug High School - Pomperaug Regional School District 15

REGION 15 MIDDLE SCHOOL FALL SPORTS REGISTRATION PACKET
This packet includes rules and regulations for sports participation, information on the signs,
dangers and care of concussion injuries, and the fall sports registration form.
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2.
3.
Read the rules and regulations on pages 2 and 3 of this document.
Read the concussion information and consent form on page 4 & 5.
Write in the Name, Address and Phone number of the student on page 6
of this document.
4.
Both a parent and the student must sign on page 6.
5.
The fee is $150.00. Checks only please, made out to “Region 15”. You
must send a different form and a different check for each child for
each sport that they play throughout the school year. (There is a
$600.00 family limit.)
6.
Check the box next to the sport that the student is playing.
7.
Check the box next to the payment option.
8.
Attach the check to the bottom of page 6.
9.
Complete the information on page 7
10. Only return page 6 and 7, with the check attached check to page 6:
o You may need to submit a sports physical form to our nurses office.
A yearly updated physical is required. It is available at
www.region15.org.
o You can view the most up to date sports schedules for Region 15
sports at www.region15.org.
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Region 15 Rules and Regulations for Middle School Sports
Please read and review the following rules and regulations.
1. Students must be in good academic standing to tryout and participate. (Please refer to
the student handbook for details on academic eligibility).
2. Attendance at all practices and games is mandatory. Athletes and parents must realize
that missed practice time may affect playing time of the athlete. Students who will be
absent from or late to practice should speak directly to the coach in advance. Do not
pass a message on via another person.
3. Students must be in school to participate in practice or game on that day. Exceptions
may be made with prior approval from the principal.
4. An injured athlete who has had medical treatment cannot participate until a release from
the doctor is presented to the coach.
5. Uniforms or parts of uniforms may be worn only at the coaches’ discretion. Students are
financially responsible for uniforms issued to them. All uniforms must be returned to
the coach at the conclusion of the season. Any athlete who has not turned in equipment
and/or payment obligations at the close of the season will not be allowed to compete in
any further competition until the obligation is completed.
6. Athletes are expected to maintain the highest order of sportsmanship at all times.
7. Coaches have the sole responsibility for the selection of all team members. The team
selection is based on the subjective opinion of the coach who will consider the students’
athletic ability, sportsmanship, and citizenship when making choices.
8. The amount of playing time, the position the athlete plays is the sole decision of the
coach. Payment of the participation fee is not a guarantee of any playing time.
9. All athletes are expected to fully participate in Physical Education class. If an athlete is
unable to participate fully in Physical Education he/she will not be allowed to participate
in their sport for that day.
10. Students are responsible for their personal property. Students should never leave
property unlocked. Students should keep their property with them at the practice area.
11. An athlete who is on suspension from school is not eligible to practice or take part in a
contest until he/she is allowed to return to school.
12. Spectators, including students, parents and others attending contests shall refrain from
criticizing officials, coaches, opponents or players. Inappropriate spectator behavior can
result in banishment from contests.
13. Possession, use or being under the influence of alcohol, tobacco or illegal drugs
(including steroids or other performance enhancing drugs) on school grounds, at school
functions off school grounds, en route to, during, or driving from a contest is strictly
forbidden. As a result of this infraction an athletic penalty will be imposed ranging from
a three week suspension up to removal from the team for the remainder of the season.
14. Athletes are expected to maintain the highest order of sportsmanship at all times.
15. No student at may take part in bullying, initiations or hazings. Students do not have the
right to impose their will on other students, nor should they feel compelled to be
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initiated by others. Sport teams should be welcoming, comfortable and inclusive. There
will be a penalty imposed on those who participate in bullying, initiations or hazings.
16. Athletes must travel to and from contests in school provided transportation with the
following exceptions. With prior permission from the coach, a student may go to and/or
from a contest with his/her parent. With prior permission from the coach and a written
note from his/her parent, a student may go to and/or return from a contest with another
adult. With written permission of the parent and the prior permission of the coach,
students can drive themselves to and/or from an event. No student may drive to and/or
from an athletic contest with another student. No student may be driven to and/or from
an athletic contest by the coach unless the coach has the proper licensing. Families are
responsible for travel to practices that occur on weekends and for practices that do not
occur immediately after school. In addition, families may be required to provide
transportation to specific contests as identified in advance by the coach.
17. Parents must pick up students within 1/2 hour of the conclusion of practices or games.
18. The school may print and publish a students’ picture and name in various publications
including but not limited to newspapers, newsletters, CIAC and Region 15 Web Sites
and other forms of print and electronic media.
19. Students must follow the school rules.
20. Parents have the right to set academic and behavioral standards above and beyond the
school standards for their children. Parents have the right to revoke their child’s
privilege to participate on an interscholastic team.
Working together to develop responsible young people is a team effort, and we need you on our
team!
Rev. 5/13/14
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Regional School District 15 Concussion and Head Injury Student/Parent Awareness & Consent Form
NOTE: Very often a student athlete may receive a serious head injury and it may have delayed symptoms. Also, the injured
student athlete will most likely not be able to articulate the seriousness of their injury so it is imperative that parents and
other student-athletes understand and recognize the hazards associated with a concussion so they can assist in getting the
injured athlete immediate medical care. This document was developed to provide student athletes and their parents with a
review of current and relevant information regarding concussions and head injuries.
A concussion is a type of traumatic brain injury or (TBI), “that changes how the cells in the brain normally work. A concussion is
caused by a blow to the head or body that causes the brain to move rapidly inside the skull. Even a “ding,” “getting your bell
rung,” or what seems to be a mild bump or blow to the head can be serious. Concussions can also result from a fall or from
players colliding with each other or with obstacles, such as a goalpost” (Centers for Disease Control and Prevention, 2009).
Part I – SIGNS AND SYMPTOMS OF A CONCUSSION
- A concussion should be suspected if any one or more of the following signs or symptoms are present, OR if the evaluator is
unsure.
1. Signs of a concussion may include (what the athlete looks like):
• Confusion/disorientation/irritability
• Loss of consciousness
• Constant attempts to return to play
• Trouble resting/getting comfortable
• Amnesia/memory problems
• Constant motion
• Lack of concentration
• Act silly/combative/aggressive
• Disproportionate/inappropriate
• Slow response/drowsiness
• Repeatedly ask same questions
reactions
• Incoherent/ slurred speech
• Dazed appearance
• Balance problems
• Slow/clumsy movements
• Restless/irritable
2. Symptoms of a concussion may include (what the athlete reports):
• Headache or dizziness
• Blurred or double vision
• Nausea or vomiting
• Oversensitivity to sound/light/touch
• Ringing in ears
• Feeling foggy or groggy
If a concussion is suspected the athlete should be given immediate medical care from a licensed health care professional.
(Note: Public Act No. 10-62 requires that a coach MUST immediately remove a student- athlete from participating in any
intramural or interscholastic athletic activity who (A) is observed to exhibit signs, symptoms or behaviors consistent with a
concussion following a suspected blow to the head or body, or (B) is diagnosed with a concussion, regardless of when such
concussion or head injury may have occurred).
Part II – RETURN TO PARTICIPATION (RTP)
- Currently, it is impossible to accurately predict how long concussions will last. There must be full recovery before someone is
allowed to return to participation. Connecticut Law now requires that no athlete may resume participation until they have
received written medical clearance from a licensed health care professional (Physician, Physician Assistant, Advanced Practice
Registered Nurse, Athletic Trainer) trained in the evaluation and management of concussions.
Concussion management requirements:
1. No athlete SHALL return to participation (RTP) on the same day of concussion.
2. Any loss of consciousness, vomiting or seizures the athlete MUST be immediately transported to the hospital.
3. Close observation of an athlete MUST continue following a concussion. This should be monitored for an appropriate amount
of time following the injury to ensure that there is no escalation of symptoms.
4. Any athlete with signs or symptoms related to a concussion MUST be evaluated from a licensed health care professional
(Physician, Physicians Assistant, Advanced Practice Registered Nurse, Athletic Trainer) trained in the evaluation and
management of concussions.
5. The athlete MUST obtain written clearance from one of the licensed health care professionals mentioned above directing
them into a well defined RTP stepped protocol similar to one outlined below. If at any time signs or symptoms should return
during the RTP progression the athlete should cease activity*
6. After the RTP protocol has been successfully administered (no longer exhibits any signs or symptoms or behaviors consistent
with concussions) , final written medical clearance is required by one of the licensed health care professionals mentioned
above for them to fully return to unrestricted participation in practices and competitions.
Medical Clearance RTP protocol (Recommended one full day between steps)
Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage
1. No activity Complete physical and cognitive rest until asymptomatic. School may need to be modified.
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Recovery
2. Light aerobic activity Walking, swimming or stationary cycling keeping intensity ,<70% of maximal exertion; no resistance training
Increase Heart Rate
3. Sport Specific Exercise Skating drills in ice hockey, running drills in soccer; no head impact activities
Add Movement
4. Non-contact Training drills
Progression to more complex training drills, ie. passing drills in football and ice hockey; may start progressive resistance training
Exercise, coordination and cognitive load.
5. Full Contact Practice Following medical clearance, participate in normal training activities
Restore confidence and assess functional skills by coaching staff
*If at any time signs or symptoms should return during the RTP progression the athlete should stop activity that day. If the athlete’s
symptoms are gone the next day, s/he may resume the RTP progression as the last step completed in which no symptoms were
present. If symptoms return and don’t resolve, the athlete should be referred back to their medical provider
Part III - HEAD INJURIES
– Injuries to the head includes:
• Concussions: (See above information). There are several head injuries associated with concussions which can be severe
in nature including:
a) Second impact Syndrome - Athletes who sustain a concussion, and return to play prior to being recovered from the
concussion, are also at risk for Second Impact Syndrome (SIS), a rare but life-altering condition that can result in
rapid brain swelling, permanent brain damage or death; and
b) Post Concussion Syndrome - A group of physical, cognitive, and emotional problems that can persist for weeks,
months, or indefinitely after a concussion.
• Scalp Injury: Most head injuries only damage the scalp (a cut, scrape, bruise or swelling)… Big lumps (bruises) can occur
with minor injuries because there is a large blood supply to the scalp. For the same reason, small cuts on the head may
bleed a lot. Bruises on the forehead sometimes cause black eyes 1 to 3 days later because the blood spreads downward
by gravity;
• Skull Fracture: Only 1% to 2% of children with head injuries will get a skull fracture. Usually there are no other symptoms
except for a headache at the site where the head was hit. Most skull fractures occur without any injury to the brain and
they heal easily;
• Brain Injuries are rare but are recognized by the presence of the following symptoms:
(1)difficult to awaken, or keep awake or (2) confused thinking and talking, or (3) slurred speech, or (4) weakness of arms
or legs or (5) unsteady walking”(American Academy of Pediatrics – Healthychildren, 2010) .
References:
1. NFHS. Concussions. 2008 NFHS Sports Medicine Handbook (Third Edition). 2008: 77-82.
http://www.nfhs.org.
2. McCrory, Paul MBBS, PhD; Meeuwisse, Willem MD, PhD; Johnston, Karen MD, PhD; Dvorak, Jiri MD; Aubry, Mark MD; Molloy,
Mick MB; Cantu, Robert MA, MD. Consensus
Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. Clinical Journal
of Sport Medicine: May 2009 Volume 19 - Issue 3 - pp 185-200
http://journals.lww.com/cjsportsmed/Fulltext/2009/05000/Consensus_Statement_on_Concussion_in_Sport_3rd.1.aspx.
3. Centers for Disease Control and Prevention. Heads Up: Concussion in High School Sports.
http://www.cdc.gov/NCIPC/tbi/Coaches_Tool_Kit.htm.
4. U.S. Department of Health and Human Services Centers For Disease Control and Prevention. A Fact Sheet for Coaches.(2009).
Retrieved on June 16, 2010.
http://www.cdc.gov/concussion/pdf/coaches_Engl.pdf
5. American Academy of Pediatrics - Healthychildren. Symptom check: Head Injury. Retrieved on June 16, 2010.
http://www.healthychildren.org/english/tips-tools/symptom-checker/pages/Head-Injury.aspx
Resources:
• Centers for Disease Control and Prevention. Injury Prevention & Control: Traumatic Brain Injury. Retrieved on June 16, 2010.
http://www.cdc.gov/TraumaticBrainInjury/index.html
• Centers for Disease Control and Prevention. Heads Up: Concussion in High School Sports Guide for Coaches. Retrieved on June 16,
2010.
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Region 15 Middle School Fall Sports Registration Form
(You only need to return this page.)
Print Student’s Name: _____________________________________
Phone:
_____________________________________
Address:
_____________________________________
_____________________________________
_____________________________________

By my signature, I acknowledge that I have read and understand the rules, policies and procedures as printed in “The
Region 15 Rules and Regulations for Middle School Sports”. I agree to comply with these rules and regulations. And…

By my signature, I understand that participation in athletics in Region 15 Interscholastic Athletics involves the
potential for injury, which is inherent in all sports. I agree to hold Regional School District 15 and any person
connected therewith, harmless from any and all claims from bodily injury and property damage arising from the
use of facilities or during the course of an activity sponsored by the above organizations. I give my permission for
my child, named above to participate and understand that such activity involves the potential for injury, which is
inherent in all sports. Injuries are always a possibility. On rare occasions, these injuries can be so serious as to
result in total disability, paralysis or even death. And..

By my signature I have read and understand this document the “Region 15 Middle School Concussion and Head Injury
Student/Parent Awareness & Consent Form” and understand the severities associated with concussions and the need for
immediate treatment of such injuries.
Signed_________________________________________Date__________________
Signed________________________________________ Date__________________
(parent)
(student)
Check one:
Boys’ Soccer
Girls’ Soccer
Cross Country
Field Hockey
Check One:
I have attached a check for $150.00.
We would like to be considered for exemption from this fee due to financial hardship.
We have reached the family limit of $600.00
Attach check here.
You must send a different form and attach a different check for each child, for each sport, that they play
throughout the school year. Do not attach a check if you are applying for an exemption or have reached
the family limit.
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Student Name________________________Date of Birth_________Age______Grade_______
Date of Physical ______________________________
Address__________________________________________________Home Phone__________
Father’s
Name____________________________Occupation__________________Phone____________
Father’s Place of
Employment_______________________Address_____________________________________
Mother’s
Name____________________________Occupation__________________Phone____________
Mother’s Place of
Employment_______________________Address_____________________________________
In an emergency, if parents cannot be contacted, please notify:
Name________________________________________________________Phone___________
_
Family Doctor_______________________________________ Doctor’s Phone_____________
Family Dentist_______________________________________ Dentist Phone______________
Preferred Hospital_____________________________
Known allergies (Food, Drugs, Medications, Insect Bites or Stings):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Indicate any information that you consider of importance in case of serious injury:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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