ORONDO SCHOOL DISTRICT TREATMENT AUTHORIZATION
IMPORTANT: Medication______
Allergies______
This form must be signed by your parent or legal guardian.
Medical and Surgical Authorization: I hereby authorize and give my consent to the coaches or administration of Orondo School District to authorize any licensed physician to perform upon or administer to:
______
Name of Student Birth Date of Student
any reasonable necessary medical or surgical treatment. I also give permission to administer whatever anesthetic may be necessary or advisable during the medical or surgical procedures. This authorization is intended to cover emergency treatment, immunization, injections and minor operations and procedures.
In the event of indicated major surgery or medical procedure, the school authorities or physicians are not hereby excused from attempting to contact me by phone before relying on this authorization. This authorization does not entitle the service or physician to render any medical or surgical treatment without the student’s personal consent unless the student is unable to give consent.
This permission is good only while the student is attending the above-mentioned school.
DATE:
INSURANCE COMPANY:
SS NUMBER OR GROUP NUMBER:
STUDENTS’S BIRTH DATE
PARENT SIGNATURE:
ADDRESS:
PHONE:
EMERGENCY NAME:
EMERGENCY PHONE:
WASHINGTON INTERSCHOLASTIC ACTIVITIES ASSOCIATION
REQUEST FOR WAIVER OF ACCIDENT PLAN COVERAGE
DATE ______, 20 ____
Dear Principal,
I understand that my (son) (daughter) cannot participate in boys’ or girls’ after-school
athletics unless (he) (she) is covered either by the School Accident Coverage Plan (which is available for purchase through the school office), by your own family insurance plan, or with medical coupons. Your choice of plan must meetthe following minimum provisions:
1. Minimum death benefit of $600.00.
2. A maximum payment for any one injury of at least $500.00.
3. Coverage equivalent to the Washington State Industrial Insurance
Fee Schedule for doctors’ services or hospitalization with a 30-day
minimum for the latter.
4. X-rays to a maximum of at least $10.00.
5. Dental coverage equivalent to the Washington State Industrial
Insurance Fee Schedule to at least $100.00.
Name of your Company Providing the Coverage is:
I have insurance coverage that is equivalent or better than the above requirements of the
Washington Interscholastic Activities Association and will continue to keep it in force
throughout the sports season; therefore, I do not wish to enroll
______
(Name of son or Daughter)
in the School Accident Coverage Plan.I accept full responsibility for the cost of treatment for any injury which (he) (she) maysuffer while taking part in the program. Please waive this requirement and permit (him)(her) to take part in athletics and Sports Days.
______
Parent’s Signature
Medical Coupons meet the above requirements and a copy of them must be included.
ORONDOSCHOOL DISTRICT
STUDENT-PARENT/GUARDIAN WARNING & ASSUMPTION OF RISKS
It is the school district’s intent to provide any athlete with good instruction, safe equipment, and safe transportation; but we cannot eliminate all risks involved in sports participation ACCIDENTAL INJURY, COMPLETELY UNRELATED TO ANY PREVENTABLE CAUSE IS ALWAYS POSSIBLE.
This ASSUMPTION OF RISK form is designed to provide this school district with a degree of protection. It is not designed to deny the rights of an injured athlete. OUR SCHOOL DISTRICT PROVIDES WIAA CATASTROPHIC MEDICAL INSURANCE COVERAGE TO PARTICIPATING STUDENTS. Participation in WIAA sponsored interscholastic activities are all voluntary and extracurricular. As a condition to participation in these activities, you and your parent(s)/guardian(s) must understand THE RISKS involved in these kinds of activities.
WARNING
Participation in any athletic activity may involve injury of some type to either yourself or a fellow student athlete. Such injury can include direct physical and possible crippling injury to one’s body and the possibility of emotional injury experienced as a result of witnessing or actually inflicting injury to another. The severity of such injury can range from minor to catastrophic injury such as complete paralysis or even one’s future ability to earn a living, to engage in other business, social and recreational activities, and generally to enjoy life.
Activity injuries can result from the incorrect or correct performance of playing techniques used in tryouts, practices, warm-up, games, drills, exercises and other similar undertakings. Injury can also result from failing to follow the game, training, safety or other team rules. Injury can result from the use of transportation provided or arranged by the school district to and from interscholastic activity.
Therefore, the purpose of the WARNING is to aid you in making an informed decision as to whether you, your child or ward should participate in these activities. In addition, the purpose is to make you aware that as a student participant, or as a parent or guardian of a student participant, it is your responsibility to learn about and/or inquire of coaches, physicians, advisor or other knowledgeable persons about ANY concerns that you might have at any time regarding participant safety.
In consideration of the Orondo School District’s permitting
______
(student name)
to participate in interscholastic activities and to engage in all areas of these activities, I, the participant, and we the parent(s)/guardian(s), hereby agree to assume the risks of injury or death associated with the School District’s interscholastic program as outlined in the WARNING above.
By signing this document, we acknowledge that we have read and understand its contents and warning related to the above stated risks and give our permission for ______to participate in interscholastic activities. (student name)
______
(Signature of Parent) (Date)
Concussion Information Form
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, allconcussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.
Symptoms may include one or more of the following:
- Headaches
- “Pressure in head”
- Nausea or vomiting
- Neck pain
- Balance problems or dizziness
- Blurred, double, or fuzzy vision
- Sensitivity to light or noise
- Feeling sluggish or slowed down
- Feeling foggy or groggy
- Drowsiness
- Change in sleep patterns
- Amnesia
- “Don’t feel right”
- Fatigue or low energy
- Sadness
- Nervousness or anxiety
- Irritability
- More emotional
- Confusion
- Concentration or memory problems (forgetting game plays)
- Repeating the same question/comment
Signs observed by teammates, parents and coaches include:
- Appears dazed
- Vacant facial expression
- Confused about assignment
- Forgets plays
- Is unsure of game, score, or opponent
- Moves clumsily or displays incoordination
- Answers questions slowly
- Slurred speech
- Shows behavior or personality changes
- Can’t recall events prior to hit
- Can’t recall events after hit
- Seizures or convulsions
- Any change in typical behavior or personality
- Loses consciousness
What can happen if my child keeps on playing with a concussion or returns to soon?
Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain
swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.
If you think your child has suffered a concussion
Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new “Zackery Lystedt Law” in Washington now requires the consistent and uniform implementation of long and well-established return to play concussion guidelines that have been recommended for several years:
“a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time”
and
“…may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.
You should also inform your child’s coach if you think that your child may have a concussion Remember its better to miss one game than miss the whole season. And when in doubt, the athlete sits out.
For current and up-to-date information on concussions you can go to:
______
Student-athlete Name Printed Student-athlete Signature Date
______
Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date
ORONDO SCHOOL ACTIVITIES/ATHLETIC
CODE OF CONDUCT
It is to be understood that participation in the Interscholastic Athletic/Activities programs, grades 5TH – 7TH grades, in the Orondo School District is a privilege and completely voluntary. Therefore, your involvement requires commitments on your part with respect to your academic standing, citizenship and obligations to your school, community and teammates. With this understanding , the following regulations have been adopted for
those choosing to be involved in the athletic/activities programs.
1. There shall be absolutely no use, possession or selling of alcoholic beverages, non-prescribed drugs, narcotics, or tobacco products (to include chewing tobacco).
FIRST OFFENSE
The student will be excluded for the remainder of the sports season specific to them.The student can appeal in writing (to the school board) for a hearingto seek reinstatement to the squad. The student will be placed on probation for the remainderof the school year, which will be from the date of verification of the first offense. In addition all rules and procedures in the student handbook will apply.
Any additional violation of the Athletic Code during the probationary period will result in exclusion from participation in all athletics for the remainder of the school year.
2. ELIGIBILITY:
Students must maintain passing grades in all of their classes to be eligible to participate in competitions. In addition, students must also either maintain a 2.0 (C grade) average, or have completed all work. Students ineligible to compete may continue to participate in practice with attendance at the after school program’s homework session Tuesdays through Thursdays until eligibility is restored.
3. UNIFORMS:
Uniforms belong to the School District. Loss or damage of uniforms is the student’s financial obligation. Until this obligation isfulfilled, the student will not be allowed further competition at the OrondoSchool District. Uniforms should be taken well care of and treated with respect. This includes returning them in a clean/laundered condition prior to being checked back in. Uniforms may only be worn for official school activities, and may not be worn for personal use.
5. OTHER EXPECTATIONS:
Establish proper rest and good dietary habits during the sport season.
6. TRAVEL:
All participants must travel to and from the athletic contest with the team when transportation is provided for this purpose. There are 2 exceptions:
(1) Traveling home from the contest with parents when the student has a note on file prior to the contest, or whena parental permission form is filled out and given to the coach at the event prior to leaving. The coach/advisor has the authority to have all students return home on the bus when he/she feels it is in the best interest of the team. Parents may ride on the district provided transportation when a signed background check form is on file with the district. Parents may only sit with their own child/children on the bus. Other children whom are not participating in the activity may not be transported by district transportation.
7. OTHER RULES:
A student participant will abide by any additional rules or more stringent penalties adopted and enforced by the coach/advisor and approved by the superintendent.
NOTE:Students perform in public, therefore, they must conduct themselves on and off the field in a manner that will always reflect the high standards and
ideals of their name, team, school and the Orondo community. The following are violations of the code of conduct. Penalties or the process for dealing with the
penalty follow each.
1. Vandalism:
An act of vandalism or theft at school or while under the supervision of a coach/advisor is a violation of the Code of Conduct.
Penalty: The student will be excluded for the remainder of the sports season specific to them. The student can appeal in writing (to the school board) for a hearingto seek reinstatement to the squad. The student will be placed on probation for the remainderof the school year, which will be from the date of verification of the first offense. Any additional violation of the Athletic Code during the probationary period will result in exclusion from participation in all athletics for the remainder of the school year
2. Truancy:
Truancy from school is a violation of the Code of Conduct.
Penalty: A student who is truant from class or school during the sport/activity season will be immediately excluded from the team or squadand not reinstated until cleared by the Superintendent.
3. Other Infractions:
a. Behaviors such as negative attitudes, unsportsmanlike conduct, the use of profane or obscene language or acts of vulgarity,missed practices, or not demonstrating courtesy, fairness and respect for others, etc. are violations of the Code of Conduct.
Penalty: The head coach/advisor of that sport/activity may place a student on probation or exclude them from participation (practice orcontests) until the matter is resolved.
b. (1) HAZING, (2) harassment or intimidation
Penalty: Harassment,bullying or intimidating will not be tolerated and the penalty will be determined by the Superintendent according to the level of the offense.
APPEALS:
All appeals of the penalties noted above may be appealed to the School Board.
SPECIAL NOTE: Falsifying signatures on any required athletic/activity form will be cause for loss of eligibility for that sport/activity season.
STUDENT ATHLETIC/ACTIVITY CODE
CONTRACT
STUDENT NAME: ______
Please Print
As a student: I have read and agree to abide by the rules and regulations of the
Athletic/Activity Code. I am aware of both the benefit of participating and the consequences that may result from not following the Athletic / Activity Code.
As a parent: I have gone over the code with my son/daughter and he/she is also fully aware of the consequences that will be enforced for failure to abide by its rules and regulations. We are both aware of the cost of replacing any district issued uniforms that are missing or damaged beyond normal wear and tear.
PLEASE SIGN BELOW:
Parent/Guardian______Date______
Student______Date______
Orondo School District does not discriminate on the basis of sex, race, creed, religion, color, national origin, age, honorably discharged veteran or military status, sexual orientation including gender expression or identity, the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal by a person with a disability in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. The following employee has been designated to handle questions and complaints of alleged discrimination:
Compliance Coordinator for 28A.640 and 28A.642 RCW , Section 504/ADA Coordinator and Title IX Coordinator
Superintendent, Orondo School District
PO Box 71 Orondo, WA 98843
509-784-2443
Orondo School District will also take steps to assure that national origin persons who lack English language skills can participate in all education programs, services and activities. For information regarding translation services or transitional bilingual education programs, contact Sandra Stoddard, Programs Director.
PREPARTICIPATION HISTORY AND PHYSICAL EXAMINATION
This form is not required as long as the conditions of 18.13.0 are met.
Name: ______Birth Date: ______Exam Date: ______
Address: ______City: ______Zip:______
Phone: ______Sport: ______
HISTORY
YesNo
1 a.Have you had any illness/injury recently, or do you have an illness/injury now?
b.Have you had a medical problem, illness or injury since your last exam?
c.Do you have any chronic or recurrent illness?
d.Have you ever had any illness lasting more than a week?
e.Have you ever been hospitalized overnight?
f.Have you had any surgery other than tonsillectomy?
g.Have you ever had any injuries requiring treatment by a physician?
h.Do you have any organ missing other than tonsils ( appendix, eye, kidney, testicle, etc.)?
2.Are you presently taking ANY medications ( including birth control pill, vitamin, aspirin, etc.)?
3.Do you have ANY allergies (medicines, bees, foods, or other factors)?
4 a.Have you ever had chest pain, dizziness, fainting, passing out during or after exercise?
b.Do you tire more easily or quickly than your friends during exercise?