Pinnacle Classical Academy Eagles

Pinnacle Classical Academy Eagles

Forms for Participation

Student/Athlete’s Name:______

Grade:______

Please check the following boxes when you have completed the parent/guardian/ student portion of each form.

Forms should be returned to Pinnacle Classical Academy designated to Wesley Clark or Cory Morgan.

Pre-Participation Exam Form

Concussion Statement Form

Insurance Verification Form

Athletic Responsibility

Acknowledgement Form

Ride and Driver Form

Parental Permission Form

Parent Commitment Form

Pinnacle Classical Academy

Athlete Information

Student’s Name:______

Date of Birth:______Age:______

Address:______

Phone Number: (Home)______(Cell)______

Parent/Guardians Name(s):______

Emergency Contact Name: ______

Emergency Contact Number: (Home)______(Cell)______

Medications:______

Injuries:______

Allergies:______

Concussions

INFORMATION FOR STUDENT-ATHLETES & PARENT/LEGAL CUSTODIANS

What is a concussion? A concussion is an injury to the brain caused by a direct or indirect blow to the head. It results in your brain not working as it should. It may or may not cause you to black out or pass out. It can happen to you from a fall, a hit to the body that causes your head and your brain to move quickly back and forth.

How do I know if I have a concussion? There are may signs and symptoms that you may have following a concussion. A concussion can affect your thinking, the way your body feels, your mood, or your sleep. Here are some things to look for:

Thinking/Remembering / Physical / Emotional/Mood / Sleep
Difficulty thinking clearly
Taking longer to figure things out
Difficulty concentrating
Difficulty remembering new information / Headache
Fuzzy or blurry vision
Feeling sick to your stomach or queasy
Vomiting/throwing up
Dizziness
Balance problems
Sensitivity to noise or light / Irritability - things bother you more easily
Sadness
Being more moody
Feeling nervous or worried
Crying more / Sleeping more than usual
Sleeping less than usual
Trouble falling asleep
Feeling tired

*Table is adapted from the Centers for Disease Control and Prevention ()

What should I do if I think I have a concussion? If you are having any of the signs or symptoms listed above, you should tell parents, coach, athletic trainer, or school nurse so they can get you the help you need. If a parent notices these symptoms, they should the school nurse, athletic trainer, or family physician.

When should I be particularly concerned? If you have a headache that gets worse over time, you are unable to control your body, you vomit repeatedly, or feel increasingly more sick to your stomach, or your words are coming out slurred, you should let an adult know right away, so they can get you the help you need.

What are some of the problems that may affect me after a concussion? You may have trouble in some of your classes or even with activities at home. If you continue to play or return to play too early with a concussion, you may have long term trouble remembering things or paying attention, headaches may last a long time, or personality changes can occur. Once you have a concussion, you are more likely to have another concussion.

How do I know when it’s okay to return to physical activity after a concussion? After telling your coach, parents, and any medical personnel that you think you have a concussion, you will probably be seen by a doctor trained in helping people with concussions. Your school and your parents can help you decide who is best to treat you and help to make the decision on when you should return to activity/play or practice. Your school will have a policy in place for how to treat concussions. You should not return to play or practice on the same day as your suspected concussion.

You should not have any symptoms at rest or during/after activity when you return to play, as this is a sign your brain has not fully recovered from the injury.

This information is provided to you the the UNC Matthew Gfeller Sport-Related TBI Research Center, North Carolina Medical Society, North Carolina Athletic Trainers’ Association, Brain Injury Association of North Carolina, North Carolina Neuropsychological Society, and North Carolina High School Athletic Association.

Student-Athlete & Parent/Legal Custodian Concussion Statement

*If there is anything in this sheet that you do not understand, please as an adult to explain or read it to you.

Student-Athlete Name: ______

Parent/Legal Custodian Name(s): ______

?We have read the Student-Athlete & Parent/Legal Custodian Concussion Sheet.

*If true, please check the box.

After reading the concussion information sheet, I am aware of the following information:

Student-Athlete Initials / Parent/Guardian Initials
A concussion is a brain injury, which should be reported to my parents, my coach(es), or a medical professional, if available.
A concussion can affect the ability to perform everyday tasks, such as the ability to think, balance, and classroom performance.
A concussion cannot be “seen”. Some symptoms might be present right away. Other symptoms can show up later.
I will tell my parents, coach(es), and/or a medical professional about the concussion. / N/A
If I think a teammate has a concussion, I will tell my coach(es), parents, or a medical professional immediately. / N/A
I will not return to play in a game or practice if a hit to my head or body causes concussion-related symptoms. / N/A
I will/my child will need written permission from a medical professional trained in concussion management to return to play or practice after a concussion.
Based on the latest data, concussions take days or weeks to get better. A concussion may not subside right away. I realize that resolution from this injury is a process and may require more than one medical evaluation.
Sometimes, repeat concussions can cause serious and long-term problems.
I have read the concussion symptoms on the Concussion Information Sheet.

Pinnacle Classical Academy

INSURANCE VERIFICATION

All students should be covered by insurance to participate in athletics.

(Please fill out appropriate section).

Section I:

Date: ______School Year: ______

Insurance Coverage: Although we strive to keep all injuries to a minimum, due to the nature of athletics, injuries do occur. Most injuries are minor and require no attention by a physician. However, occasionally an injury will occur that requires medical attention by someone other than a member of our staff. Normally most health policies cover all sports other than football. If your child has coverage, please fill out the following:

This is to certify that (student name) ______is covered by

Insurance Company______

Policy Number______

Parent Signature______

Section II:

Date: ______

(Player name) ______is not covered by insurance if injured while participating in athletics. I assume any financial obligations incurred as a result of injury during the athletic season. I understand that Pinnacle Classical Academy is not responsible for payment of any medical bill resulting from medical attention by a physician or other licensed person as a result of an injury suffered while participating in PCA athletic activities.

Parent Signature: ______

Coach's’ Initials: ______

Athletic Director's’ Initials ______

Athletic Responsibility Acknowledgement Form

Prior to participating in interscholastic athletics, each athlete must:

1. Successfully pass a physical examination by a registered physician and the copy of such examination must be on file in the office of the Athletic Director.
2. Return the Athletic Responsibility Acknowledgement form, properly signed, to the Pinnacle Classical Academy Athletic Department.

As a Pinnacle Classical Academy student-athlete participating voluntarily in interscholastic athletics, I understand that:

1. I will abide by the Pinnacle Classical Academy student Code of Conduct, the school’s Athletic Handbook, the coaches’ team rules, and the rules of the North Carolina High School Athletic Association.
2. I will conduct myself in an exemplary social manner at all times.
3. I will be responsible for all athletic equipment issued to me throughout the season, will return such equipment at the conclusion of the season, and will pay the current replacement cost for any of the equipment not accounted for by me at the end of the season.
4. I will not use or be in possession of tobacco, alcohol, or narcotics. If I do use any of these substances, am in the possession of such substance, or am suspended from school for the use or possession of these substances, I will be subject to disciplinary actions as outlined in the Athletic Handbook.
5. I acknowledge that I have been properly advised, cautioned and warned by the administrative and coaching personnel of Pinnacle Classical Academy, that I am exposing myself to the risk of injury, including but not limited to, the risk of sprains, fractures, and ligament and/or cartilage damage which could result in a temporary or permanent, partial or complete, impairment in the use of my limbs, brain damage, paralysis, or even death. Having been so cautioned and warned, it is still my desire to participate in athletics and to do so with the full knowledge and understanding of the risk of injury.
6. I, along with my parent or guardian, certify that i have read and understand all of the Pinnacle Classical Academy Athletics policies in the Athletic Handbook (FOUND ON THE WEBSITE SOMEWHERE) and in order the be eligible for participation, I must comply with the requirements listed.

Pinnacle Classical Academy

Athletic Responsibility Acknowledgement 2017-2018

Student Athletic Handbook can be found on the PCA website, under “Athletics”.

Student

Signature: ______Date: ______

Parent

Signature: ______Date: ______

Pinnacle Classical Academy

Ride and Driver Form

Dear Parent or Guardian:

As you know, Pinnacle Classical Academy is limited with our bus usage. PCA must use other means of transportation to get our students to and from different venues for different clubs, organization, athletic events and/or miscellaneous events. In the events that a bus is not available, we may have to call on PCA staff members, or parent volunteers to carpool to the event. Please sign this document clearing PCA, staff of PCA or any parent volunteer of any and all liability due to an automobile accident.

●I agree and understand that everything that is listed above and give my child permission to ride with a PCA staff member and/or parent volunteer to an event.

______

(print student name) (print parent/guardian name) (parent/guardian signature) (date)

Parent/Guardian:

PCA’s athletic teams practice and play home games off campus. PCA will allow student-athletes who have their driver’s license to drive to practices and games. This will only allow your student to drive by themselves. They will not be permitted to carry anyone in the car with them. If you permit you student to drive, please sign this document clearing PCA and the coaching staff of PCA of any and all liability due to an automobile accident. Along with this signed document, a copy of your student’s driver’s license is required.

●I agree and understand that everything that is listed above and give my child permission to drive to practice and games.

______

(print student name) (print parent/guardian name) (parent/guardian signature) (date)

Parental Permission

(To be completed by the parent or guardian)

I have read and reviewed the general requirements for school eligibility and I have discussed these requirements with my student-athlete. I understand that additional questions or specific circumstances should be directed to my student’s principal, athletic director, or coach.

I certify that the home address shown below is my sole residence and I will notify the school headmaster immediately of any change in residence, since such a move may alter the eligibility status of my student-athlete. I further acknowledge I must not falsify any official eligibility information such as residency, address, or birthdate. Penalty for such acts will result in loss of eligibility for 365 days. All other information contained on this form is accurate and current.

In accordance with the rules of the NCHSAA, I hereby give my consent for the participation of my student-athlete named below for the following activities circled below:

BaseballGolfSwimmingBasketball Tennis Cross Country Track & Field Cheerleading

VolleyballFootballSoccerWrestling Archery Softball

Other (school may list): ______

Date: ______Parent/Guardian Signature: ______

Name of Student-Athlete (print): ______

Name of Parent/Guardian (print): ______

Address of Parent/Guardian: ______

NOTE: This statement will be on file in the Athletic Director’s office and is valid for one academic year only.

Parent Commitment Pledge

Parents are discouraged from approaching coaches after practices and games and agree not to discuss playing time, coaching strategies and other athletic matters. The coaching staff is not obligated to answer any question as it pertains to these items. Please schedule a meeting with the Athletic Director and/or coaching staff if you have other concerns.

Athlete’s name : ______

Parent/Guardian Signature: ______Date: ______