FancherCreekElementary
2023-2024 - Athletics Permission to Participate - Elementary - Version: 1

DearParents/Guardians,

Athletic events are here and we are excited to have yourchild participate inourco-curricularactivities!

PleaserevieweachoftheattachedformsincludedinthisPermission-Clickapplication.

Thelastpagewillaskyouto"agree"andelectronicallysubmitalltheformsyou'vecompletedatonceto theschool.

Please note thatyouracceptance ofthe forms are requiredforstudentparticipation in athletics.

Ifyouhave furtherquestions,please contactthe schooloffice.

Thank youand we hope youenjoythis time saving process.

Please provide your answerstothe parent specificquestionsbelow

Parent/Guardian Contact #1 Parent/GuardianContact#1

FirstandLastName

PhoneNumber

Parent/GuardianContact#2

PhoneNumber

Please provide your answerstothe student specificquestionsbelow SCHOOLTOEDITClassroomTeacherName (Selectone)

Createoptions-separatewithcomas
Please selectwhichsports yougive permissionforyourchild to participate inafterschool.

FallSport (Selectone)

BoysCrossCountry	GirlsCrossCountry	Football	GirlsVolleyball WinterSport (Selectone)
BoysBasketball	GirlsBasketball	Wrestling SpringSport (Selectone)
Baseball	GirlsSoftball	BoysTrack	GirlsTrack	BoysVolleyball

Code of Conduct for Student Athletes Code ofConductforStudentAthletes

IhavereadandreviewedtheCodeofConductforStudentAthleteswithmystudent.Iunderstandthat acceptingthetermsoftheCodeofConductarerequiredinorderformystudent-athleteto participate. (Selectone)

Iagree

Parent/Athlete Concussion Information Parent/Athlete ConcussionInformation

IhavereadandreviewedtheParent/AthleteConcussionInformationsheetwithmychild.Iunderstand thedangersignsandsymptomsofaconcussion. (Selectone)

IAgree

Prescription Opioids: What You Need To Know

IhavereadtheinformationprovidedasanattachmenttothisformentitledPrescriptionOpioids: What YouNeedToKnowandunderstandtherisksandsideeffectsofOpioiduse. (Selectone)

IAgree

Keep Their Heart in the Game

IhavereadandreviewedtheKeepTheirHeartintheGameattachmentwithmychild.Iunderstandthe dangersandsignsofsuddencardiacarrest. (Selectone)

IAgree

ATHLETICS – WARNING OF RISK FOR ALL SPORTS

SERIOUS,CATASTROPHICANDPERHAPSFATALINJURYMAYRESULTFROMATHLETICS PARTICIPATION.

Byits verynature,competitive athletics mayputstudents insituations inwhichaccidents mayoccur.Manyforms of athletic competitionresultinviolentphysicalcontactamong players,the use ofequipmentthatmayresultin accidents,strenuous physicalexertion,and numerous otherexposures to risk ofinjury.

Students and parents mustassess the risks involved insuchparticipationand make theirchoice to participate in spite ofthose risks.No amountofinstruction,precaution,orsupervisionwilltotallyeliminate allrisk ofinjury.Justas driving anautomobile involves choice ofrisk;athletic participationbystudents also maybe inherentlydangerous. The obligationofparents and students inmaking this choice to participate cannotbe overstated.There have been accidents resulting inserious permanentphysicalimpairmentas a resultofathletic competition.Students willbe instructed inpropertechniques to be used inathletic competitionand inproperutilizationofallequipmentwork or used inpractice and competition.Students mustadhere to thatinstructionand utilizationand mustrefrainfrom improperuses and techniques.Bygranting permissionforyourstudentto participate inathletic competition,you,as a parentorguardian,acknowledge thatsucha risk exists.Bychoosing to participate inathletic competitions,you, the student,acknowledge thatsucha risk exists.

FOOTBALLPLAYERS: Nohelmetcanpreventallheadorneckinjuriesaplayermayreceivewhile participatinginfootball.

DONOTUSEYOURHELMETTOBUTT,RAMORSPEARANOPPOSINGPLAYER.Thisisinviolationof thefootballrulesandsuchusecanresultinsevereheadorneckinjuries,paralysisordeathtoyouand possibleinjurytoyouropponent.

Ifanyofthe foregoing is notcompletelyunderstood,please contactthe office atyourschoolforfurtherinformation.

We have read and understand the material included in the “Warning of Risk”, including the Football Helmet warning. I certifythat I have read and understand the warning.	Yes	No

MEDICAL INSURANCE

I understand that mychild must have medical insurance that provides at least $1,500 accidental injury coverage.	Yes	No

I have medical insurance that provides coverage of at least $1,500 for accidental injury.	Yes	No PleaseprovideInsuranceCompanyName

Pleaseprovideinsurancepolicynumberorinsurancegroupnumber.

Pleaseprovideinsurancepolicyexpirationdate(mo/yr),ifapplicable.

WAIVER
CLOVIS UNIFIED SCHOOL DISTRICT ATHLETIC PROGRAM PARTICIPATION

RELEASE OF LIABILITYand MEDICAL TREATMENTAUTHORIZATIONAGREEMENT

Iunderstand and acknowledge thatparticipationinthe above Athletic Programand anyrelated activities (collectivelyknownhereinas "Activity"),bytheirverynature,pose the potentialrisk ofserious injury/illness to individuals who participate.Ialso realize thatthe Activitymaybe strenuous,and thatIhave the optionto seek the advice ofa physicianbefore Iparticipate inthis Activity.Iunderstand and acknowledge thatsome ofthe injuries/illnesses whichmayresultfromparticipating inthis Activityinclude,butare notlimited to,the following:

••Sprains

••Fractured bones

••Unconsciousness

••Head and/orback injuries

••Paralysis

••Activityrelated injury/illness

••Loss ofeyesight

••Communicable diseases

••Death

The above listis notintended to be inclusive ofallinjuries thatmayoccur,butratherto informme ofthe types of risks inherentinparticipationinthe above Activityso thata voluntarychoice canbe made to participate ornot participate.

In the event of accident or illness, I do herebyconsent to whatever x-rayexamination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care considered necessaryin the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facilityfurnishing medical or dental services. Further, I agree that Clovis Unified School District ("District") and its personnel are not legallyor financiallyresponsible or liable for anyclaimarising fromany

consent given in good faith in connection with diagnosis or advised treatment.	Yes	No

Inconsiderationofbeing permitted to participate inthe above Athletic Programand anyrelated activities,Iagree to assume anyand allliabilityand responsibilityforthe potentialrisks whichmaybe associated withparticipationin suchActivityoranyactivities incidentalthereto.Ifurtheragree bymysignature belowto exemptand relieve,on behalfofmyselfand myheirs,executors,administrators and assigns,the Clovis Unified SchoolDistrict,its Board, officers,agents,employees orvolunteers fromanyand allliabilityorresponsibilityforpropertydamage,personal injury,and bodilyinjury(including wrongfuldeath)thatmightbe sustained whichis incidentto,associated with preparing for,and/orwhile participating inanyactivityconnected withsaid Athletic Program,including travel provided bythe Districtto and fromActivitylocations.Iunderstand thatthis provisionis intended to be as broad and inclusive as permitted bylaw,and thatifanyportionis held invalid,itis agreed thatthe balance shallcontinue infull legalforce and effect.

I acknowledge that I have carefullyread and understand this Athletic ActivityProgramWaiver, Release of Liability and Medical Treatment Authorization Agreement, and that I voluntarilyagree to its terms and conditions.

Yes	No

Waiver

As the parent/guardianofthe above-named child and onbehalfofmyselfand mychild,agents,heirs,and successors,Ivoluntarilyagree to:(1)assume allrisks ofinjury,illness,ordeathto mychild arising outoforresulting frommychild’s participationinand/orattendance atthe above-stated programoractivity,suchrisks to include but are notlimited to,injury,illness,ordeathdue to being exposed to orinfected bycontagious diseases,including COVID-19;(2)waive and release allclaims,causes ofactions,actions,liabilities,and costs againstthe Clovis Unified SchoolDistrict(District)and its governing board and members thereof,officers,employees,agents,and volunteers (collectivelyDistrictPersonnel)and hold harmless the Districtand DistrictPersonnelfromanyclaims, causes ofactions,actions,liabilities,and costs thatmayarise outoforresultfrommychild’s participationinor attendance atsuchprogramoractivity;and (3)assume allobligations foranymedical,financial,and othercosts and/orliabilities thatbe sustained orincurred bymychild,myself,ormyagents,heirs,and/orsuccessors.The Districtassumes no responsibilityand shallnotbe liable foranyinjury,illness,death,liabilities,damages,orcosts thatmychild,myself,myagents,heirs,and/orsuccessors maysustainorincurarising outoforresulting fromthe aforementioned programoractivity.

WaiverAgreement (Selectone) Ihaveread,understandandagree.

Release of Student to Parent/Guardian After Field Trip or Activity Release ofStudentto Parent/GuardianAfterField Trip orActivity

Whena studentis transported to anathletic eventbybus,the lawrequires the studentto be returned bybus to the school.A parent/guardianmaychoose to release the studentto theircustodyafterthe eventbyproviding a listof authorized individuals to whomthe studentmaybe released.Complete the fields below-be sure to include the parent/guardians as well.
WaiverofClaims:

Iagreethatoncemyson/daughterisreleasedtomycustody,Iassumefullresponsibilityforhis/her health,safetyandwelfareandasprovidedforinCaliforniaEducationCodeSection35330.Iagreeto waiveallclaimsagainsttheDistrictandholdtheDistrict,itsofficers,agentsandemployees,harmless fromanyandallliabilityorclaims,whichmayariseoutoforinconnectionwithmychild’sparticipationin thisactivity.Thiswaivershallnotapplytoanyoccurrenceswhichmayarisesolelyoutofthenegligence oftheDistrict,itsemployeesoragents. (Selectone)

Iagree
Itis the responsibilityofthe designated schoolofficialto ensure allstudents are properlyaccounted forbefore transportationto orfroma schoolactivityoccurs.

AuthorizedIndividual#1(FirstandLastName)

AuthorizedIndividual#2(FirstandLastName)

AuthorizedIndividual#3(FirstandLastName)

AuthorizedIndividual#4(FirstandLastName)

AuthorizedIndividual#5(FirstandLastName)

AuthorizedIndividual#6(FirstandLastName)

Student'sFullName*

Parent'sEmailAddress*

Parent'sFullName*

ParentSignature

Parent/Athlete Concussion Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow, or jolt to the
head or body that causes the head and brain to move rapidly back and forth. Even a “ding,”“getting your bell rung,” or what seems to be a mild bump or blow

to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of

concussion listed below after a bump, blow, or jolt to

Did You Know?

• Most concussions occur without loss of consciousness.

• Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.

• Young children and teens are more likely to get a concussion and take longer to recover than adults.

the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is
symptom-free and it’s OK to return to play.

SIGNS OBSERVED BY COACHING STAFF
	
SYMPTOMS REPORTED BY ATHLETES
	
Appears dazed or stunned
	Headache or “pressure” in head
	
Is confused about assignment or position
	Nausea or vomiting
	
Forgets an instruction
	Balance problems or dizziness
	
Is unsure of game, score, or opponent
	Double or blurry vision
	
Moves clumsily
	Sensitivity to light
	
Answers questions slowly
	Sensitivity to noise
	
Loses consciousness (even briefly)
	Feeling sluggish, hazy, foggy, or groggy
	
Shows mood, behavior, or personality changes
	Concentration or memory problems
	
Can’t recall events prior to hit or fall
	Confusion
	
Can’t recall events after hit or fall
	Just not “feeling right” or “feeling down”

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

• One pupil larger than the other

• Is drowsy or cannot be awakened

• A headache that not only does not diminish, but gets worse

• Weakness, numbness, or decreased coordination • Repeated vomiting or nausea
• Slurred speech

• Convulsions or seizures

• Cannot recognize people or places

• Becomes increasingly confused, restless, or agitated • Has unusual behavior
• Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal.While an athlete’s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their
brain.They can even be fatal.

Remember

Concussions affect people differently.While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more seri-ous concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed
and monitored by a health care professional.

It’s better to miss one game than the whole season. For more information on concussions, visit:www.cdc.gov/Concussion.

Student-Athlete Name Printed

Parent or Legal Guardian Printed

Student-Athlete Signature	Date

Parent or Legal Guardian Signature	Date

KeepTheirHeartintheGame ASuddenCardiacArrestInformationSheetforAthletesandParents/Guardians

What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens blood stops flowing to the brain and other vital organs. SCA is NOT a heart attack. A heart attack is caused by a blockage that stops the flow of blood to the heart.SCAisamalfunctionintheheart’selectricalsystem,causingthevictimtocollapse. Themalfunctioniscausedbyacongenitalorgeneticdefectintheheart’sstructure.

How common is sudden cardiac arrest in the United States? AstheleadingcauseofdeathintheU.S.,therearemorethan300,000cardiacarrests outsidehospitalseachyear,withnineoutof10resultingindeath.Thousandsof suddencardiacarrestsoccuramongyouth,asitisthe#2causeofdeathunder25 andthe#1killerofstudentathletesduringexercise.

FAINTING
is the
#
1SYMPTOM
OFAHEARTCONDITION
Who is at risk for sudden cardiac arrest? SCAismorelikelytooccurduringexerciseorphysical activity,sostudent-athletesareatgreaterrisk. While aheartconditionmayhavenowarningsigns,studies showthatmanyyoungpeopledohavesymptomsbut neglecttotellanadult.Thismaybebecausetheyare embarrassed,theydonotwanttojeopardizetheirplay-
ingtime,theymistakenlythinkthey’reoutofshapeandneedtotrainharder,or theysimplyignorethesymptoms,assumingtheywill“justgoaway.”Additionally, somehealthhistoryfactorsincreasetheriskofSCA.

What should you do if your student-athlete is experiencing any of these

TheCardiacChainofSurvival On average it takes EMS teams up to 12 minutes to arrive

to a cardiac emergency. Every minute delay in attending to a sudden cardiac arrest victim decreases the chance of survival by 10%. Everyone should be prepared to take action in the first minutes of collapse.

Early Recognition of Sudden Cardiac Arrest Collapsedandunresponsive. Gasping,gurgling,snorting,moaning orlaboredbreathingnoises.
Seizure-likeactivity.

Early Access to 9-1-1

symptoms?
Weneedtoletstudent-athletesknowthatiftheyexperienceanySCA-related symptomsitiscrucialtoalertanadultandgetfollow-upcareassoonaspossible withaprimarycarephysician.IftheathletehasanyoftheSCAriskfactors,these shouldalsobediscussedwithadoctortodetermineiffurthertestingisneeded. Waitforyourdoctor’sfeedbackbeforereturningtoplay,andalertyourcoach, trainerandschoolnurseaboutanydiagnosedconditions.

Confirmunresponsiveness. Call9-1-1andfollowemergency dispatcher'sinstructions.
Callanyon-siteEmergencyResponders.

Early CPR
Begincardiopulmonaryresuscitation (CPR)immediately.Hands-onlyCPRinvolvesfast
andcontinualtwo-inchchestcompressions—

What is an AED? Anautomatedexternaldefibrillator(AED)istheonlywaytosaveasudden cardiacarrestvictim.AnAEDisaportable,user-friendlydevicethatautomat-
AED
icallydiagnosespotentiallylife-threateningheart rhythmsanddeliversanelectricshocktorestorenor-malrhythm.AnyonecanoperateanAED,regardlessof training.Simpleaudiodirectioninstructstherescuer whentopressabuttontodelivertheshock,while otherAEDsprovideanautomaticshockifafatalheart rhythmisdetected.Arescuercannotaccidentlyhurta
victimwithanAED—quickactioncanonlyhelp.AEDsaredesignedtoonly shockvictimswhoseheartsneedtoberestoredtoahealthyrhythm.Check withyourschoolforlocationsofon-campusAEDs.

about100perminute.

Early Defibrillation Immediatelyretrieveanduseanautomated externaldefibrillator(AED)assoonaspossible torestorethehearttoitsnormalrhythm.Mobile AEDunitshavestep-by-stepinstructionsforaby-
standertouseinanemergencysituation.

Early Advanced Care EmergencyMedicalServices(EMS) Respondersbeginadvancedlifesupport
includingadditionalresuscitativemeasuresand transfertoahospital.

Cardiac Chain of Survival Courtesy of Parent Heart Watch

KeepTheirHeartintheGame

RecognizetheWarningSigns&RiskFactors ofSuddenCardiacArrest(SCA)
Tell Your Coach and Consult Your Doctor if These Conditions are Present in Your Student-Athlete

PotentialIndicatorsThatSCAMayOccur

 Faintingorseizure,especiallyduringor rightafterexercise

 Faintingrepeatedlyorwithexcitementor startle

 Excessiveshortnessofbreathduringexercise

 Racingorflutteringheartpalpitationsor irregularheartbeat

 Repeateddizzinessorlightheadedness

 Chestpainordiscomfortwithexercise

 Excessive,unexpectedfatigueduringor afterexercise

FactorsThatIncreasetheRiskofSCA

 Familyhistoryofknownheartabnormalitiesor suddendeathbeforeage50

 SpecificfamilyhistoryofLongQTSyndrome, BrugadaSyndrome,HypertrophicCardiomyopathy,or ArrhythmogenicRightVentricularDysplasia(ARVD)

 Familymemberswithunexplainedfainting,seizures, drowningorneardrowningorcaraccidents

 Knownstructuralheartabnormality,repairedor unrepaired

 Useofdrugs,suchascocaine,inhalants, “recreational”drugs,excessiveenergydrinksor performance-enhancingsupplements

What is CIF doing to help protect student-athletes?

CIF amended its bylaws to include language that adds SCA training to coach certification and practice and game protocol that empowers coaches to removefromplayastudent-athletewhoexhibitsfainting—thenumberonewarningsignofapotentialheartcondition.Astudent-athletewhohasbeen removedfromplayafterdisplayingsignsorsymptomsassociatedwithSCAmaynotreturntoplayuntilheorsheisevaluatedandclearedbyalicensed healthcareprovider.Parents,guardiansandcaregiversareurgedtodialoguewithstudent-athletesabouttheirhearthealthandeveryoneassociated withhighschoolsportsshouldbefamiliarwiththecardiacchainofsurvivalsotheyarepreparedintheeventofacardiacemergency.

IhavereviewedandunderstandthesymptomsandwarningsignsofSCAandthenewCIFprotocoltoincorporateSCApreventionstrategiesintomystu-dent’ssportsprogram.

STUDENT-ATHLETESIGNATURE

PARENT/GUARDIANSIGNATURE

PRINTSTUDENT-ATHLETE’SNAME	DATE

PRINTPARENT/GUARDIAN’SNAME	DATE

For more information about Sudden Cardiac Arrest visit

California Interscholastic Federation http.www.cifstate.org

Eric Paredes Save A Life Foundation http:www.epsavealife.org

CardiacWise (20-minute training video) http.www.sportsafetyinternational.org

PURSUING VICTORY WITH HONOR CODE OF CONDUCT FOR INTERSCHOLASTIC
STUDENT-ATHLETES

Interscholastic athletic competition should demonstrate high standards of ethics and sportsmanship and promote the development of good character and other important life skills. The highest potential of sports is achieved when participants are committed to pursuing victory with honor according to six core principles: trustworthiness, respect, responsibility, fairness, caring, and good citizenship (the “Six Pillars of Character”). This code applies to all student-athletes involved in interscholastic sports in California.

TRUSTWORTHINESS
1.	Trustworthiness – be worthy of trust in all I do.
•	Integrity – live up to high ideals of ethics and sportsmanship and always pursue victory with honor; do what’s right even when it’s unpopular or personally costly.
•	 Honesty – live and compete honorably; don’t lie, cheat, steal or engage in any other dishonest or unsportsmanlike conduct.
•	Reliability – fulfill commitments; do what I say I will do; be o time to practices and games. •	Loyalty – be loyal to my school and team; put the team above personal glory.

RESPECT
2.	Respect – treat all people with respect all the time and require the same of other student-athletes.
3.	Class – live and play with class; be a good sport; be gracious in victory and accept defeat with dignity; give fallen opponents help, compliment extraordinary performance, show sincere respect in pre- and post-game rituals.
4.	 Disrespectful Conduct – don’t engage in disrespectful conduct of any sort including profanity, obscene gestures, offensive remarks of a sexual or racial nature, trash-talking, taunting, boastful celebrations, or other actions that demean individuals or the sport.
5.	 Respect Officials – treat contest officials with respect; don’t complain about or argue with official calls or decisions during or after an athletic event.

RESPONSIBILITY
6.	Importance of Education – be a student first and commit to getting the best education I can. Be honest with myself about the likelihood of getting an athletic scholarship or playing on a professional level and remember that many universities will not recruit student-athletes that do not have a serious commitment to their education, the ability to succeed academically or the character to represent their institution honorably.
7.	 Role-Modeling – Remember, participation in sports is a privilege, not a right and that I am expected to represent my school, coach and teammates with honor, on and off the field. Consistently exhibit good character and conduct yourself as a positive role model. Suspension or termination of the participation privilege is within the sole discretion of the school administration.
8.	 Self-Control – exercise self-control; don’t fight or show excessive displays of anger or frustration; have the strength to overcome the temptation to retaliate.
9.	Healthy Lifestyle – safeguard your health; don’t use any illegal or unhealthy substances including alcohol, tobacco and drugs or engage in any unhealthy techniques to gain, lose or maintain weight.
10.	Integrity of the Game – protect the integrity of the game; don’t gamble. Play the game according to the rules.

FAIRNESS
11.	Be Fair – live up to high standards of fair play; be open-minded; always be willing to listen and learn.

CARING
12.	Concern for Others – demonstrate concern for others; never intentionally injure any player or engage in reckless behavior that might cause injury to myself or others.
13.	 Teammates – help promote the well-being of teammates by positive counseling and encouragement or by reporting any unhealthy or dangerous conduct to coaches.

CITZENSHIP
14.	Play by the Rules – maintain a thorough knowledge of and abide by all applicable game and competition rules.
15.	Spirit of rules – honor the spirit and the letter of rules; avoid temptations to gain competitive advantage through improper gamesmanship techniques that violate the highest traditions of sportsmanship.

An athlete may be disciplined or removed from a team for violation of any of the provisions of the Pursuing Victory with Honor Code of Conduct.