MARIETTA CITY SCHOOLS’ ATHLETIC PHYSICAL, INSURANCE, AND CONSENT FORM

Address

(School must be notified if student moves from the above address.)

In case of emergency contact

PARENTAL CONSENT FOR ATHLETIC PARTICIPATION

Warning: Although participation in supervised interscholastic athletics and activities may be one of the least hazardous in which students will engage in or out of school, BY ITS NATURE, PARTICIPATION IN INTERSCHOLASTIC ATHLETICS INCLUDES A RISK OR INJURY WHICH MAY RANGE IN SEVERITY FROM MINOR TO LONG TERM CATASTROPHIC, INCLUDING PERMANENT PARALYSIS FROM THE NECK DOWN OR DEATH. Although serious injuries are not common in supervised school athletic programs, it is possible only to minimize, not eliminate the risk

Participants can and have the responsibility to help reduce the chance of injury. PLAYERS MUST OBEY ALL SAFETY RULES, REPORT ALL PHYSICAL PROBLEMS TO THEIR COACHES, FOLLOW A PROPER CONDITIONING PROGRAM, AND INSPECT THEIR EQUIPMENT DAILY.

By signing this permission form, you acknowledge that you have read and understand this warning. PARENTS OR STUDENTS WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS PERMISSION FORM.

to:

1. Compete in athletics at Marietta High School/Marietta Middle School in Georgia High School Association approved sports;
2. Accompany any school team of which the student is a member on any of its local or out-of-town trips;
3. Have his/her injuries evaluated and receive appropriate treatment/OTC medication from the MCS Athletic Trainers;
4. and, I hereby verify that the information on this form is correct and understand that any false information may result in my son/daughter being declared ineligible.
5. Students found illegally enrolled out of their school attendance zone could be ruled ineligible for GHSA competition for one (1) full year

This acknowledgment of risk and consent to allow participation shall remain in effect until revoked in writing.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

INSURANCE AND AUTHORIZATION INFORMATION

Insurance

All MCS athletes are responsible for having medical insurance coverage prior to participation in any athletic activity. Please complete the information below. If you do not have insurance, please check line 2 and pick up a school insurance packet in the Sports Medicine Office or the Athletic Office at the high school.

Authorization

may compete in high school athletics in Marietta City Schools. I also understand that this medical evaluation is only to determine fitness for athletics and is not to take the place of regular medical examinations. In case of an emergency or accident on the school grounds or during any school activity involving my child which in the opinion of school authorities present requires immediate medical or surgical attention, I hereby grant permission to said school authorities to obtain the services of a physician or to transport said child to hospital if it is deemed necessary by school authorities. I hereby grant permission, also, to said physicians to treat said condition unless I am present and request otherwise or until I later request otherwise.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

** ATHLETES WITH SPECIAL NEEDS WILL NEED TO COMPLETE A SUPPLEMENTAL HISTORY FORM THAT IS AVAILABLE WITH THE PHYSICAL FORM ON-LINE OR IN THE TRAINING ROOM OR ATHLETIC OFFICE.

COMPETITIVE INTERSCHOLASTIC ACTIVITY CODE

The Marietta Board of Education believes that a properly controlled, well-organized competitive interscholastic activities program allows a student the opportunity to develop to his or her fullest physical, mental, and emotional potential. Students involved in competitive interscholastic activities enjoy high visibility and serve as role models for their peers and younger students. Therefore, the Marietta Board of Education requires students to abide by the Competitive Interscholastic Activity Code (Board Policy IDF-R), as well as the Marietta City Schools Discipline Handbook (Board Policy JCDA).

TRAINING RULES AND RULES OF CONDUCT

I. General Rules

1. Attendance

a. A student involved in competitive interscholastic activities must be in school at least one-half of the school day (2 blocks or 11:00 a.m.) in order to participate in any game, performance, practice, tryout, or conditioning. Documentation must be provided to school officials.

b. If a student is illegally absent, truant, suspended, or placed in an alternative education environment for any part of a school day, he/she may not participate in any competitive interscholastic activity that day, including games, performances, practices, tryouts or conditioning.

c. Students should report to school on time each day. Students should be in school the day following a competitive interscholastic event. If a pattern of unexcused absences or tardiness develops, it would indicate that the individual is unable to cope with the demands of being involved in competitive interscholastic activities. Appropriate disciplinary measures will be taken.

2. Travel

Marietta City Schools will provide transportation to and from most competitive interscholastic events. Students are expected to ride school transportation when provided.

II. Infractions

Regardless of whether infractions occur on or off campus, during or after the school day, during or after the school year, the following infractions may result in suspension or dismissal from a competitive interscholastic activity. Each case will be evaluated on an individual basis.

a. Use, possession, distribution, or being under the influence of alcohol, tobacco products, illegal drugs or related paraphernalia, and the abuse of prescription or non-prescription drugs.

b. Theft or being in possession of stolen property.

c. Vandalism of school property.

d. Acting in an un-sportsmanlike manner.

e. Any act which results in student suspension.

f. Unexcused absence from any practice, performance, or game.

g. Violating curfew.

h. Any offensive act, which, in the opinion of coaches/sponsors, and/or administration, reflects in a negative manner on the competitive interscholastic activities program at Marietta High School, Marietta Middle School, or Marietta City Schools in its entirety.

III. Duration

This policy is in effect year round

IV. Enforcement

Violations of the Competitive Interscholastic Code, verified through a reliable source (law enforcement agency, school system staff member, school system administrator, teacher, entry into a drug treatment program, parent of an involved student, etc.), shall be investigated by the Competitive Interscholastic Activity Council. The Council shall be comprised of a school administrator from the school the student attends, the school system’s Athletic Director, a coach/sponsor of the student, one additional coach/sponsor selected by the Athletic Director and one teacher from the student’s school council. The council will determine the guilt or innocence of the student and determine the appropriate discipline of guilty students, but under no circumstances shall assign discipline outside the guidelines established in Infraction Consequences. Any Council discipline decision rendered outside the guidelines established for Infraction Consequences shall be voided by the Superintendent of Schools, and the appropriate discipline shall be assigned by the Superintendent within the guidelines provided therein.

V. Infraction Consequences

First Offense: Based on the decision of the Competitive Interscholastic Activity Council, the range of penalties shall be suspension for part or all of the current season and/or part or all of the next season in which the student participates to permanent suspension from participation in competitive interscholastic activities. The student shall complete the season in which the suspension is in effect. The school reserves the right to permanently dismiss a student from all competitive interscholastic activity programs for the remainder of their school career at Marietta High School and/or Marietta Middle School upon arrest, conviction or plea, including nolo contender for any misdemeanor or felony crime.

Second Offense: Suspension from all competitive interscholastic activity programs for a period of not less than one year from the date of the second violation to permanent dismissal from all competitive interscholastic activity programs for the remainder of their school career at Marietta High School and/or Marietta Middle School.

Third Offense: Permanent suspension from all competitive interscholastic activity programs for the remainder of their school career at Marietta High School and/or Marietta Middle School.

I have read and understand the Competitive Interscholastic Activity Code for Marietta City Schools.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

RELEASE OF TRANSCRIPTS: During the course of the year, colleges interested in recruiting athletes may request official or unofficial copies of student transcripts to facilitate the recruiting process. I give permission for Marietta High School to release copies of my son’s/daughter’s transcript to any college recruiter requesting one.

Georgia High School Association Student/Parent Concussion Awareness Form

DANGERS OF CONCUSSION

Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue. Adolescent athletes are particularly vulnerable to the effects of concussion. Once considered little more than a minor “ding” to the head, it is now understood that a concussion has the potential to result in death, or changes in brain function (either short-term or long-term). A concussion is a brain injury that results in a temporary disruption of normal brain function. A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a result of a blow to the head or body. Continued participation in any sport following a concussion can lead to worsening concussion symptoms, as well as increased risk for further injury to the brain, and even death.

Player and parental education in this area is crucial – that is the reason for this document. Refer to it regularly. This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics. One copy needs to be returned to the school, and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION

• Headache, dizziness, poor balance, moves clumsily, reduced energy level/tiredness
• Nausea or vomiting
• Blurred vision, sensitivity to light and sounds
• Fogginess of memory, difficulty concentrating, slowed thought processes, confused about surroundings or game assignments
• Unexplained changes in behavior and personality
• Loss of consciousness(NOTE: This does not occur in all concussion episodes.)

BY-LAW 2.68: GHSA CONCUSSION POLICY: In accordance with Georgia law and national playing rules published by the National Federation of State High School Associations, any athlete who exhibits signs, symptoms, or behaviors consistent with a concussion shall be immediately removed from the practice or contest and shall not return to play until an appropriate health care professional has determined that no concussion has occurred. (NOTE: An appropriate health care professional may include licensed physician (MD/DO) or another licensed individual under the supervision of a licensed physician, such as a nurse practitioner, physician assistant, or certified athletic trainer who has received training in concussion evaluation and management.

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed, OR (b) cannot be ruled out.

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professional prior to resuming participation in any future practice or contest. The formulation of a gradual return to play protocol shall be a part of the medical clearance.

By signing this concussion form, I give Marietta City Schools System permission to transfer this concussion form to the other sports that my child may play. I am aware of the dangers of concussion and this signed concussion form will represent myself and my child during the 2019-2020 school year. This form will be stored with the athletic physical form and other accompanying forms required by the Marietta City Schools System.

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

GHSA BY-LAW 2.67 – “Practice Policy for Heat and Humidity”

Schools must follow the statewide policy for conducting practices and voluntary conditioning workouts in all sports during times of extremely high heat and/or humidity that will be signed by each head coach at the beginning of each season and distributed to all players and their parents or guardians. The policy shall follow modified guidelines of the American College of Sports Medicine in regard to:

1. The scheduling of practices at various heat/humidity levels
2. The ratio of workout time to time allotted for rest and hydration at various heat/humidity levels
3. The heat/humidity level that will result in practice being terminated

A scientifically approved instrument that measures Wet Bulb Globe Temperature (WBGT) reading must be utilized at each practice to ensure that the written policy is being followed properly.

ACTIVITY GUIDELINES & REST BREAK GUIDELINES

Normal activities --Provide at least three separate rest breaks each hour of minimum duration of 3 minutes each during workout

Use discretion for intense or prolonged exercise; watch at-risk players carefully; Provide at least three separate rest breaks each hour of a minimum of four minutes duration each.

Maximum practice time is two hours. For Football: players restricted to helmet, and either pants/shorts or no shoulder pads during practice. All protective equipment must be removed for conditioning activities. For all sports: Provide at least four separate rest breaks each hour of a minimum of four minutes each

Maximum length of practice is one hour, no protective equipment may be worn during practice and there may be no conditioning activities. There must be 20 minutes of rest breaks provided during the hour of practice.

No outdoor workouts; Cancel exercise; delay practices until a cooler WBGT reading occurs

GUIDELINES FOR HYDRATION AND REST BREAKS

1. Rest time should involve both unlimited hydration intake (water or electrolyte drinks) and rest without any activity involved
2. For football, helmets should be removed during rest time
3. The site of the rest time should be a “cooling zone” and not in direct sunlight.
4. When the WBGT reading is over 86:

a. ice towels and spray bottles filled with ice water should be available at the “cooling zone” to aid the cooling process.

b. Cold immersion tubs must be available for practices for the benefit of any player showing early signs of heat illness.

DEFINITIONS

1. PRACTICE: the period of time that a participant engages in a coach-supervised, school-approved sport or conditioning-related activity. Practices are timed from the time the players report to the field until they leave.
2. WALK THROUGH: this period of time shall last no more than one hour, is not considered to be a part of the practice time regulation, and may not involve conditioning or weight-room activities. Players may not wear protective equipment.

PENALTIES: Schools violating the heat policy shall be fined a minimum of $500.00 and a maximum of $1,000.00.

HISTORY FORM

(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Explain “Yes” answers below.

GENERAL QUESTIONS

HEART HEALTH QUESTIONS ABOUT YOU

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

BONE AND JOINT QUESTIONS

MEDICAL QUESTIONS

FEMALES ONLY

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PHYSICAL EXAMINATION FORM

PHYSICIAN REMINDERS

1. Consider additional questions on more sensitive issues

• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
• Have you ever taken anabolic steroids or used any other performance supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION

ABNORMAL FINDINGS

MUSCULOSKELETAL

(a) Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam

(b) Consider GU exam if in private setting. Having third party present is recommended.

(c) Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.