Elkins High School Athletic Department

Athletic EligibilityThis form is used to report eligibility data to the WVSSAC.Please make sure it is accurate and easy to read the data.

SPOilT:(Circle}

FotlthaliMen's C:O:iJ Ccur.tfYWrestlingWDmen'$ Tnrd:t

Men'sw-e.erWomen's Cross CountrySwImmingMen's Ter.nis

Wcmen's S()<"~t

Volleyball5.se~1IVJo1TJ~r/'S Ieants

Cheerleadir.gWomen'.s Ba5l1!tn __ll

SaftbaR

GoffMen's 6!slcet.!xi1lMen'.!1'riti.

Student Athlete's full Name, ---= Student ID# _

Student Athlete's Father's First Name _

Student Athlete's Mother's First Name _

Current Grade 9 10 11 12 (Please circle one)

Number of Semesters Enrolied at EHS -------[New students and Freshman" 1, Sophomores: 3, Juniors: 5, Seniors = 7]

"'There are 2 semesters per year"Includes upcoming semester

Date of Birth -------Month Day Year

Place of Birth

Do You live in the £HSSchool District? YES NO (Please circle onej

Name of School You Attended Last Semester _

EHSBoosters InformationPlease list below the names and phone numbers of adults from this family who could work the concession stand.

Narne Pnone _

Narne Phone _

TODD PRICE--ATHLETIC DIRECTOR 304-636-9173

Elkins High School Athletic Department

_____ E_m_e_rg_e_n_c_y_C_a_r_e_In_fo_rm_a_ti_o_n ~Although it rarely occurs, an emergency can arise, whereby immediate action is required to preserve the health and welfare of astudent-athlete. The agreement set fort~ below is designed to protect both student and Coach, if an emergency arises whichrequires the immediate action that a parent would take, if they were present. Since minors, as a general rule, may not beadministered an anesthetic or have surgery performed on them without written consent of a parent or guardian, we are requestingthat parents or guardians sign the following statement. Your signature will prevent a dangerous delay in case an emergency arisesand all efforts to contact parent or guardian may have failed.

In the event of illness or injury to _--'-- --Student-Athlete's Name

a Coach, Trainer, Athletic Director or Principal is hereby Authorized to obtain the services of a licensedpractitioner and, where required, to give consent for each treatment as may be necessary to the extent andwith the same effect as though we had given it.

Date Parent or Guardian's Signature Student-Athlete's Birt.hday

Address _

City, State ZIP _

EMERGENCY PHONE NUMBERS

Hon1ePhone _ VVorkPhone . _

Beeper _ Cell Phone _

Family Doctor Name and Phone _

HEALTH INFORMATION

Any allergies or preexisting medical conditions: _

Policy Identification Number _

Student's Full Name _

Student's Social Security Number _

TODD PRICE--ATHLETIC DIRECTOR 304-636-9173

WESTVJRGINIA SECONDARY SCHOOL ACTIVITIES COMMISSION2875 Staunton Turnpike - Parkersburg, WV 26104

ATHLETIC PARTICIPATlONJPARENTAL CONSENTIPHYSICIAN'S CERTIFICATE FORM(Form required each school year on or after June 1<1. File in School Administration Office)

ATHLETIC PARTICIPATION J PARENTAL CONSENTPART!

Name ----;r-::;;;------"";:;;;-----------"rn---- School Year: Grade Entering: _(Last) (F:m) (Mj

Home Address: Home Address of Parents; _

City:

Phone:

____________________________________ C~ ___________ Date of Birth: -'--_ Place of Birth:

Last semester J attended (High School) Dr (Middle School). We have r~ad the condensed eligibility rulesof the WVSSAC athletics. If accepted as a team member, We agree to make every effort to keep up school woiX and abide by the rulesand regulations of the school authorities and the WVSSAC.

fNDMDUAL ELIGIBILITY RULESAttention Athlete! To be eligible to represent your school in any interscholastic contest, you ...___ must be a regular bona fide student in good standing of the school. (See exception under Rule 127-2-3)___ must qualify under the Residence and Transfer Rule (127-2-7)___ must have eamed at leas! 2 units of credit the previous semester. Summer School may be included, (127-2-6)___ must have attained an overall "C' (2.00) average the previous semester. Summer School may be included. (127-2-6)___ must not have reached your 15th (MS). 16th (9th) or 19th (HS) birthday before August 1 of the current school year. (127-2-4)__ must be residing with parent(s) as specified by Rule 127-2-7 and 8.

___ unless parents have made a bona fide change of residence during schocl term.___ unless an AFS or other Foreign-Exchange student (one year of eligibility only).___ unless the residence requirement was met by the 365 calendar days attendance prior to participation.

___ if living with legal guardian/custodian, may not participate at the varsity level. (127-2-8)___ must be an amateur as deflned by Rule 127-2-11.___ must have submitted to your principal before becoming a member of any school athletic team Participation/Parent ConsentJPhysician Form,

completely filled in and properly signed, attesting that you have been examined and found to be physically fit for athletic competition and thatyour parents consent to your participation. (127-3-3)

___ must not have transferred from one school to another for athletic purposes. (127-2-7)___ must not have received, in recognition of your ability as a HS or MS athlete, any award not presented or approved by your school or the

INVSSAC. (127·3-5)___ must not, while a member of a school team in any sport, become a member of any other organized team or as an individual participant in an

unsanctioned meet or toumament in the same sport during the school sport season (See exception 127-2-10). -__ must follow All Star Participation Rute. (127-3-4)___ must not have been enrolled In more than (8) semesters in grades 9 to 12. Must not have participated in more than two (2) seasons in the same

sport In grades 7 and 8 or more than three (3) seasons while in grades 6·7-8. (Rule 127·2-5).___ must not have been retained without failing in grades 6, 7 or 6. (127-2·5)

Eligibility to participate in interscholastic athletics is a privilege you eam by meeting not only the above listed minimum standards butalso aU other standards set by your school and the WVSSAC. If you have any questions regarding your eligibility or are in doubt about the effectany activfty or action might have on your eligibility, check with your principal or athletic director. They are aware of the interpretation and intent of eachrule. Meeting the intent and spirit of INVSSAC standards will prevent athletes, teams, and schools from being penalized.

PART 1/- PARENTAL CONSENT

In accordancewith the rulesof the III'VSSAC. I give my consentand approvalto the participationof the studentnamed above for the sport NOT MARKED OUT BELOW:

BASEB.l\l.lBASKETBALLCHEERLEADING

MEDICAL. DISQUAUFlCATION OF THE STUDENT-ATHLETE IWlTHHOLDlNG A STUDENT-ATHLETE FROM ACTIVITYThe member school's team physician has the final responsibility to determine when a student-athlete is removed or withheld from participation due to aninjury, an illness or pregnancy. In addition. clearance for that individual to return to activity is solely the responsibility of the member school's teamphysician or that physician's designated representative.

I understand that participation may include, when necessary, early dismissal from classes and travel to participate In Interscholastic athleticcontests. I will not hold the school authorities or West Virginia Secondary School Activi1ies Commission responsible in case of accident or injury as aresult of this participation. I also understand that participation in any of those sports listed above may cause permanent disability or death. Please checkappropriate space: He!She has student accident insurance available through the school ( ); has football insurance coverage available through theschool ( ); is insured to our satisfaction ( ).

I also give my consent and approval for the above named student to receive a physical examination, as required in Part IV, Physician's Certificate,of this form, by an approved health care provider as recommended by the named student's school administration.

I consent to WVSSAC's use of L'le herein named student's name, likeness, and athletically related information in reports of Inter-School Practices orScrimmages and Contests, promotional literature of the Association, and other materials and releases related to interscholastic athletics.

I have read/reviewed the concussion irrformatjon as available through the school and at WVSSAC.org. (Click Sports Medicinel

CROSS COUNTRYFOOTBALL

GOLFSOCCER

sOrlBALLSWIMMING

tENNISTRACK

VOLLEYBAll.WRESTLING

08t6: _ Student Signature

Parent Signature

PART 111-STUDENT'S MEDICAL HISTORY(To be completed by parent or guardian prior to examination)

Name ---Birthdate " ' _ Grade Age __

18. Haveyou everbeentold not to participate in any sport?19. Do you know of any reasonthis student should n~t partici-

pate in sports?20. Have a suddendeathhistoryin your family?21, Have a family historyof heart attack before age 50?22. Developcoughing,wheezing,or unusualshortness of breath

when you exercise?Yes No 23. (FemalesOnly)Doyou have any problems with your men-

strual periods.

I also give my consent for the physician in attendance and the appropriate medical staff to give treatment at any athletic event for anyinjury.

YesYesYesYesYesYesYesYesYesYes

Has the studenteverhad:Yes No 1. Chronicor recurrentillness? (Diabetes,Asthma, Seizures,

etc.,)2. Any hospitalizations?3. Any surgery(excepttonsils)?4. Any injuriesthatprohibitedyour participationin sports?5. Dizzinessor frequentheadaches?6. Knee,ankle or neckInjuries?7. Brokenbone or dislocation?8. Heatexhaustion/sunstroke?9. Faintingor passingout?

10. Haveany allergies?11. Concussion? If Yes _

NoNoNoNoNoNoNoNoNoNo

Does the student:.Yes No 12. Have any problemswith heart/bloodpressure?Yes No 13. Has anyonein your family ever fainted during exercise?Yes No 14. Takeany medicine? List _Yes No 15. Wearglasses_,contactlenses_, dental appliances_?Yes No 16. Have any organsmissing (eye, kidney,testicle, etc.)?Yes No 17. Has it been longer than 10 years since your last tetanusshot?Yes NoYes No

CaleCs)

Yes NoYes NoYes No

PLEASE EXPLAIN ANY ''YES'' ANSWERS OR ANY OTHERADOmONAL CONCERNS.

SIGNATURE OF PARENT OR GUARDIAN _ DATE __ --". t , _

PART IV - VITAL SIGNS

Height _ Weight _ Pulse _ Blood Pressure _

Visual acuity: Uncorrected _-;- '__ --::__L R

Corrected __ --;-,--_.! __ -;;-__1: R

Pupils equal diameter: Y N

PART V - SCREENING PHYSICAL EXAMThis exam is not meant to replace a full physical examination done by your private physician.

Mouth: Respiratory: Abdomen:Appliances Y N Symmetrical breath sounds Y N Masses Y NMi'ssing/loose teeth Y N Wheezes Y N Organomegaly Y NCaries needing treatment Y N Cardiovascular: Genitourinary (males only);

Enlarged lymph nodes Y N Murmur Y N Inguinal hernia Y NSkin - infectious lesions Y N Irregularities Y N Bilaterally descended testicles Y NPeripheral pulses equal Y N Murmur with Valsalva Y N

Musculoskeletal: (note any abnormalities)Neck: Y N Elbow: Y N Knee/Hip: y N Hamstrings: Y NShoulder: Y N Wrist: Y N Ankle: Y N Scoliosis: Y N

RECOMMENDATIONS BASED ON ABOVE EVALUATION:

After my evaluation, I give my:

___ Full Approval;

___ Full approval; but needs further evaluation by Family Dentist __ ; Eye Doctor __ ; Family Physician __ ; Other __ ;

___ Limited approval with the following restrictions:

___ Denial of approval for the following reasons:

MDfDO/DC/Advanced Registered Nurse Practitioner/Physicians Assistant Date

5530.01f1 - STUDENT DRUG TESTING FORMS

STUDENT FORM

Section to be Filled Out by Activity Student. Driving Studer:!Lor Opt-in Participant

MUST BE COMPLETED AND RETURNED TO SCHOOl BY September 1 OR THE 1ST DAY OF THE SECOND SEMESTER.

Please Print or Tvpe:

Student's Last Name First Nome Mi

I, the above named student, after having read the Student Drug Testing Policy and "Student Drug Testing ConsentForm" understand that, out of care for my safety and health, Randolph County Schools enforces the rules applyingto the consumption or possession of illegal and performance-enhancing drugs .. lI.s a member of a Randolph CountySchools interscholastic extra-curricular activity or one who drives and parks on school property, or an Opt-inparticipant, I realize that the personal decision that! make daily in regard to the consumption or possession ofillegal or performance-enhancing drugs may affect my health and well-being as well as the possible endangermentof those around me and reflect upon any organization with which i am associated. If I choose to violate schoolpolicy regarding the use or possession of il/egai or performance-enhancing drugs any time while I am involved inin-season or off-season activities or driving, I understand upon determination of that violation I will be subject tothe restrictions as outlined in the Policy.

OR

i

I,i!

!i:,II

Check all that apply: . u Activity Studentu Driving Student

! ! Opt-in Participant

Signature of Student Date

12

PARENT FORM

Section to be Filled Out by Parent/Guardian and Principal/Coach/Sponsor

We have read and understand the Randolph County Schools Student Drug Testing Policy and "Student DrugTesting Consent Form." We voluntarily agree on behalf of the student named above that, in order to participatein interscholastic extra-curricular activities; and/or to be granted permission to drive to and park on property ofRandolph County Schools; and/or by electing to have him/her included in the testing pool as an Opt-inParticipant, the student must submit to drug testing and must also agree to be subject to the terms of Rando/phCounty Schools' drug testing policy. We accept the method of obtaining hair samples, testing and analysis of suchspecimens, and all other aspects of the program. WE further agree and consent to the disclosure of the sampling,testing, and results as provided in this program.

Signature of Parent/Custodia! Guardian Date

Signature of Principal/Coach/Sponsor Date

13

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RANDOLPH COUNTY SCHOOLSAthletic Transportation Waiver Consent Form

Randolph County Schools makes every attempt to ensure that all athletic participants areafforded transportation via Randolph County Schoo' bus to and from away athletic events.

If a parent or legal guardian will be transporting another student/athlete (excluding their ownchild), this student/athlete's parent/legal guardian must complete this RANDOLPHCOUNTYSCHOOLSTransportation Waiver Consent Form. The form must be completed and given to theHead Coach before the bus departs to the event.

As the parent or legal guardian, Igive permission for my designee to provide transportationfor the athletic event listed below. Ihave carefully read this agreement and understand itscontents. Iam aware that this is an assumption of risk, waiver and a release of liability and Isignit voluntarily. A new form must be completed for each event.

Consent Form

Iam aware of the transportation procedures and Igive my permission for my child

(Child's Name)

To Be Transported By: _

(Name of Adult Responsible for Transporting the Student)

Athletic Event: _(Name the Event/Game and location)On: _

(Date)

Signature of Parent/legal Guardian: _

Signature of Designee: _

Date:, 20__

Stude nt!Ath lete: Date: 20__

Head Coach/Athletic Director: Date: ,20__

l .~rr.

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WHAT IS A CO~jCUSSION?A concussion is a brain injury. Concussion, are causedby a bump or blow to the head. Everi a ·"ding," "Qettingyour bei! rung," or what SEems to be a mild blimp orb!o"Y to the head can he serious.

You can't see a CO'iClissioil. Signs and symptoms afconcussion can show up rig!1!. after tile injury Qt. may

not appear or be noticed until days G~'weeks after tneinjury. r f your child reports an.y syrnprorns of concussion,or if you notice the symptoms yo Irseif, seeK medit:3!attention right away.

Wi-lAl ARE IHE SIGNS ANDSYMPTOMS OF A CONCUSSWN?

i11 Signs Observed bl' Parents Of Guardians

If your child has experienced a bump or blow to tnehead during (J game or practice, look for any ')j the

jo{iowing signs and symptoms of a concession:Apcears dazed or stunnedis c0!1flJsed about assignment Of postionForgets an instruct!Oi1Is unsure of gi.!:lie, score, or opponentlVioyes clumsilyAnswers questions ~IowiyLoses consciousness (even b!"'lEfiy)

Show; bchavtcr or personauty cr.sngc'sCan't recaH events prior to hit Of fallCan't recall events after hit O~ fedl

Symptoms Reported by AthleteHeadache Of "pressure" in headNausea or vCi1Iithq

Balanre problems or dizzines:,Double or blurry visionSensitivity to fightS':'115itivity to nois~reeling sluggisil, hazy, foggy, or groggyConcentration or memory problemsConfusionDues not '''fet?i right;:

-¥_.$.':~~~~-,~~~;~~T ...or HEALTH AND HUMAN SERVICES

C~NtEJ:l~-FqR OISEI-Se: CONTROL AND PRE"lIENTION

A Fact Sheet for 1?AR!ENr~

HOW CAN veu m::lP YOUR CHILOrRE~Nr f!. COf\lCUSSj(H~?

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.. ~Df ·r.l~f~~!nfaritl?t!h'~j and (13 o.n:k;:.CidJiH~niilIJJa{C:ii3L"·fr~¥-lii-c.fi~gel .I!isi~.!f~~.w.~dc.gGii;tom;il5s1iJr.my~th5po~s__:__._

Every sport is differef't, but t'1ere are steps yeur childrencan take to protect ~he"1selve5 Irorn concussion.

Ensure that they fo.low their coach's rules forsafety and the rules of the soort,Encourage lhern to practice goed sportsmanship

at all times.Make sure tiley wear the right crotecuve equipmEntfor their activity (such as helmets, pi:.JcEng, silinguards, and eye .3:;d rr.O:.lih quards). Protective

equipment should fit pmperiy, be well mainiaineo,?.nd be worn CG'1s:stentiy a"'-d : !)"TC::::tly.

Learn the signs ilnd symntcms Ili a concussion.

Wl-ilri Sf-lOUUi \'GU DO If YOU nHflJi{YOUR GraUl MAS [.~CONGUS5IO~j?

1. Seef( medical attention tight away. A ileaithcare professional v.'~libe cb~Eto de·:ide h0V,i seriousthe concession is and \;';iI~n ii is 'Safe for your- ::hiiuto rEli.W1 to SP(W~s.

2. I{eep your child out of play. Concussior.s taxetime to heal. Dcn't :ct YO,lf ch::d retun: to playunti! a health ca·'-c prctess.ona' sevs it's OJ(

Ch;ldren who return to piay too soon -wh.le thebrain is still hea!ing--risk a QreJt~r chance ofhaving a second COnCU5$i0n. Second OY later

concussions can be Very' SerkHJ5.They :':lfl c~us::permanent brain dafTJagEI afft.:tir:g yo:..r :hi~dfor<: 'lifetime.

I3. Tell your child's coach about any recent

cencusslon. Coaches should know if yo<;r cldehac! a recent concussic« in I~,Wi sport. Yourchild's coach may not know about a concussionYGW' child received j" and: 1('" sport or acli'Ji lyt.!:1I€s~you t~ii the coach.

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