tustin unified school district athletic/activities

TUSTIN UNIFIED SCHOOL DISTRICT ATHLETIC/ACTIVITIES CLEARANCE FORM

(Print or Type)

Last Name: ______________________________ First Name: ______________________________ MI. _______

Birth date: ________________________ Sports/Activities:________________/________________/_________________ SEASON Fall Winter Spring

Address: ______________________________________ City: ________________________ Zip: ____________

Students Home Phone: ___________________________ Students Year in School: Grade________/Age________

_________________________________________________________________________________________________ Father’s First Name Last Name Cell/Work Phone Email

__________________________________________________________________________________________________ Mother’s First Name Last Name Cell/Work Phone Email

INSURANCE

MY MEDICAL COVERAGE POLICY FOR AT LEAST $1500 IS ISSUED BY: ____________________________________

Insurance Company Policy Number #

I have purchased Myers-Stevens Insurance: _____ Yes _____ No (Dental provided extra cost)

Football Only: _____ Yes _____ No I further assure that the insurance policy or policies I hereby verify will remain current and in force during the time the above named

student participates in or practices for inter-school athletic events or while being transport and to and from such athletic events. I agree to indemnify

and hold the Tustin Unified School District harmless against responsibility for insurance.

TRANSPORTATION PERMISSION

It is my understanding that transportation will be provided in one of the following ways:

AUTHORIZATION TYPE OF TRANSPORTATION INSURANCE COVERAGE ____ YES A. School Bus School District - primary

____ YES ____ NO B. Private Car (employee driven) Owner - primary; School District - Secondary

____ YES ____ NO C. Private Car (parent driven w/ approved paperwork) Owner - primary; School District - Secondary

________ Initial on this line indicates that you will allow your son/daughter/ward to drive his/her car to the athletic event(s),

WITHOUT ANY OTHER PASSENGERS when authorized by the School or Coach. (High School Only)

ASSUMPTION OF RISK

The undersigned hereby acknowledges that he/she knowingly and voluntarily assumes all risks of bodily injury to his/her child, as stated,

and expressly acknowledges their intention, by executing this instrument, to exempt and relieve the Tustin Unified School District (District), its

officers, agents, and employees, from any liability for personal injury, bodily injury, property damage or wrongful death that may arise out of or in

any way be connected with the above-described activity. I have read the foregoing and have voluntarily signed this agreement. I am aware of the

potential risks involved in this activity and I am fully aware of the legal consequences of signing this instrument. I further acknowledge that the

District does not provide liability insurance for this program, nor does the District provide medical coverage for participants in this activity.

AUTHORIZATION TO TREAT A MINOR

I (WE) the undersigned parent(s)/legal guardian of __________________________________________ , a minor, do hereby authorize and

consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the

medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or a Dentist licensed under the provisions of the

Dental Practice Act and on the staff of any emergency general hospital holding a current license to operate a hospital form the State of California

Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being

required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may

deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the

above treatment will not be withheld if the undersigned cannot be reached. Medical, health, and other information may be shared with school

officials in accordance with district policies and procedures.

__________________________/_______________ __________________________/_______________ Student’s Signature Date Parent/Guardian Signature Date

Stu #________

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STUDENT AND PARENT MUST SIGN ELEVEN

(11) TIMES.

Athletic physical education classes, workout and/or practice, or games may vary in days and/or times. Athletes are granted the privilege of an off-campus

permit since Class, Workouts, or Games may be scheduled outside the regular school day. The conditions of the off-campus athletic permit are as follows:

1. Neither the District nor its officers or employees are liable for the off-campus conduct or safety of the students during this time.

2. I.D. Card must be carried at all times and shown on request to authorities.

3. Students must depart campus at the beginning of their last period, or wait in the athletic area for their ride.

4. Students are not to go on any other school ground or campus unless approval has been granted.

5. This is a privilege and may be terminated if conditions are not met.

I have read and agree to the conditions of the Off-Campus Athletic Permit.

_________________________/__________ _________________________/__________

Student’s Signature Date Parent/Guardian Signature Date

We have read and fully understand the information outlined in the Regulation 5131.6 Tustin Unified School District Code of Conduct for Co-Curricular and

Extra-Curricular Participation and agree to comply with all policies and responsibilities.

_________________________/__________ _________________________/__________


We have read the CIF Athlete Code of Ethics and agree to comply with all policies and responsibilities.

_________________________/__________ _________________________/__________


We understand and accept the “Assumption of Risk” outlined on the Athletic Clearance Form. I understand hydration is essential to the safety of my child.

Research conducted on one high school football team showed that as many as 70 percent of the team arrived at practice already significantly dehydrated. Your

child should hydrate properly while getting used to the heat, so remind him to consume fluids before, during and after exercise to ensure that he is not losing

weight during activity.

_________________________/__________ _________________________/__________


We are aware and acknowledge that the District does not provide liability insurance for those that participate in athletics, nor does the District provide

medical coverage for the participants in athletics.

_________________________/__________ _________________________/__________


As required by California Education Code Section 35330, I hereby waive all claims of liability against the Tustin Unified School District, the County of

Orange and the State of California for injury, accident, illness, and emotional duress or death which may occur during or by reason of participation in

athletics.

_________________________/__________ _________________________/__________


The participating student/athlete and the Parent/Guardian hereby agree that the student shall not use androgenic/anabolic steroids without the written

prescription of a fully licensed physician (as recognized by the AMA) to treat a medical condition. We also recognize that under CIF Bylaw 200.D, there could

be penalties for false or fraudulent information. We also understand that the Tustin Unified School District policy regarding the use of illegal drugs will be

enforced for any violations of these rules.

_________________________/__________ _________________________/__________


We acknowledge that per California state law (AB25), athletes sustaining a concussion/head injury in an athletic activity outside of the regular school day

must be immediately removed from the activity. The student shall not return to activity until evaluated by a licensed healthcare provider. A written

clearance from the provider is needed for the student to return to activity. Please contact your school if you need further information.

_________________________/__________ _________________________/__________


We acknowledge that certain information would benefit our child, such as information on athletic or academic awards and information for news releases. We

consent for press, television, other news media, District and school web sites that the release or posting of information or photos concerning participation in

athletics, activities, the winning of honors and awards and other such information.

_________________________/__________ _________________________/__________


Press, television, other news media, District and school websites (information concerning participation in athletics, activities, the winning of honors and

awards, and other such information).

_________________________/__________ _________________________/__________


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TUSTIN UNIFIED SCHOOL DISTRICT

Off Campus Activity/Class

Transportation Waiver Agreement

Some activities in the Tustin Unified School District take place at sites which are located off-campus

A student who wishes to participate in these activities will be required to provide his/her own

transportation to and from these sites. Please fill out this form to acknowledge your understanding

and acceptance of these requirements.

Students Name: __________________________________ Grade: __________

School: _________________________________________________________

Parents/Guardian Name: ____________________________________________

Address: ________________________________________________________

Street City Zip

Home Phone: ___________________ Work Phone: ______________________

Activity: ________________________________________

I understand that my son/daughter is participating in an activity which meets

off-campus. I further understand and accept responsibility for providing proper

transportation to and from the site.

I am aware this activity is an elective activity and not required by the Tustin Unified

School District to fulfill any requirements for graduation from high school. If I do

not wish to be responsible or my son/daughter’s transportation, I understand that

he/she may enroll in an alternate class which regularly meets on-campus.

I understand that transportation to or from the designated off-campus site will not

be organized, conducted, or supervised by the Tustin Unified School District.

_________________________ _________________________

Parent/Guardian Signature Parent/Guardian Printed Name

Date: ____________________

DISTRITO ESCOLAR UNIFICADO DE TUSTIN FORMULARIO DE AUTORIZACIÓN DE DEPORTES/ACTIVIDADES

(Imprenta o a Maquina)

Apellido: ________________________ Nombre: _____________________________ Inicial del segundo nombre ____

Fecha de Nacimiento: ____________________ Deportes/Actividades: ___________/______________/_____________ TEMPORADA Otoño Invierno Primavera

Domicilio: _________________________________ Ciudad: _____________________ Código Postal: ___________

Número de Teléfono del Alumno: __________________________ Año Escolar del Alumno: Grado_____/Edad _____

_________________________________________________________________________________________________

Nombre del Padre Apellido Número del Celular/Trabajo Correo electrónico

_________________________________________________________________________________________________

Nombre de la Madre Apellido Número del Celular/Trabajo Correo electrónico

SEGURO MÉDICO

MI PÓLIZA DE SEGURO MÉDICO DE POR LO MENOS $1500 ES EMITIDA POR: _______________________________________

Compañía de Seguro # de la Póliza He comprado Seguro Myers-Stevens: _____ Sí _____ No (Se provee Dental a un costo adicional)

Solamente “Football”: _____ Sí _____ No Les aseguro que la póliza o pólizas de seguro que por este medio verifico se mantendrán al día y vigente durante el tiempo que el alumno

nombrado arriba participe o practique en eventos deportivos entre escuelas o durante su transporte y desde y hacia tales eventos deportivos. Estoy

de acuerdo en indemnizar y mantener al Distrito Escolar Unificado de Tustin indemne frente a la responsabilidad de los seguros.

PERMISO DE TRANSPORTE

Tengo entendido que el transporte se proveerá en una de las siguientes formas:

AUTHORIZACIÓN TIPO DE TRANSPORTE COBERTURA DE SEGURO ____ SÍ A. Autobús Escolar Distrito Escolar - primero

____ SÍ ____ NO B. Vehículo Privado (conducido por un empleado) Dueño - primero; Distrito Escolar - Secundario

____ SÍ ____ NO C. Vehículo Privado (conducido por un padre con el papeleo aprobado) Dueño - primero; Distrito Escolar - Secundario

________ Las iniciales en esta línea indica que va a permitir que su hijo/hija/pupilo conduzca su auto para el evento(s) deportivo(s),

SIN OTROS PASAJEROS cuando haya sido autorizado por la Escuela o Entrenador. (Solamente la Preparatoria)

SUPOSICIÓN DE RIESGO

El abajo firmante por este medio reconoce que él/ella conscientemente y voluntariamente asume todos los riesgos de lesiones corporales a

su hijo/a, como se indica y reconoce expresamente su intención, mediante la ejecución de este formulario, para eximir y relevar el Distrito Escolar

Unificado de Tustin, sus funcionarios, agentes y empleados, de cualquier responsabilidad por lesiones personales, lesiones corporales, daños

materiales o muerte ilícita que surja de o en modo alguno relacionado con la actividad descrita anteriormente. He leído lo anterior y he firmado este

acuerdo. Estoy consciente de los riesgos potenciales relacionados con esta actividad y estoy totalmente consciente de las consecuencias al firmar

este formulario. También reconozco que el Distrito no provee seguro de responsabilidad para este programa y tampoco provee cobertura médica

para los participantes en esta actividad.

AUTORIZACIÓN PARA EL TRATAMIENTO DE UN MENOR DE EDAD

Yo (NOSOTROS) abajo firmantes padres/tutores legales de __________________________________________, un menor de edad, doy

mi autorización y consentimiento para cualquier examen de rayos X, anestesia, diagnóstico médico o quirúrgico prestados bajo la supervisión

general o especial de cualquier miembro del personal médico y personal de la sala de emergencia con licencia bajo las disposiciones de la Ley de la

Practica de la Medicina o un Dentista con licencia bajo las disposiciones de la Ley de la Practica Dental y en el personal de cualquier hospital

general de emergencia que posea una licencia vigente para utilizar un formulario del hospital del Departamento de Salud Pública del Estado de

California. Queda entendido que esta autorización se otorga antes de cualquier diagnóstico, tratamiento u hospitalización especifica que se requiere,

pero se da para proveer la autoridad y el poder para rendir el cuidado que el médico mencionado en el ejercicio de su mejor juicio podrá considerar

conveniente. Queda entendido que se hará lo posible para contactar a los abajo firmantes antes de rendir tratamiento al paciente, pero que

cualquiera de los tratamientos anteriores no se retendrán si los abajo firmantes no se pueden localizar. Cualquier información médica, de salud u

otro se puede compartir con las autoridades escolares de acuerdo con las políticas y los procedimientos del distrito.

____________________________/____________ ____________________________/____________ Firma del Alumno Fecha Firma de Padres/Tutor Legal Fecha

Stu #________

1

EL ALUMNO Y PADRE DEBEN FIRMAR ONCE

(11) VECES.

Las clases deportivas de educación física, entrenamiento y/o practica o juegos pueden variar en días y/u horas. A los deportistas se les otorga el privilegio de

un permiso para salir fuera de la escuela ya que la clase, Entrenamientos o Juegos pueden llevarse a cabo fuera del horario regular de clases. Las

condiciones del permiso deportivo para salir fuera de la escuela son las siguientes:

1. Ni el Distrito ni sus funcionarios o empleados son responsables por la conducta fuera de la escuela o la seguridad de los alumnos durante este tiempo.

2. Debe traer una identificación en todo momento y se debe mostrar a petición de las autoridades. 3. Los alumnos deben salir de la escuela al principio de su último periodo o esperarse en el área atlética para que los recojan.

4. Los alumnos no se deben ir a cualquier otro terreno de la escuela o campus a menos que les haya concedido la autorización.

5. Este es un privilegio y puede ser terminado si no se cumplen las condiciones.

He leído y acepto las condiciones del Permiso Deportivo para Salir Fuera de la Escuela.

_________________________/__________ _________________________/__________

Firma del Alumno Fecha Firma de Padres/Tutor Legal Fecha

He leído y entendiendo completamente la información descrita en el Reglamento 5131.6 del Código de Conducta para la Participación de Actividades

Co-Curriculares y Extra-Curriculares del Distrito Escolar Unificado de Tustin y acepto cumplir con todas las políticas y responsabilidades.

_________________________/__________ _________________________/__________


He leído el Código de Deportes CIF de Ética y acepto cumplir con todas las políticas y responsabilidades.

_________________________/__________ _________________________/__________


Entiendo y acepto la “Suposición de Riesgo” descrita en el formulario de autorización deportiva. Entiendo que la hidratación es esencial para la seguridad

de mi hijo. La investigación llevada a cabo por un equipo de “football” de una preparatoria mostró que hasta 70 porciento del equipo llegó a la práctica ya

significantemente deshidratado. Su hijo debe hidratarse bien mientras se acostumbra al calor, así que recuérdele a su hijo que tome líquidos antes, durante y

después del ejercicio para asegurar que no pierda peso durante la actividad.

_________________________/__________ _________________________/__________


Sabemos y reconocemos que el Distrito no provee seguro de responsabilidad para los que participen en deportes, el Distrito tampoco proveerá cobertura

médica para los que participan en atletismo.

_________________________/__________ _________________________/__________


Como requisito del Código de Educación de California Sección 35330, por este medio renuncio a todos los reclamos de responsabilidad en contra del Distrito

Escolar Unificado de Tustin, el Condado de Orange y el Estado de California por lesión, accidente, enfermedad y la presión emocional o muerte que pudiera

ocurrir durante o debido a la participación en atletismo.

_________________________/__________ _________________________/__________


El alumno/atleta participante y el Padre/Tutor Legal aceptan que el alumno no debe usar esteroides androgénicos/anabólicos sin receta escrita por un

médico con licencia (reconocido por la AMA) para tratar una condición médica. También reconocemos que bajo el Estatuó CIF 200.D, podría haber

sanciones por información falsa o fraudulenta. También entendemos que la política del Distrito Escolar Unificado de Tustin con respecto al uso de drogas

ilegales se aplicará por cualquier violación de estas reglas.

_________________________/__________ _________________________/__________


Reconocemos que por la ley del Estado de California (AB25), los atletas que sufren de una contusión/lesión en la cabeza en una actividad deportiva fuera del

horario escolar regular deben ser retirados inmediatamente de la actividad. El alumno no debe regresar a la actividad hasta que sea evaluado por un

profesional médico con licencia. Se necesita una autorización escrita del proveedor para que el alumno regrese a la actividad. Por favor comuníquese con la

escuela si necesita más información.

_________________________/__________ _________________________/__________


Reconocemos que cierta información le beneficiaria a nuestro hijo, tal como información acerca de permios atléticos o académicos e información para los

comunicados de prensa. Damos nuestro consentimiento para la prensa, televisión u otros medios de comunicación, el Distrito y los sitios Web escolares

comuniquen o publiquen información o fotografías relativas a la participación en atletismo, actividades, el ganar honores y premios y otra información

similar.

_________________________/__________ _________________________/__________


La prensa, televisión u otros medios de comunicación, el Distrito y los sitios Web escolares (relativas a la información de la participación en atletismo,

actividades, el ganar honores y premios y otra información similar).

_________________________/__________ _________________________/__________


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DISTRITO ESCOLAR UNIFICADO DE TUSTIN

Contrato de Renuncia al Transporte

Para las Actividades/Clases Fuera de la Escuela

Algunas de las actividades del Distrito Escolar Unificado de Tustin que se llevan a cabo en sitios que se

encuentran fuera de la escuela. Un alumno que desee participar en estas actividades deberá tener su

propio transporte desde y hacia estos sitios. Por favor llene este formulario para reconocer su comprensión

y aceptación a estos requisitos.

Nombre del Alumno: __________________________________ Grado: __________

Escuela: ____________________________________________________________

Nombre de Padre/Madre/Tutor Legal: _____________________________________

Domicilio: ___________________________________________________________

Calle Ciudad Código Postal

Teléfono de Casa: ________________ Teléfono del Trabajo: __________________

Actividad: ________________________________________

Entiendo que mi hijo está participando en una actividad que se hace fuera de la

escuela. Además, entiendo y acepto la responsabilidad de proveer el transporte

adecuado hacia y desde el sitio.

Estoy consciente de que esta actividad es una actividad electiva y no requerida por

el Distrito Escolar de Tustin para cumplir con los requisitos para graduarse de la Preparatoria. Si no deseo ser responsable por el transporte de mi hijo, entiendo

que él/ella puede inscribirse en una clase alternativa que se reúne diariamente en la escuela.

Entiendo que el transporte desde o hacia el sitio designado fuera de la escuela no será organizado, realizado o supervisado por el Distrito Escolar Unificado de Tustin.

____________________________ ______________________________

Firma de Padre/Madre/Tutor Legal Nombre de Padre/Madre/Tutor Legal En letra imprenta

Fecha: ______________________

Preparticipation Physical Evaluation

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503 9-2681/0410

4/2014 – TUSD v.2

GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports for any reason?

2. Do you have any ongoing medical conditions? If so, please identify

below: Asthma Anemia Diabetes Infections Other:

3. Have you ever spent the night in the hospital? 4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?

6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during exercise? 8. Has a doctor ever told you that you have any heart problems? If so,

check all that apply:

High blood pressure A heart murmur

High cholesterol A heart infection

Kawasaki disease Other:

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected during exercise?

11. Have you ever had an unexplained seizure? 12. Do you get more tired or short of breath more quickly than your friends

during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No

13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No

17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?

18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an injury that required x-rays, MRI, CT scan,

injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture? 21. Have you ever been told that you have or have you had an x-ray for neck

instability or atlantoaxial instability? (Down syndrome or dwarfism)

22. Do you regularly use a brace, orthotics, or other assistive device? 23. Do you have a bone, muscle, or joint injury that bothers you? 24. Do any of your joints become painful, swollen, feel warm, or look red? 25. Do you have any history of juvenile arthritis or connective tissue disease?

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.)

Date of Exam

Name

Date of birth

Sex Age Grade

School Sport(s)

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

Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

MEDICAL QUESTIONS Yes No

26. Do you cough, wheeze, or have difficulty breathing during or after exercise?

27. Have you ever used an inhaler or taken asthma medicine? 28. Is there anyone in your family who has asthma? 29. Were you born without or are you missing a kidney, an eye, a testicle

(males), your spleen, or any other organ?

30. Do you have groin pain or a painful bulge or hernia in the groin area? 31. Have you had infectious mononucleosis (mono) within the last month? 32. Do you have any rashes, pressure sores, or other skin problems? 33. Have you had a herpes or MRSA skin infection? 34. Have you ever had a head injury or concussion? 35. Have you ever had a hit or blow to the head that caused confusion,

prolonged headache, or memory problems?

36. Do you have a history of seizure disorder? 37. Do you have headaches with exercise? 38. Have you ever had numbness, tingling, or weakness in your arms or

legs after being hit or falling?

39. Have you ever been unable to move your arms or legs after being hit or falling?

40. Have you ever become ill while exercising in the heat? 41. Do you get frequent muscle cramps when exercising? 42. Do you or someone in your family have sickle cell trait or disease? 43. Have you had any problems with your eyes or vision? 44. Have you had any eye injuries? 45. Do you wear glasses or contact lenses? 46. Do you wear protective eyewear, such as goggles or a face shield? 47. Do you worry about your weight? 48. Are you trying to or has anyone recommended that you gain or

lose weight?

49. Are you on a special diet or do you avoid certain types of foods? 50. Have you ever had an eating disorder? 51. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY 52. Have you ever had a menstrual period? 53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months?

Explain “yes” answers here

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

Signature of athlete Signature of parent/guardian Date

Preparticipation Physical Evaluation

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

HE0503 9-2681/0410

4/2014 – TUSD v.2

PHYSICAL EXAMINATION FORM

Name Date of birth

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

Height Weight Male Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Y N

MEDICAL NORMAL ABNORMAL FINDINGS

Appearance • Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat • Pupils equal • Hearing

Lymph nodes Heart a

• Murmurs (auscultation standing, supine, +/- Valsalva) • Location of point of maximal impulse (PMI)

Pulses • Simultaneous femoral and radial pulses

Lungs Abdomen Genitourinary (males only)b

Skin • HSV, lesions suggestive of MRSA, tinea corporis

Neurologic c

MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional • Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. bConsider GU exam if in private setting. Having third party present is recommended. cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for

Not cleared

Pending further evaluation

For any sports

For certain sports

Reason

Recommendations

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).

Name of physician (print/type) Date Address

Phone Signature of physician ,

MD or DO

Please Place Physician’s

Stamp Here.


REGULATION

STUDENTS 5131.6

Elementary and Secondary

Code of Conduct for Co-Curricular and Extra-Curricular Participation

Page 1 of 5

Each high school takes a vital interest in co-curricular and extra-curricular participation

in athletics, student council, band, orchestra, cheerleading, drama, dance team, choral

groups, and clubs by promoting fair discipline as well as responsible standards for

behavior, dress, and grooming. It is recognized that these regulations are necessary to

maintain team/club/group morale, individual discipline and effective learning.

Participation in co-curricular and extra-curricular activities is a privilege, not a right, and

may be revoked by the principal/designee whenever a student violates this regulation.

This Administrative Regulation is the expression of the minimum standard for the code

of conduct of participants in co-curricular and extra-curricular activities. As such, an

individual school site, activity, or program is not prohibited from establishing a higher

standard of conduct as long as the participant in the activity is aware of, and consented to,

that higher standard as a requirement for participation.

Tustin Unified School District co-curricular and extra-curricular student participants must

be good citizens. As defined in this Administrative Regulation, “participant” means a

student who has either enrolled or attended at least one meeting of a student club or

activity.

Citizenship

1. Student participation in activities requires good citizenship. Any student who

verbally or through gestures, communicates profanity to an opponent, official, or fans

will be evaluated for disciplinary action

2. Infractions involving hazing or other serious violations of the Education Code can

carry a penalty of suspension from the activity and restricted participation in school

activities. The principal/designee(s) will review the infractions. The response to the

incident may include, but is not limited to the following:

a. First Offense—Suspension for 1 to 10 days of participation

b. Second Offense—Suspension from 1 to 15 days of participation

c. Third Offense—Suspension from the activity for up to one year

3. Infractions of a less serious nature may result in a student being suspended from an

activity directly by the coach/teacher/advisor. If a coach/teacher/advisor suspends a

participant for more than one day, the coach/teacher/advisor must contact the

principal/athletic director/activities director/designee as well as the student’s parents.


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4. Discipline problems arising within the domain of the activity and/or contest are to be

handled at the coach’s/teacher’s/advisor’s discretion. Parents/guardians/caregivers

will be informed at the earliest time possible.

Alcohol/Narcotics

Any student in the Tustin Unified School District who possesses, uses, transports, or is

under the influence of any controlled substance, alcoholic beverage, intoxicant of any

kind, or who possesses or sells any drug paraphernalia shall be subject to suspension

and/or expulsion from the school and activity.

Any student who sells or provides a controlled substance or intoxicant of any kind shall

immediately be suspended and shall be recommended for expulsion.

The above provisions apply to related school activities, or attendance at such activities,

which occur at any time, including, but not limited to any of the following:

While on school grounds

While going to or coming home from school

During lunch period on or off campus

During or while going to or coming from a school sponsored activity

Any student who violates the District’s Drug and Alcohol Policy shall be ineligible to

represent their school in competition or performances (in athletics, activities, or

performing arts) for ten consecutive calendar weeks from the date of the infraction,

excluding summer break (recess).

The ramifications for violation of this code of conduct policy do not preclude the ability

of the school site or District to impose discipline, including involuntary transfer,

suspension, or expulsion.

Participant Dismissal and Abandonment

1. A participant dismissed from any team will be removed from the appropriate co-

curricular/extra-curricular class.

2. Abandonment of any activity precludes the participant from participating in another

activity for the period of time the abandoned activity is in season. A participant

“abandons” an activity when the participant departs without the knowledge or

permission of the coach/teacher/advisor.


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Scholastic Eligibility (6-12)

1. District Policy 6145

a. In order to be eligible for co-curricular or extra-curricular activities, a student

shall maintain a 2.0 grade point average (GPA) during the preceding grading

period.

b. A student who does not maintain a 2.0 GPA shall be placed on probation for the

following grading period, the student shall continue to be eligible, providing

he/she maintains a satisfactory attendance (three hours a week) in a designated

tutorial class.

c. If the student does not maintain satisfactory attendance in the tutorial class, he/she

will be declared ineligible. If at the end of the probationary grading period the

student has not achieved a 2.0 GPA, he/she shall be ineligible for the following

grading period.

d. Two or more “U’s” in citizenship from two or more separate teachers will result

in a student being ineligible for co-curricular or extra-curricular activities for the

remainder of that grading period.

Equipment and Financial Obligations

1. Each participant is responsible for the use and care of the equipment issued to

him/her.

2. Any participant who does not return or pay for all school equipment issued to him/her

immediately at the close of each sport season or activity will not be issued any further

equipment and will not be allowed to report to another activity until the debt is

cleared.

3. Each student participant is responsible for the Transportation Fee at the beginning of

each season of activity.


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Security Procedures for Personal Property

1. It is highly recommended that the utmost care be taken in securing student equipment

and personal articles. The school does not assume responsibility for the loss of

items.

General Athletic Information

1. Participants must be in attendance for at least four periods the day of the contest.

Unexcused absences may result in a one-day suspension from participation in the

activity. Failure to attend four classes will subject the student to a one-contest

suspension on that day. There is an expectation that participants will not have any

unexcused absences from school on the day of the event or activity.

2. Contest:

a. The appointed coach will be in charge of the team before, during, and after the

athletic contest.

b. Game time and location shall be arranged so that participants miss a minimum

amount of their class work. It is the responsibility of each participant to make up

all missed assignments.

3. Overflow Class:

a. After the season is complete, participants may be placed in the Overflow Class

(“0” period) or a regular physical education class to fulfill the physical education

requirement.

4. Transportation:

a. The usual means of transportation to athletic contests is by school bus.

Occasionally other means of transportation will be authorized, but only when

specifically approved in advance.

b. All participants must travel to contests by school bus or other authorized

transportation. Participants arriving at contests by other means will be denied the

privilege of participation.


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c. All students participating in field trips or competitive events shall return with the

group unless released by the coach, using a verified signature log, to the student’s

parents/guardians/caregivers. (See TUSD Regulation 6174.)

California Interscholastic Federation—Southern Section (“CIF”) – Code of Ethics

The CIF Southern Section publishes a “Code of Ethics for Athletes” and each year that is

part of its constitution and bylaws (Blue Book). The current CIF Code of Ethics for

Athletes is incorporated by reference into this Administrative Regulation.

Date

Effective: 11/14/05

Revised: 5/9/13

10932 Pine Street Telephone: 562-493-9500 Los Alamitos, California 90720 Fax: 562-493-6266

Code of Ethics - Athletes Athletics is an integral part of the school’s total educational program. All school activities, curricular and extra-curricular, in the classroom and on the playing field, must be congruent with the school’s stated goals and objectives established for the intellectual, physical, social and moral development of its students. It is within this context that the following Code of Ethics is presented. As an athlete, I understand that it is my responsibility to:

1. Place academic achievement as the highest priority. 2. Show respect for teammates, opponents, officials and coaches. 3. Respect the integrity and judgment of game officials. 4. Exhibit fair play, sportsmanship and proper conduct on and off the playing field. 5. Maintain a high level of safety awareness. 6. Refrain from the use of profanity, vulgarity and other offensive language and gestures. 7. Adhere to the established rules and standards of the game to be played. 8. Respect all equipment and use it safely and appropriately. 9. Refrain from the use of alcohol, tobacco, illegal and non-prescriptive drugs, anabolic steroids or

any substance to increase physical development or performance that is not approved by the United States Food and Drug Administration, Surgeon General of the United States or American Medical Association.

10. Know and follow all state, section and school athletic rules and regulations as they pertain to eligibility and sports participation.

11. Win with character, lose with dignity.

As a condition of membership in the CIF, all schools shall adopt policies prohibiting the use and abuse of androgenic/anabolic steroids. All member schools shall have participating students and their parents, legal guardian/caregiver agree that the athlete will not use steroids without the written prescription of a fully licensed physician (as recognized by the AMA) to treat a medical condition (Article 523). By signing below, both the participating student athlete and the parents, legal guardian/caregiver hereby agree that the student shall not use androgenic/anabolic steroids without the written prescription of a fully licensed physician (as recognized by the AMA) to treat a medical condition. We recognize that under CIF Bylaw 202, there could be penalties for false or fraudulent information. We also understand that the (school/school district name) policy regarding the use of illegal drugs will be enforced for any violations of these rules. Printed Name of Student Athlete Signature of Student Athlete Date Signature of Parent/Caregiver Date A copy of this form must be kept on file in the athletic director’s office at the local high school on an annual basis and the Principal’s Statement of Compliance must be on file at the CIF Southern Section office. Revised 7/11

You do not Sign this page, when you sign #9 on the Athletic Clearance Form it states, "We acknoledge that perCalifornia state law (AB25), athletes sustaining a concussion/head injury in an athletic activity outside of the regularCalifornia state law (AB25), athletes sustaining a concussion/head injury in an athletic activity outside of the regularschool day must be immediately removed from the activity. The student shall not return until evaluated by a licensedhealthcare provider. A written clearance from the provider is neeeded for the student to return to activity." Please keepthis and the ENTIRE TUSD Code of Conduct for your records.

tustin unified school district athletic/activities

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