Superintendent Marty T. Hemric, Ed. D
WILKES COUNTY SCHOOLSHIGH SCHOOL ATHLETIC PARTICIPATION FORMPlease PrintName: _ __ Home Phone:_ _ High School: _ Gender: M FDate of Birth: _Race: _Age :_ _Father's Name: _ _ _Daytime Phone: _Cell Phone:Other: _ Mother's Name: ____ _Daytime Phone:Cell Phone:Other: _ _ Email: _Street Address: _ County: _ City:. __ State:_ _ __ Zip Code:__ _ Alternate Emergency Contact Person:__ Day Ph _____ Cell Ph. _We certify that the home address shown in this document file is my sole bona fide residence, and Iwill notify the school principal immediately of any change in residence,since such a move may alter the eligibility status of my student athlete. All other information contained in this form is accurate and correct.Parent/Legal Guardian Signature: Athlete Signature: Convictions: Check the box that applies to (student name} .( ) Is not convicted of a felony in this or any other state OR adjudicated as a delinquent for an offense that would be a felony if committed by an adult in this or any other state.( ) I s convicted of a felony in this or any other state.( ) I s adjudicated as a delinquent for an offense that would be a felony if committed by an adult in this or any other state.The following must be completed if the student is convicted of a felony or is adjudicated as a delinquent:Convicted or adjudicated of: __ _ City and State :Date Convicted/Adjudicated:_ Description of Offense:_Court Counselor:Telephone Number:This is my consecutive semester in High School,and Ientered the ninth grade in the fall of (yr.). Last semester I attendedSchool and passed(number) courses. Ihave also not been convicted of a felony or an act that would have been a felony if Iwere not classified a juveni le.Request for Permission:We, the undersigned student and the student's parenUguardian, apply for permission to participate in interscholastic athletics in the following sports: (Please check all sports that apply.)( ) Basketball ( ) Baseball( ) Cheerleading ( ) Cross Country( ) Football ( ) Golf( ) Tennis( ) Soccer ( ) Softball( ) Swimming( ) Track( ) Volleyball ( ) WrestlingInsurance :Wilkes County School(WCS) furnishes an Interscholastic Athletic Insurance Policy which provides limited benefits for all students in the system who participate in high school sponsored and supervised interscholastic athletic activities . The policy provides excess coverage for students with other insurance coverage, but it pays only when other benefits have been exhausted. It is a secondary insurance! In cases in which a student has no other coverage with either a commercial insurance agency,Medicare or Medicaid,the WCS athlet ic insurance policy is the primary policy.If your son or daughter should be injured while participating in a high schoolsponsored or supervised interscholastic athletic event, the following procedures must be followed to process a claim under the insurance provided by WCS.Use the claim form you received in your parent meeting or download a form at icanadvantagei nsurance .com/fi1es/Brochures/K%20&%20K%20C laim%20form.pdf .See a physician within 30 days of the plete and submit the Accident Claim Form. The claim form must be filed with the insurance company within 60 days of the injury and should include the Explanation of Benefits form from your primary insurance carrier. Please list below the name of your primary insurance carrier and policy number.Risk of InjuryWe acknowledge and understand that there is a risk of injury involved in athletic participation. We understand that the student athlete will be under the supervis ion and direction of a WCS athletic coach. We agree to follow the rules of the sport and the instructions of the coach in order to reduce risk of injury to the student and other athletes. However, we acknowledge and understand that neither the coach nor WCS can eliminate the risk of injury in sports. Injuries may and do occur. Sports injuries can be severe and, in some cases, may result in permanent disability or even death. We freely, knowingly, and willfully accept and assume the risk of injury that might occur from participation in athletics.Code of Sportsmanship:It is recognized that public school interscholastic athletic events should be conducted in such a manner that good sportsmanship prevails at all times. Every effort should be made to promote a climate of wholesome competition. Unsportsmanlike acts will not be tolerated. A player is under the coach's control from the time he/she arrives at the athletic field untilhe/she leaves the field. The penalties listed in the North Carolina High School Athletic Association Handbook willbe adhered to for any athlete ejected from an athletic contest.Protect your Eligibility: Know the Rules: To represent your school in Athletics, YOU:Must be a properly enrolled student at the time you participate, must be enrolled no later than the 151h day of the present semester, and must be in regular attendance at that school. Must also have met local promotion standards.Must not be convicted of a felony in this or any other state,or adjudicated as a delinquent for an offense that would be a felony if committed b an adult in this or any other state.Must not have more than 12 absences (85% attendance requirement) in the semester prior to athletic participation.Must not have exceeded eight (8) consecutive semesters of attendance or have participated more than four (4) seasons in any sport since first entering grade nine (9).Must be less than 19 years of age on or before August 31st, 2013 .Must Jive with your parents or legalcustodian wit hin the high school district that you attend. Schoolof Choice policy 4150 of Wilkes County Schools addresses exceptions and penalties for this rule.Must be present at school half of the day in order to participate in an athletic event for that day. This includes games and practices.Must have passed a minimum of three courses during the previous semester in a block schedule.Must have received a medical examination by a licensed physician within the past 365 days. If you miss five (5) or more days of practice due to illness or injury, you must receive a medical release from a licensed physician before practicing or playing.Must not accept prizes, merchandise, or anything that exceeds a value of $20 per season as a result of athletic participation . This includes being on a free list or loan list for equipment, etc. No amount of money can be accepted at any time!Must not have signed a professionalcontract, have played on a junior college team, or be enrolled and attending a class in college. This doe: not affect a regularly enrolled high schoolstudent who is taking a college course(s) for advanced credit.Must not participate in unsanctioned all-star or bowl games.May not receive team instructions from your school's coaching staff during the school year outside your sports season. Instruction is limited to the coach and one or multiple participants in small group settings (skill development sessions).May not,as an individual or a team, practice or play during the school day.May not play,practice or assemble as a team with your coach on Sunday.May not dress for a contest, sit on the bench, or practice if you are not eligible to participate .Must not play more than three (3) games in one sport per week (exceptions: Baseball, Softball, Cheerleading, and Volleyball) ;and not more than one (1) contest per day in the same sport (exceptions: Baseball, Softball, Cheerleading, or Volleyball).NCHSAA Regulations Student Athlete Pledge:As a student athlete, Iam a role model. Iunderstand the spirit of fair play while playing hard. Iwill refrain from engaging in all types of disrespectful behavior, including inappropriate language, taunting ,trash talking, and unnecessary physical contact. Iknow the behavior expectations of my school, my conference, and the NCHSM, and hereby accept the responsibility and privilege of representing this school and community as a student athlete.Student-Athlete Signature: _ _Parent Pledge:As a parent, Iacknowledge that Iam a role model. Iwill remember that school athletics is an extension of the classroom, offering learning experiences for the students. Imust show respect for all players, coaches, spectators, and support groups. Iwill participate in cheers that support, encourage and uplift the teams involved. Iunderstand the spirit of fair play and the good sportsmanship expected by our school, our conference and the NCHSM. I hereby accept my responsibility to be a model of good sportsmanship that comes with being the parent of a student athlete.Parent/Legal Guardian Signature: Coaches Pledge:As a coach, Iacknowledge that I am a role model. Iknow that the principles of good sportsmanshi p are integrity, fairness, and respect. While teaching the skills of the game, Imust also teach student athletes how to win and lose graciously, and that sport is meant to be educational and fun. Iknow the behavior expectations of me by this school, conference, and the NCHSM, and hereby accept my responsibility to be a model of ethical behavior, integrity,and good citizenship.Coaches Signature: _ _ _Date: _Policy for Quitting a High School TeamIf an athlete quits a team after a tryout period, that athlete may not participate in skill development practice sessions or tryout for another sport until the team that he/she quit is finished with their season. A tryout period is defined as before final team selection. A team's season is defined as the first practice after final team selection until all games are complete. This includes conference tournaments and state playoff games. If an athlete quits a team it is the responsibility of the coach to notify the athletic director immediately. There are no exceptions to this rule! A coach may not release a student-athlete if he/she quits their team! In sports where there is not a designated tryout period (football, wrestling, track, cross country, etc.), a student-athlete will have two weeks to decide whether or not to participate. After two weeks an athlete is considered an official team member.Student-Athlete Initials: _Parent/Legal Guardian Initials: __ _Wilkes County Schools Hazing PolicyThe Wilkes County schools will not tolerate hazing of any kind. Athletes found guilty of hazing will be immediately removed from athletic participation . This suspension will not be less than one school term (18 weeks).This punishment will be in addition to any school discipline given by the principal.Student-Athlete Initials: _Parent/Legal Guardian Initials: _NCHSAA Sportsmanship/Ejection Policy:The policy applies to all persons i nvolved in an athletic contest, including student-athletes, coaches, managers and game administrators. The following examples include behavior or conduct which will result in an ejection from a contest:Fighting,which includes, but is not limited to, combative acts such as:An attempt to strike an opponent with a fist , hands, arms, legs, or feetAn attempt to punch or kick an opponent,regardless of whether or not contact is madeAn attempt to instigate a fight by committing an unsportsmanlike act toward an opponent that causes an opponent to retaliateLeaving the bench area to participate in a fight (contact or no contact)Biting observed by an officialTaunting, baiting,or spitting toward an opponentProfanity,directed toward an officialor opponentObscene gestures, including gesturing in a manner as to intimidateDisrespectfully addressing (physically contacting an official is subject to automat ic expulsion and can result in ineligibility for remainder of career) an officialPenalty for an ejection for the above reasons:Football-ejection from the contest and miss the next contest at that leveland contests in the interim (EXCEPTION: fighting equals two missed contestsAll other sports-ejection from that contest; miss the next two contests at that level and all contests in the interim (EXCEPTION: fighting equals 4 missed contests)Players receiving two ejections for unacceptable behavior as defined above will be suspended from all sports for the remainder of that sport season. Receiving a third ejection in a school year will result in suspension from athletics for calendar year (365 days from the date of the third ejection).Student-Athlete Initials: ___Parent/Legal Guardian Initials: _Transportation for Athletic Events:If student transportation is by a Wilkes County Schools System-owned vehicle, the school system vehicle liability coverage is applicable to any vehicula1 accident. If student transporta tion is by private vehicle,the vehicle owner's liability coverage is applicable to any vehicular accident.Student athletes will travel to/from athletic events with their teams and coaches . Any athlete failing to comply will not be allowed to dress an( participate at that game/match. If the violation occurs on the trip home, then the athlete will not dress nor participate in the next game. A second offense will result in removal from the team.Request for Exception to the Transportati on Policy : I request that my son/daughter be given an exception to the transportation policy. Iunderstand and agree that with this request Iaccept total responsibility for my child's safe return home from his/her game for the entire season. Iunderstand and agree that Iam responsible for any and all arrangements related to my child's ride home. Iunderstand and agree that my child may not ride home with another person other than their parent(s) or adult(s) designated by the parent(s)! If a parent wishes to designate an adult or adults to take their chil( home they may list those adult(s) on a form prior to the season starting. Each form willbe verified by the coach and athletic director. If he/she does not follow this policy he/she w ill sit out a game on the first offense and wi ll be removed from the team on the second offense. I hereby release the Wilkes County Board of Education, its individual members, its employees and its agents from any loss, damage, injury, claim, liability or responsibilitywhatsoever arising out of, during,or in any way connected with the transportation of my child from an athletic event where school transportation is not utilized.Parent/Legal Guardian Initials Athlete Initials: We,the undersigned student and parent/guardian, have read this document and understand all of these requirements for athletic participatio at our high school,and agree to comply with the requirements set forth in this document.Student: Date:SignatureParent/Guardian: Date:(Please Print)Parent/Guardia n: Date:(Signature)IIII Wi l kesSuperintendent Marty T. Hemric, Ed. D=m= county Illschools L- -Associate Superintendent Wanda P. Hutchinson, Ed.D.2692907-374859Athletic DepartmentAssistant Superintendent Anna R. Lankford6716268-544912Emergency Information and Parental ConsentStudent Name: _ _ Birthdate _ Age _Parent's Name: ----------- Home Phone: -----------Address: _City__ _ Grade_ _ Day Phone Number of Parents: Father _ Mother _ __ In an emergency, if the parents cannot be reached, notify:-------------------Phone ------------Family Doctor: _ __ Phone _ _ Known Allergies: ---------------------------Pennission is hereby granted to the attending physician to proceed with any medica l or minor surgical treatment, x-ray, examination and immunizations for the above named student. In the event of an emergency arising out of serious illness, the need for major surgery, or a significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious way possible. Ifthe said physician is not able to communicate with me, the treatment necessary for the best interest of the above named student may be given.Pe1miss ion is also granted to the Certified Athletic Trainer to provide the needed emergency treatment prior to the student's admission to the medical facilities.Parent Signature: _ __ _ _ Date_ _ _Revised: August 12, 2011613 Cherr}Street ? :\'orth \Vilkesboro, NC 28659 ? Telephone 336.667.l121,vw,r.,Yil kes.kl 2 .nc.usCONCUSSIONINFORMATION FOR STUDENT-ATHLETES & PARENTS/LEGAL CUSTODIANSWhat is a concuss ion? A concussion is an injury to the brain caused by a direct or indirect blow to the head. It results in your brain not working as it should. It may or may not cause you to black out or pass out. It can happen to you from a fall, a hit to the head, or a hit to the body that causes your head and your brain to move quickly back and forth.How do Iknow if Ihave a concussion? There are many signs and symptoms that you may have following a concussion. A concussion can affect your thinking, the way your body feels, your mood, or your sleep. Here is what to look for:Thin king/Rememberin,zPhysicalEmotional/MoodSleepDi fficulty thinking clearly1-kadacheIrritability-t h ings bother youSleeping more than usualmore easilyTaking longer to figure things outFuzzy or bluny visionSleeping less than usualSadnessDi fficulty concentratingTrouble falling asleepFeeling sick to yourBeing more moodyDifficulty remembering newstomach/queasyFeeling tiredinfom1ationFeeling nervous or worriedVomiting/throwing upCrying moreDizzinessBalance problemsSensitivity to noise or lightTable is adaptedfrom the Centersjar Disease Control and Prevention (!1ttp:l/mvw.cdc.z,o.-/co 11cussio11/)What should Ido if Ithink Ihave a concussion? If you are having any of the signs or symptoms listed above, you should tellyour parents, coach, athletic trainer or school nurse so they can get you the help you need. If a parent notices these symptoms, they should inform the school nurse or athletic trainer.When should Ibe particularly concerned? If you have a headache that gets worse over time, you are unable to control your body, you throw up repeatedly or feel more and more sick to your stomach, or your words are coming out funny/slurred, you should let an adult like your parent or coach or teacher know right away, so they can get you the help you need before things get any worseWhat are some of the problems that may affect me after a concussion? You may have trouble in some of your classes at school or even with activities at home. If you continue to play or return to play too early vvith a concussion, you may have long term trouble remembering things or paying attention, headaches may last a long time, or personality changes can occur Once you have a concussion, you are more likely to have another concussion.How do Iknow when it's ok to return to physicalactivity and my sport after a concussion? After telling your coach, your parents, and any medical personnel around that you think you have a concussion, you will probably be seen by a doctor trained in helping people with concussions. Your school and your parents can help you decide who is best to treat you and help to make the decision on when you should return to activity/play or practice. Your school will have a policy in place for how to treat concussions.You should not return to play or practice on the same day as your suspected concussion.You should not have any symptoms at rest or during/after activity when you return to play, as this is a sign your brain has not recovered from the injury.This information is provided to you by the UNG Matthew Gfeller Sport-Related TBI Research Center, North Carolina Medical Society, North Carolina Athletic Trainers' Association, Brain Injury Associat ion of North Carolina, North Carolina Neuropsychological Society, and North Carolina High School Athletic Association.Student-Athlete & Parent/Legal Custodian Concussion Statement*If there is anything on this sheet that you do not understand, please ask an adult to explain or read it to you.46177299439This form must be completed for each student-athlete, even if there are multiple student-athletes in each household.ParenULegal Custodian Name(s):o We have read the Student-Athlete & Parent/Legal Custodian Concussion Information Sheet.If true, please check box.After reading the information sheet, Iam aware of the following information:Student-AthleteParent/LegalInitialsCustodianInitialsA concussion is a bra in injury which should be repo1ted to my paren ts, my coach(es), or a medical professional if one is ava ilable.A concussion can affect the ability to perfonn everyday activities such as the ability to think, balance, and classroom performance.A concussion cannot be "seen." Some symptoms might be present right avvay. Other symptoms can show up hours or days after an injmy.I will tell my parents, my coach, and/or a medical professiona l about myinjuries and illnesses.NIAIf I think a teammate has a concussion, I should tell my coach(es), parents, ormedical professional about the concussion.N/A I will not return to play in a game or practice if a hi t to my head or body causesany concussion-related symptoms.N/AI will/my child will need w1itten pe1mission from a medical professional trained in concussion management to return to play or practice after aCOllCUSSlO!l.Bases on the latest data, most concussions take days or weeks to get better. A concussion may not go away right away. I realize that resolution from this injury is a process and may require more than one medical evaluation.I realize that ER/Urgent Care physicians will not provide clearance if seen right away after the injury.After a concussion, the brain needs time to heal. I understand that 1am/my child is much more likely to have another concussion or more serious brain injury ifretum to play or practice occurs before concession symptoms go away.Sometimes, repeat concussions can cause serious and long-lasting problems. I have read the concussion symptoms on the Concussion Infonnation Sheet.Signature of Student-AthleteDateSignatur e of Parent/Legal CustodianDateIll W ilkesSuperinte ndent Marty T. Hemric, Ed. DIllcounty475487451990IllschoolsAssociate Superintendent Wanda P. Hutchinson, Ed.D.Assistant Superintendent Anna R. Lankford ._. .._. J..;..??_ , 5472684-102806----'---\-VCS Department of Athletics Transportation Release Form331470080131Student Name:Request for Exception to the Transporta tion Policy: I request that my son/daughter be given an exception to the transpo1iation policy. I understand and agree that with this request I accept total responsibility for my child's safe rehu11 home from his/her games that the sh1dent does not ride school transportation for the entire season. I understand and agree that I am responsible for any and all arrangements related to my child's ride home. I understand and agree that my child may not ride home with another person other than their parent(s) or adult(s) designated by the pa rent(s)! Ifa parent wishes to designate an adult or adults to take their child home they may list those adult(s) on this fo1111 prior to the season starting. Each form will be verified by the coach and athletic director at the beginning of the season. The adult(s) designated to take your student-athlete home must sign them out on the documentation sheet on the back of this letter before they leave the off campus facility that they arevisiting. Ifhe/she does not follow this policy he/she will sit out a game on the first offense and will be removed from the team on the second offense. I hereby release the Wilkes County Board of Education , its individualmembers, its employees and its agents from any loss, damage, injury, claim, liability or responsibility whatsoever arising out of, during, or in any way connected with the transporiation of my child from an athletic event where school transporiation is not utilized.Signahire of Sh1dent-AthleteDateSignature of Parent/Legal GuardianDate List below the adult designee(s) for each sport season:Fall:vVin ter:Spring:1)1)1) 2)2)2) 3)3)3) 4)4)4) 5) 5)5)613 Cherry Street ? l'lorth \Yilkesboro, NC 28659 ? Telephone 336.667.1121\\Ww .wilkes.kl 2.nc.us\Vilkes County Schools Sign Out Docu111entation Sheet400964426754Student Name:Printed Name of PersonSignature of Person Transporting StudentTransporting StudentVenue/SiteDate613 Che rry Street ? i\'orth Wilkesbo ro, l\C 2S659 ? Telepho ne 336.667.112 1w,,w.wilkcscoun tyscho ols.o rg016-2017 1\'orth Carolina High School A thletic Association Eligi bility and Au thoriza tion Statemen t!This document is to be si!!Jled by the participant of an NCHSAA member school and bv the participant's parent .I have read, understand and acknowledge rec eipt of the eligi bi lity mies of the North Carol ina High School Athletic Association. I understand that a copy of the NCHSA.-l Handbook is on file with the principal and ath letic administratorand that I may revi ew it, in its entirety, if I so choose. All NCHSAA bylaws and regulations from the Handbook are also posted on the NCHSAA web site at ,,ww.nchs:ia.orn:I understand that an NCHSAA member school must a dh ere to all rules and regulations that pertain to the interscholastic athletics programs that the school sponsors, but that local mies may be more stringent than 'KCHSAA mies.I understand that part i cipation in interscholastic athletics is a priYilege not a righ t.Studen t Code of Respon sibilitvAs a st11dent athlete, I und erstand and accept the following respons i bilities:I ,viii respect the rights and beliefs of others and will treat others with courtesy and consideration. I wi ll be fully respon sible for my own actions and the consequences of my actions.I will respect the property of others.I will respect an d obey the rules of my school and la\\·s of my community, state and country.I wil l show respect to those who are responsible for enforcing the rules of my school and the laws of my community, state and country.I u nderstand that a student whose character or conduct violates the school 's Athletic Code or School Code of Responsibility could be deemed ineligible for a period of time as dete1mined by the principal or school system AdministrationI und erstand that if I drop a class, take course work through Post Secondary Enrollmen t Option, or other educational options, this action could affect compliance with NCHSAA academic standards and my rm ed Consen t -By its nahire, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety mies, report all physical and hygiene problems to their coaches, follow a properconditioning program, and inspect thei r own equipment daily . PARENTS, LEGAL CUSTODIAN'S OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED I:\1 THIS WAR..i'i'ING SHOULD N OT SIGN THIS FOR.."i \I. STUDE:\1TS MAY NOT PARTICIPATE IN A NCHSAA-SPOSORED SPORT WITHOUT THE STUDENT'S ANDPARENT'S/GUARDIAN'S SIGNATURE.I understand that in the case of injury or illn ess requiri ng treatm ent by medical personnel and transpo rtation to a health care facility, that a reasonable attempt will be made to contact the parent/lega l custodian in the case of the st11dent-athlete being a minor, but that, if necessary, the student -athlete will be treated and transported via ambulance to the nearest hospital.I consen t to medical treatmen t for the st11dent following an injury or illness suffered during practice and/or a contest.I und erstand all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. Further I understand tha t if my student is removed from a practice or competition due to a suspected concussion, he or she will be unable to return to participation that day. After that day, written authorization from aphysician (M.D. or D.O.) or an athletic trainer working under the supervision of a physician will be required in order for the st11dent to return to participation.I h ave received, read and sign ed the Gfeller-\Yaller Concussion Information Sheet.I consen t to the NCHSAA use of the h erein nam ed stu den t's name, likeness, and athletic-related infomrntion in reports of contests, promotional l iterature of the Association and other materials and releases related to interscholastic athletics.By signing this docu ment, we acknowledge th at we have read the above inform ation and tha t we consent to the herei n na m ed student's participation.Must Be Signed Before ParticipationSn1dent's Signan1reBirth dateGrade in SchoolDateSignature of Pare111 or Legal CustodianDatesociaci6n de Atletismo d e las Escuelas d e Secundaria Su erior de Carolina del l\'orte ElegibilidadDeclaraci6n de Autorizaci6n 2016-2017Este documento debe ser firmado por el participante de una escuela miembro de la NCHSAA y por el padre/madre del participante.He leido, entendido y acuso recibo de las regla s de elegibilidad de la Asociaci6n de Atletismo de las Escuelas de Secundaria Superior de Carolina de! Norte (NCHSAA, por sus siglas en ingles). Entiendo que una copia de!Manual de l a NCHSA...A esta en archivo con el director y el administrador de atletismo y yo podria revisarlo, en su tota lidad, si lo deseo. Todos los estatutos y reglamentos de la NCHSAA que estan en el manual, tambien estan publ icados en el sitio web de l a NCHSAA en nch saa.ore:Entiendo que una escuela miembro de l a NCHSAA debe cumplir con tod as las reglas y regulacio nes que se refieren a l os programa s de atletismo inter-escolar patrocinados por la escuela, pero que las reglas locales puedeo ser mas estrictas que las reglas de la NC HSAA .Entiendo que la participaci6n en atletismo inter-escolar es un privilegio no un derecho.Codigo de responsabilidad del estudian teComo un estudiaote atleta, entiendo y acepto las responsabilid ades siguientes:Resp etare los derechos y creencia s de los demas y tratare a los demas con cortesia y consideraci 6n . Sere completamen te responsable de mis prop ias acciones y las consecuencias de mis acciones.Respetarc la propiedad de los demas.Respetare y obedecere las reglas de mi escuela y las ]eyes de mi comunidad, estado y pais.Mostrare respeto a aquellos que son responsab les de hacer cumplir las reglas de mi escuela y las!eyes de mi comunidad, estado y pais.En tiendo que un estu diante cuyo caracter o conducta viola el C6digo de Atletico de la escuela o el C6digo deResponsabilidad de la escuela podria ser coosiderado(a) no elegible por un periodo de tiempo determinado por el director o la administraci6n de! sistema escolarEntiendo que si retiro una clase, tomo trabajo de] curso a traves de la opcion de Inscripci6o Post Secundaria, u otras opciooes educativas, esta acci6n podria afectar el cumplimiento de los estandares academicos de la NCHSAA y mi elegibilidad.Consentimiento fundamentado -Por su naturaleza, la participaci6n en actividades deportivas inter-escolares incluye el riesgo de lesiones y la transrnisi6n de enfermedades infecciosas como el VIH y la hepatitis B. Aunque las lesiones serias no son comunes y el riesgo de transmisi6n del VIH es casi inexistente en Jos progrnmas deportivos escolares supervisados, es imposible eliminar todo el riesgo. Los participantes tienen la responsabi lidad de ayudar a reducir ese riesgo. Los participantes deben obedecer todas las reglas de seguridad, informar todos los problema s fisicos y de higiene a sus entreoadores, seguir un programa de acondicionarniento adecuado, e inspecciooar su propio equipo cada dia. PADRES DE FAl\lILIA, TUTORES LEGAL O ESTUDLJ\.TES QUE NO DESEEi\ ACEPTAR EL RIESGO DESCRITO El\ ESTA ADVERTENCIA l\"O DEBEl\ FIR.MAR ESTE lULARIO. ESTUDIA.l\TES i\O PUEDEN PARTICIPAR EN UN DEPORT? PATROCINADO POR LA NCHSAA SIN LA FIRi\U DEL ESTUDIAl\"TE Y PADRE I MADRE/ TUTOR.Entiendo que en caso de lesion o enfermeda d que requiere tratamiento por personal medico y de transporte a un cen tro de atenci6n medica, se hara un intento razonable para comunicar se con el padre I madre I h1tor legal, en caso que el esh1diante-atleta sea un menor de edad, pero que, de ser necesario, el estudiante-atleta sera tratad o y transportado en ambulancia al hospital mas cercano.Doy consentimiento para tratamiento medico para el esh1diante despues de una lesion o enfennedad sufrida duran te la practica y I oun concurso.En tien do que todas las concusiones son potencialmente serias y puede dar lugar a compl icaciones, incluyendo dai""io cerebralprolongado y muerte si no se reconoce y se maoeja adecuadamente. Ademas entiendo que si m i estudiante se retira de una practica o competencia debido a una sospecha de concusi6n, el/ella no podra volver a partic ipar ese dia. Despues de ese dia, la autorizaci6n escrita de un medico (M.D. o D..O..) o tm entrenador de atletismo, que trabaja baj o la supervision de un medico, sera requerida para que el esh1diante pueda volver a pa1iicipar.He recibido, leido y firmado la Hoja de informaci6n de concusi6n Gfeller-Waller.Doy mi consentimiento para qu e la NCHSAA use el nombre del aqui llam ado estu diante, semejanza, y la infonnaci6n relacionada con atletismo en los infmmes de las competencias, la l iterah1ra promoc ional de la Asociaci6n y otros materiales y comunicados relacionados con el atletismo inter-escolar.Al firmar este documento, reconocemos que hemos leido la informa ci6n anterior y que damos consentimiento de la participaci6n clel estudia nte nombrado en el presente docu mento.Debe ser firmado an tes de la participaci6nFirma de!esmd ianteFecha de Naci mientoGrado en la escuelaFeehar.: _ .J-1 _ _ .J ,_ _ .J ,.... - - 1- --1265175-142152Notice of Wilkes County Schools Random Student Drug Testing PolicyThe Board of Education recognizes that drug and alcohol use by students results in a significant health and safety risk to students and the educational environment. The Random Student Drug Testing Policy is intended to be a helpful part of the overall physical, mental and health education ofstudents. In addition to the alcohol and drug testing program, the school district will continue to utilize the school health curriculum and local community substance abuse education and treatment providers to teach students about the harmful effects of drug and alcohol use and to prevent students from using drugs and alcohol.All students in grades 9 - 12 who desire to participate in any of the following voluntary school activities orprivileges must agree to participate in the random student drug testing program:oExtracurricular activities, interscholastic athletics , campus driving and parking privileges Once students are in the random drug testing pool, parents must sign an opt-out form if student stops participation in extra-curricular activities, interscholastic athletics, or campus driving.This program is not intended to punish students, but to help them. However, students who test positive will be excluded from participation from extracurricular activities included in this policy until the student completes a comprehensive substance abuse assessment, provides a medical doctor's release for participation in the activities included in this policy, and has a negative drug test to protect his/her safety and health and that of others in the school environment.Any parent of a student in grades 9-12 may consent to the student voluntarily participating in the random drug testing program, whether or not the student is a participant in any of the privileged activities listed above. The same procedures will apply for all students participating in random student drug testing.Nothing in this policy is intended to alter other school district policies or practices in dealing with drug or alcohol use or possession. No OSS or charges will be filed based on the results of a random drug test.Wilkes County School personnel shall not assist with the actual testing or physical collection of the student samples, shall have no access to the test samples, and shall not select the students who will be randomly tested.The contracted test administrator (vendor) will "randomly" select the students to be tested. Only the MRO (Medical Review Officer, provided by the vendor) and the District Drug Test Coordinator will know the results.In the event that a student tests "positive" for a prohibited substance, the MRO will inform the District Drug Testing Coordinator of the positive test result. The District Drug Testing Coordinator will contact the parent/guardian of the student and give them the opportunity to explain the positive result (through prescription or other medical information), to have the remaining sample retested (if available and at the student and parent/guardian's expense), or to have a new sample tested, pursuant to procedures established for this policy. Any expense incurred in an attempt to refute a positive drug test will be assumed by the parent and/or guardian.If a student refuses to participate when selected to be tested, it will be treated as a positive test result. If a student leaves school or skips class without a valid excuse after it becomes known that students are being tested, this shall be considered a refusal to be tested. If a student indicates that he/she is physically unable to be tested due to medical reasons, the medical review officer will consult with the student's physician and determine whether or not the student has a legitimate medical reason for being excused from the testing.Students will be subject to a mandatory drug retest within 60 calendar days of the first positive test by the school system contracted provider to be paid for by WCS.If a student fails a drug test for the second time during the same academic year, whether from a subsequent random test or the mandatory follow-up test, the student will be excluded from participation in the privileges named in this policy for the remainder of the semester.TO READ THE ENTIRE POLICY VIS ITWWW.WILKESCOUN 58521649160Wilkes County Schools Random Student Drug Testing 2016-2017Statement of ParticipationStudent's Full Name: ----------------------------------(First)(Middle)(Last)Student's ID#: _ _ __Please check the box that corresponds to the school your child currently attends:[J East Wilkes High School [J North Wilkes High School [J West Wilkes High School [J Wilkes Central High School[J Wilkes Early College High SchoolBy signing below, Iattest to the fact that I have read, understand, and agree to abide by the WCS Random Student Drug Testing Policy. I understand that this form must be completed in its entirety and returned to the school my child attends before he/she is eligible to participate in extra-curricular activities, interscholastic athletics, and/or drive on campus.Furthermore, by signing below, I am giving consent for my child to be included in the random drug testing pool for the 2016-2017 school year.Student Signature: __Date: _ _ _Parent Signature :__ _ _Date: _ _ ................
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