2019-2020 BLYTHEWOOD CHEERLEADING TRYOUT PACKET

Dear Parents: We are excited that your child is trying out for cheerleading at Blythewood High School April 23rd through April 26th. This letter gives us the chance to let you know more about the program, as well as some of the things we expect from our cheerleaders. First, we have three cheerleading squads at Blythewood: JV, Varsity Basketball Spirit and Varsity Competitive. Varsity Spirit will ONLY be responsible for cheering for basketball season. All three teams require a high level of commitment. The students who make the teams must understand this. They are not to try out for other teams or activities that will eliminate them from cheering and attending practices. They MUST be willing to make this commitment. Secondly, their scholarship is as important to us as it is to you. Cheerleaders must maintain a credible scholastic record, an overall passing average, in their academic classes. Cheerleading is under the South Carolina High School League guidelines, so grades will be monitored. A failing grade could, therefore, cause the cheerleader to be removed from the team. Third, a normal schedule may cause a cheerleader to be out one evening during the week in the fall and two evenings a week during the winter for games. Once school starts, JV and Varsity Competitive cheerleaders will typically have every Wednesday off to schedule appointments, tutoring, etc. However, occasionally, an exception is necessary during our competition season. Schedules will be given out each month. We ask that you help your child plan around our practice and game schedules. All practices and events are mandatory! Fourth, it will be necessary to do fundraising for items that are required for cheerleading. In this packet, you will find an expenditure list of what will be needed. The reason we do fundraisers is to offset the cost for the parents. The first fundraiser of the season is not mandatory. However, for those who participate, all proceeds made from the first fundraiser will be deducted from the total cost of your child’s required items. There will be a parent meeting on May 1st for anyone who makes a team. The stunt clinic payment and booster club fee will be due at that time. Packets for the first fundraiser will also be handed out at the meeting. Each team will decide on a plan for additional fundraising. As a part of the team, everyone is expected to participate. Our goal as coaches is to encourage the following qualities in every cheerleader: time management, good sportsmanship, leadership, good manners, mature and responsible behavior, cooperative attitude, and an awareness of fulfilling one’s obligations. We hold very high expectations for all of our cheerleaders and expect them to be model students, as they will be chosen to represent Blythewood High School, as well as this program. THIS IS SOMETHING WE TAKE VERY SERIOUSLY. A cheerleader who continuously fails to meet these qualities will be dismissed from the team. Please rest assured that each and every attempt to achieve this goal is with your child’s best interest at heart. Please talk with your child about these goals and expectations. If they feel that it is too much to ask of them, please encourage them not to try out. However, if they feel they can make such a commitment and you feel that you can support them in this, please encourage them in every way. We look forward to another great season! Sincerely, Kelly Edrington Joe Mulero Kim Scott BHS Head Varsity Cheer Coach BHS Assistant Varsity Cheer Coach BHS Varsity B-Ball Spirit Cheer Coach

Brittney White Brantley Herndon BHS Head JV Cheer Coach BHS Assistant JV Cheer Coach

General Rules and Regulations for Cheerleading Tryouts

1. All uniforms must be turned in and athletic fees must be paid in full from the previous

year in order to tryout. 2. You must be eligible under the provisions of the South Carolina High School League

and Richland School District Two. These guidelines state that a student must have a passing average (2.0) to be eligible for participation in athletics.

3. Attend all tryout practices unless you are involved in another BHS athletic event. If you are involved in a spring sport, that sport has to come first! If you miss a tryout practice, you will need to find out what was covered at practice and learn this on your own time. PLEASE CONTACT/SEE COACH KELLY IF THIS APPLIES TO YOU!

4. Blythewood Cheerleading clothes are not to be worn at tryouts. Dress for all tryout practices in shorts, tank top/t-shirts, adequate support tennis shoes (no platforms or casual tennis shoes) and socks. Hair will need to be secured away from your face in a neat ponytail with a bow.

5. Be on time for each tryout practice. PLEASE CONTACT/SEE COACH KELLY IN ADVANCE IF YOU HAVE A CONFLICT!

6. FINAL EVALUATIONS – Wear a white t-shirt with navy, gold, grey or black shorts & a bow. Look ready to perform!

7. Please be attentive at all times. Excessive talking during demonstrations and practice will not be permitted.

8. No jewelry will be worn during tryouts. This is considered a safety violation in cheerleading.

9. Fingernails will need to be cut so that if you are looking at your palm you would see no part of the nail.

10. No chewing gum. 11. You are encouraged to bring a water bottle to use throughout tryouts to keep you

hydrated.

Final evaluations will take place on FRIDAY, APRIL 26TH. In addition to the evaluation you receive that day, your performances from Tuesday, Wednesday & Thursday will also be

considered.

PLEASE KNOW THAT THE JUDGES’ DECISIONS ARE FINAL!!

IMPORTANT DATES FOR BLYTHEWOOD CHEERLEADING TRYOUTS Spring 2019 Tryout Schedule

Date Time Location Material

Tuesday, April 23 4:30-7:30 BHS Big Gym Learn material

Wednesday, April 24 4:30-7:30 BHS Big Gym Tumble/Stunt/Review

Thursday, April 25 4:30-7:30 BHS Big Gym Tumble/Stunt/Review

Friday, April 26 4:30-Until BHS Big Gym Final Evaluations

2019-2020 MINIMUM SQUAD REQUIREMENTS JV (Year Round) Each candidate will be required to do the following:

- Cheer/Sideline - Dance - Toe Touch - Jump of Choice - Standing Back Handspring (strongly recommended) - Round off Back Handspring (strongly recommended)

VARSITY BASKETBALL SPIRIT (Basketball ONLY) Each candidate will be required to do the following:

- Cheer/Sideline - Dance - Toe Touch - Jump of Choice

VARSITY COMPETITIVE (Football) Each candidate will be required to do the following:

- Cheer/Sideline - Dance - Toe Touch - Jump of Choice - Clean Standing Back Handspring* - Round off Tuck* - Standing Tuck OR Two to Tuck* - Two to Layout and/or Round off Back Handspring Layout (strongly recommended)

Each candidate will be evaluated in the following categories:

Attitude, Academics, Cheerleading Ability, Dance, Gymnastics (Tumbling), Jumps, Motion Technique, Projection, Stunting and Teacher Recommendations

*The coach reserves the right to place candidates on the team with tumbling less than the requirements based on their stunting position and other athletic abilities.

* Please attach picture here*

BLYTHEWOOD CHEERLEADING TRYOUT INFORMATION SHEET

NAME: _______________________________ CURRENT GRADE: _______________ ADDRESS: ____________________________CELL #: ________________________ HOME PHONE: ________________________ EMAIL ADDRESS: _______________ MOTHER'S NAME: _____________________ CELL #: ________________________ MOTHER’S EMAIL ADDRESS: ____________________________________________ FATHER'S NAME: ______________________ CELL #: ________________________ FATHER’S EMAIL ADDRESS: _____________________________________________ Cheer Information Have you cheered before? How long? ____________________________ What teams have you cheered for? ____________________________ RISING FRESHMEN: Would you cheer on a non-competitive B-Team? YES NO RISING JUNIORS: Would you cheer JV as a Junior? YES NO Should you make Varsity, please circle which team(s) you would like to participate on. (Please note the tumbling requirements for Varsity Competitive on the previous page.) FB/COMPETITIVE ONLY B-BALL SPIRIT ONLY COMPETITIVE AND B-BALL SPIRIT What position will you be trying out for? (Circle all that apply.) If you choose “flyer” you will be asked to pull body positions showing flexibility skills at tryouts. BASE FLYER SPOTTER What tumbling skills can you perform BY YOURSELF? (Do not list a skill if you cannot perform it by yourself because you will be asked to perform this skill at tryouts!!) What tumbling skills are you currently working on? Do you have any extracurricular activities that would interfere with cheerleading? If so, what are they? Tell me anything you think I should know about you.

Will you be attending Blythewood High School through our District School CHOICE Program? (Circle one.) Yes No If yes, please attach school of choice documentation and indicate what high school you are zoned for below. ____________________________ Are you a rising 7th or 8th grader? (Circle one.) Yes No **If you are a rising 7th or 8th grader, you will need to complete the middle school eligibility form from the Richland School District Two website.** **If you are transferring to BHS from another school, you will need to complete the transfer student form from the Richland School District Two website.**

2019-2020 BLYTHEWOOD CHEER EXPENDITURE LIST & INFORMATION

Time commitment involved in COMPETITIVE cheerleading: May: One to two days a week, plus Rockstar Week of May 6: All teams begin Rockstar (VA Comp: Mon. 5:30 PM-7:30 PM, JV: Tues. 6:30 PM-

8:30 PM, JV Flyer Stretch: Tues. 6:00 PM-6:30 PM) May 18: Skills Clinic at Rockstar from 9:00 AM-3:00 PM (VA Comp & JV Only) June 3: Begin practicing Mon., Tues. & Thurs. during June (VA Comp & JV Only) June 10-14: OFF June 18-20: Little Girls Clinic (VA Comp Only) June 22-23: Choreography (VA Comp Only) June 22 or 29 (TBD): Car Wash Fundraiser (JV Only) Month of July: OFF August 1: Official start of MANDATORY practice August 16-17: Choreography (JV Only) Items/events cheerleaders pay for: These prices are APPROXIMATE. Payment dates are spread out and fundraisers can be done to help lower the costs to individuals. REQUIRED: Poms: $30.00 Athletic Eligibility Fee (JV/VA Comp Only): $50.00 (paid to BHS) Booster Club Fee: $30.00 (paid to Blythewood Cheer Booster) Skills Clinic (JV/VA Comp Only): $65.00 (includes 1 practice outfit) Practicewear (JV/VA Comp Only): $200.00 (includes 3 practice outfits and bows, if needed) Choreography (VA Comp Only): $200.00 Choreography (JV Only): $150.00 Competition Bow (JV/VA Comp Only): $30.00 Rockstar (JV: May-Oct./VA Comp: May-Nov.): $50 per mth (includes 2 hour weekly squad class) Additional Tumbling Class (JV: Aug.-Oct./VA Comp: Aug.-Nov.): Option 1 – Rockstar: $70 per mth (includes 2 hour weekly squad class and 90 minute weekly tumbling class) OR Option 2 – ACX Twisters: $40 per mth (includes 1 hour weekly tumbling class) *Members of the Varsity Competitive team may also be required to purchase a pair of black or grey cheer shoes at an estimated $115.00 depending on the new competition uniforms.*

IF NEEDED:

Briefs: $10.00 Bag (including monogram): $85.00 Warm Up (including name on jacket): $195.00 Shoes: $95.00 Bows: $8.00-$10.00 per bow BHS Sweatshirt: $65.00 (required for Varsity Competitive/Optional for

Varsity Basketball Spirit & JV) OPTIONAL:

Bengal Pullover (VA Comp Only): $115.00 *highly recommended* Varsity Letter Jacket (Varsity Only): $125.00

Blythewood Cheerleading Parent/Student Permission Form

_______________________________________ has my permission to try out for cheerleading at Blythewood High School. I recognize that cheerleading is a strenuous activity. In that regard, I know of no pre-existing condition, injury, or illness, etc. which would limit my child’s participation at tryouts. I give permission for my child to participate in stunting, tumbling and all other cheerleading activities for tryouts. I have read the tryout packet and will assist in helping to see that the cheerleading rules are upheld both during tryouts and if my child should make the squad. I will also see that he/she gets a physical dated after April 1, 2019, attends all summer camps, practice sessions and games unless excused by the coach in advance. I have read and understand the costs I will acquire if my child is selected to be a cheerleader at Blythewood High School, and I accept the responsibility of these costs if my child is chosen. I understand that should my child be selected for a competitive team, he/she is required to participate in a weekly squad class at Rockstar and an additional weekly tumbling class at Rockstar or ACX Twisters. I also understand that the decisions of the coaches are final. _______________________________________ ____________________ Parent/Guardian Signature Date ________________________________________ Parent/Guardian Name in Print

______________________________________ ____________________ Student Athlete’s Signature Date ______________________________________ Student Athlete’s Name in Print

BHS Cheer Participant Acknowledgment and Agreement

The student must read the statement below and sign to indicate his/her understanding of all rules and regulations of this tryout. I will attend all scheduled practices and accept the final decision of the coaches. I am willing to abide by the rules and regulations established for this tryout and will be in the gym at the specified times in this packet on the dates specified for tryout practices. I have read this packet and understand the dates, locations and times that tryouts are being held. I also understand that if I make any cheerleading squad at Blythewood High School, I am expected to uphold the standards specified by the coach. I agree to uphold the specified standards and understand that if I do not I can be dismissed from the cheerleading program. I understand that I am allowed 2 unexcused absences during football/competitive season and 2 unexcused absences during basketball season and that if I exceed those absences I may be removed from the team. I understand that I am required to participate in a weekly squad class at Rockstar and an additional weekly tumbling class at Rockstar or ACX Twisters and that if I miss either it will count against my absences. I also understand that the decisions of the coaches are final. ______________________________________ __________________ Student Signature Date ______________________________________ Student’s Printed Name

TEACHER RECOMMENDATION FORM

__________________________ __________________________ Name of Student School/Current Grade Level __________________________ __________________________ Teacher Subject This student is trying out for cheerleading at Blythewood High School for the upcoming school year. Each participant must have at least 2 teacher recommendations completed as part of the eligibility requirements. These forms are confidential and will at no time be seen by the student. Please complete the form below and e-mail it to kelly.edrington@att.net or return it to the box marked “BLYTHEWOOD CHEERLEADING” located in the main office before Friday, April 12th at 4:00 PM. Thank you so much for your time and efforts in helping to build positive school spirit at Blythewood! Sincerely, Kelly Edrington BHS Varsity Cheerleading Coach

Please use the following rating system:

0 1 2 3 4 5 very poor poor fair good very good excellent ______ Gets along well with others ______ Dependability & Honesty ______ Completes tasks without complaint ______ Punctuality ______ Follows directions/Respects authority ______ Effort ______ Conduct in the classroom ______ Academic responsibility ______ Total Points Did this student have a “D” or below for the semester in your class? _______________ Has this student received any discipline referrals, ISS or OSS? _______________ Comments:______________________________________________________________________________________________________________________________________________________________________________________________

TEACHER RECOMMENDATION FORM

__________________________ __________________________ Name of Student School/Current Grade Level __________________________ __________________________ Teacher Subject This student is trying out for cheerleading at Blythewood High School for the upcoming school year. Each participant must have at least 2 teacher recommendations completed as part of the eligibility requirements. These forms are confidential and will at no time be seen by the student. Please complete the form below and e-mail it to kelly.edrington@att.net or return it to the box marked “BLYTHEWOOD CHEERLEADING” located in the main office before Friday, April 12th at 4:00 PM. Thank you so much for your time and efforts in helping to build positive school spirit at Blythewood! Sincerely, Kelly Edrington BHS Varsity Cheerleading Coach

Please use the following rating system:

0 1 2 3 4 5 very poor poor fair good very good excellent ______ Gets along well with others ______ Dependability & Honesty ______ Completes tasks without complaint ______ Punctuality ______ Follows directions/Respects authority ______ Effort ______ Conduct in the classroom ______ Academic responsibility ______ Total Points Did this student have a “D” or below for the semester in your class? _______________ Has this student received any discipline referrals, ISS or OSS? _______________ Comments:______________________________________________________________________________________________________________________________________________________________________________________________

■ Preparticipation Physical Evaluation

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.

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?

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 _____________________

©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

Signature of athlete Signature of parent/guardian Date

■ Preparticipation Physical Evaluation

PHYSICAL EXAMINATION FORM

Name __________________________________________________________________________________ Date of birth __________________________

PHYSICIAN REMINDERS1. 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 condi-

tions 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

©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

Signature of physician

Name of physician (print/type) _____________________________________________________________________________________________________ Da

Address ___________________________________________________________________________________________________________

_____________________________________________________________________________________________________ Date

Phone _________________________

RICHLAND DISTRICT 2 SPORTS HEALTH FORM Please print clearly. Please do not leave any blanks (mark “n/a” as appropriate).

Last Name _________________________________ First Name _____________________ MI_____ Date of Birth ___/___/_____

RSD2 Email _______________________@richland2.org School Year _____-______ Grade _____ Age ______ Sex ________

Mailing Address _____________________________________________ City ___________________________ Zip __________

Athlete’s Cell # (____)_____-______ Home # (____)_____-______ Personal Email ______________________________________

Family Doctor ___________________ Phone # (___)____-______ Family Dentist _______________ Phone # (___)____-______

Family Orthopedist _______________________ Phone # (___)____-______ Preferred Hospital ___________________________

Guardian Name ______________________ Relation: _______________ Cell # (____)_____-______ Work # (____)_____-______

Guardian Name ______________________ Relation: _______________ Cell # (____)_____-______ Work # (____)_____-______

Emergency Contact Name (other than parent/guardian)________________________________ Relation to Athlete ________________

Home # (____)_____-______ Cell # (____)_____-______ Work # (____)_____-______ Other # (____)_____-______

As the parent or legal guardian of the above named student-athlete, I/we give my permission for his/her participation in athletic

activities and pre-participation physical evaluation (PPE) by a physician, physician’s assistant, or nurse practitioner for that

participation. I/We understand that the PPE is simply a screening evaluation and not a substitute for regular healthcare. I/We know

that the risk of injury/illness to my child comes with participation in sports and during travel to/from activities. I/We have had the

opportunity to understand the risk of injury during participation in sports through meetings, written information, or by some other

means and give my/our permission to participate in interscholastic athletics.

Richland School District 2 carries athletic accident insurance on all its athletes, intended to be an “excess” policy designed to pay after

the athlete’s primary health insurance. In the event of injury, while participating as a part of a SCHSL sanctioned sports team

representing RSD2, the athlete should seek the attention of their school’s Sports Medicine staff as soon as possible. A staff member

will fill out the top portion of the insurance claim form. The parent/guardian should complete the remainder of the form, follow the

attached directions, and mail the completed form to the insurance company. Medical care must be initiated within 60 days, and forms

must be submitted directly to Bollinger Insurance Company by the PARENT within 90 days of the date of injury to be eligible for

coverage. RSD2 or its schools cannot be held responsible for the financial or other costs associated with injuries sustained while

participating in athletics.

I/We grant permission to Nurses, Certified Athletic Trainers, Coaches, Physicians or those under their direction who are part of

athletic injury prevention and treatment, to have access to all necessary medical information. I/We grant the school’s Sports Medicine

staff access to medical information concerning my son/ daughter by a physician or their staff. Likewise, the school’s Sports Medicine

staff may release medical information to Physician’s offices, Coaches, Nurses, Administrators, and school/district Faculty/Staff.

I have received and understood information in some means regarding concussions and brain injury, which has informed me of the

nature and risk of concussion and brain injury, including the risks associated with continuing to participate in physical activity after a

concussion or brain injury. I understand that any symptom(s) of concussion should be reported to my child’s coach immediately, and

that my child should not participate in any physical activity, driving of a motor vehicle, or strenuous mental activity until evaluated for

concussion and cleared by an appropriate healthcare provider (physician, athletic trainer, physician assistant, or nurse practitioner). If

diagnosed with a concussion, I understand that my child must be symptom free, cleared by a licensed physician, and complete a

gradual return to play protocol supervised by a qualified medical professional prior to resuming physical activity in accordance with

South Carolina State Law. It is highly recommended that the clearing physician be specifically trained in the management of sports

related concussion.

I/We give consent for Certified Athletic Trainers and Coaches to use their own judgment in either providing or securing medical care

or ambulance service during a medical emergency, when a parent/guardian cannot be reached. Furthermore, I/we give permission for

our son/daughter to receive medical care, without explicit parental notification, from the school’s Sports Medicine staff and/or Team

Physicians if he/she becomes injured while participating in athletics.

By signing below, I attest that the provided information is correct, and that I understand and agree to the statements above regarding

Permission to Participate, Assumption of Risk, Secondary Insurance Acknowledgement, Release of Medical Information, Concussion

Acknowledgement, and Consent for Medical Treatment. I/We commit to reporting ALL injuries and illnesses to the Sports Medicine

staff, especially any symptoms of a possible concussion. Please contact the school’s Sports Medicine Staff prior to scheduling any

appointments for injuries sustained as a result of participation in athletics. I/We also understand that the Sports Medicine staff

requires written documentation and clearance from any medical care received prior to returning to activities, even if it is not the

result of participation in athletics. When the Sports Medicine staff determines that advanced medical care is required, the athlete must

provide written clearance from an appropriate provider, prior to returning to participation. I/we will not condone participation in any

activities against medical advice or until the athlete is cleared by an appropriate medical provider (as determined by the school’s

Sports Medicine staff).

Parent’s Signature __________________________________________________________________ Date _____________________

Student’s Signature _________________________________________________________________ Date _____________________

PERMISSION TO PARTICIPATE, ASSUMPTION OF RISK, SECONDARY INSURANCE ACKNOWLEDGEMENT

RELEASE OF MEDICAL INFORMATION

CONCUSSION ACKNOWLEDGEMENT

CONSENT FOR MEDICAL TREATMENT

Parent’s Signature ______________________________

Student’s Signature

Parent’s Signature Date

Date

RICHLAND DISTRICT 2 SPORTS HEALTH FORM Please print clearly. Please do not leave any blanks (mark “n/a” as appropriate).

Last Name _________________________________ First Name _____________________ MI_____ Date of Birth ___/___/_____

Does the above athlete receive Medicaid benefits? ___ Yes ___ No (If yes, RSD2 insurance becomes primary coverage.) Providing insurance information is optional, but may assist in more accurate claims processing in the event of an emergency when parents are not present. RSD2 does

not file claims to private insurance companies, and it is ultimately the parents’ responsibility to provide this information to all medical providers at the time of service.

Insurance Provider ______________________________________ Policy # _____________________ Group # _____________

Claims Mailing Address ___________________________________________ City _______________ State ____ Zip _________

Policy Holder’s Name ________________________________ Date of Birth ___/___/_____ Relation to Athlete ______________

Policy Holder’s Employer _____________________________ Referral required prior to specialist care? ___ Yes ___ No

Richland School District 2 carries athletic accident insurance on all its athletes, intended to be an “excess” policy designed to pay

after the athlete’s primary health insurance. In the event of injury, while participating as a part of a SCHSL sanctioned sports team

representing RSD2, the athlete should seek the attention of their school’s Sports Medicine staff as soon as possible. A staff member

will fill out the top portion of the insurance claim form. The parent/guardian should complete the remainder of the form, follow the

attached directions, and mail the completed form to the insurance company. Medical care must be initiated within 60 days, and

forms must be submitted directly to Bollinger Insurance Company by the PARENT within 90 days of the date of injury to be

eligible for coverage. RSD2 or its schools cannot be held responsible for the financial or other costs associated with injuries

sustained while participating in athletics.

Further information regarding the recognition and management of concussion may be requested directly from the Head Athletic

Trainer at any RSD2 high school. Parents of middle school students may request the assistance of any RSD2 high school athletic

trainer in securing appropriate medical care if their child exhibits the signs or symptoms of concussion.

The Richland Two Sports Medicine Team is dedicated to providing excellent medical services to athletes throughout the District. All

parents (including parents of middle school athletes) should feel free to contact a High School Athletic Trainer should you have any

health or injury related questions or concerns regarding your child’s participation in athletics in Richland Two.

Athletic Trainers (ATs) are health care professionals who collaborate with physicians. The services provided by ATs comprise

prevention, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions. Students

who want to become certified athletic trainers must earn a degree from an accredited athletic training curriculum. Accredited programs

include formal instruction in areas such as injury/illness prevention, first aid and emergency care, assessment of injury/illness, human

anatomy and physiology, therapeutic modalities, and nutrition. Classroom learning is enhanced through clinical education experiences.

More than 70 percent of certified athletic trainers hold at least a master’s degree. For more information about the education and

qualifications of Athletic Trainers, visit www.nata.org.

High School Athletic Trainer Email Phone

Blythewood Steve Meisel smeisel@richland2.org 803-691-4090 ext. 28932

Richland Northeast Nicole Barton nbarton@richland2.org 803-699-2800 ext. 79867

Ridge View Mike Crook jcrook@richland2.org 803-699-2999 ext. 409

Spring Valley Paul Dobyns pdobyns@richland2.org 803-699-3500 ext. 69908

Westwood Jason Nussbaum jnussbaum@richland2.org 803-691-4049 ext. 36829

HEALTH INSURANCE INFORMATION

CONCUSSION INFORMATION

DISTRICT ATHLETIC TRAINER INFORMATION