DETROIT DELTA PREP ACADEMY ATHLETIC PARTICIPATION FORM ALL HIGHLIGHTED AREAS ON 6 PAGES MUST BE COMPLETED PRIOR TO

STUDENT PARTICIPATION IN ATHLETICS *All Student Athletes MUST have on file the “MHSAA Concussion Awareness Form” prior to participation*

CONTACT INFORMATION Student Name: School Year:

Home Address: City:

Name of Parent/Guardian(s):

Address (if different from above): City:

Mother: (Home Phone): ( ) - _ (Cell): ( ) -

Father: (Home Phone): ( ) - (Cell): ( ) -

IN CASE OF EMERGENCY, CONTACT:

Name: Relationship: _

(Home) ( ) - ) (Cell ) ( ) -

Personal Physician: Phone:

ALTERNATIVE TRANSPORTATION LIABILITY RELEASE Parent Initial: Detroit Delta Prep Academy is not always able to provide transportation for students to off campus extracurricular school activities. In cases when transportation is not provided by Detroit Delta Prep Academy, as in the use of a school bus or charter bus, it is the responsibility of the student’s parents/guardian to secure their student’s attendance at such activities. Detroit Delta Prep, its employees or designees shall not be responsible for any injury or loss arising out of a student’s transportation to or from the off campus activity when such transportation is provided by parents, student, staff or any other party.

MEDIA RELEASE Parent Initial: I hereby give my consent to all photographs, audio recordings, academic work and/or video recordings taken of me or my minor child by Detroit Delta Prep Academy staff or their designee. I understand that any such photographs, audio recordings, academic work and/or video recordings become the property of the local school or district and may be used by the school, district or others within their consent, for educational, instructional or promotional purposes determined by the district in broadcast and electronic media formats now existing or in the future created.

ATHLETIC CODE OF CONDUCT

Parent lnitial: Student Initial:

Detroit Delta Prep Academys’ athletic programs are a great source of pride to our communities. Involvement in athletics helps students develop a better sense of responsibility, cooperation; self-discipline, self-confidence, and sportsmanship that will help serve them long after graduation. The lessons and values learned by participating on athletic teams last a lifetime.

All athletes are expected to abide by the highest standards of fair play and sportsmanship while on the court or field. We also have high expectations regarding behavior when the students are not engaged in athletic competitions. Students participating in Michigan High School Athletic Association extracurricular athletic activities act as representatives of Detroit Delta Prep Academy. All students are expected to conduct themselves in such a manner as to meet the highest standards of the school system at all times.

The Athletic Code of Conduct is designed to establish high expectations and standards for all students participating in Michigan High School Athletic Association sanctioned athletic activities. The Code of Conduct also provides consistent consequences when violations occur. The consequences listed on the Code of Conduct are minimum standards. The schools can set consequences over and above those listed on the Code of Conduct.

I have read the Detroit Delta Prep Academy Athletic Code of Conduct in the Athletic Handbook and I understand the potential consequences that go along with violating the Athletic Code of Conduct.

Parent Initial: Parent Initial:

PERMISSION TO TREAT I give my permission for the coaches, certified athletic trainers and/or their

designees to administer treatment for illness, injury or rehabilitation, In the event of an emergency and I cannot be reached, I grant permission to the

school personnel, coaches and/or certified athletic trainers to activate the Emergency Action Plan.

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PARENTAL CONSENT FOR ATHLETIC PARTICIPATION

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

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

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

PERMISSION FORM.

I (we) hereby give consent for _ to:

(1) Compete in athletics at Detroit Delta Preparatory Academy School for Social Justice in Michigan High School Athletic Association approved sports; (2) To accompany any school team of which the student is a member on any of local or out of town trips; (3) and I hereby verify that information included on this form is correct and understand that any false information may result in my son/daughter being declared ineligible.

The student is enrolled at Detroit Delta Prep Academy. Yes No If “No” please explain: Has student attended Detroit Delta Prep Academy for at least one full school year? Yes No

Date of Birth Date student entered the 9th grade

I accept and acknowledge the risks involved in extra-curricular activities and give consent to my child to participate. Parent/Guardian Signature Date

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

Insurance Information Please INITIAL ONE of the following statements regarding insurance coverage for your son/daughter for the school year.

My son/daughter is adequately and currently covered by accident insurance that will cover injuries sustained while

participating in interscholastic athletes (including, but not limited to, varsity and junior varsity football).

Company providing insurance Name of insured Policy#

My son/daughter is not currently covered by accident insurance.

MEDICAL AUTHORIZATION I certify that the medical history on this form is complete and accurate. I understand that this will serve as the basis for determining that my child, , may compete in high school athletics at Detroit Delta Prep Academy. I also understand that this medical evaluation is only to determine fitness for athletics and is not to take the place of regular medical examinations. In case of an emergency or accident on the school grounds or during any school activity involving my child,

, which in the opinion of school authorities present requires immediate medical or surgical attention, I hereby grant permission to physicians, consulting physicians, certified athletic trainers, emergency medical technicians, and other healthcare providers selected by school authorities to provide medical care and treatment (including hospitalization if deemed appropriate by school authorities or an appropriate healthcare provider) unless I am present and request otherwise or until I later request otherwise.

PLEASE SIGN HERE: THIS SIGNATURE CONSENTS TO TRANSPORTATION LIABILITY, MEDIA RELEASE, CODE OF CONDUCT, PERMISSION TO TREAT, ATHLETIC PARTICIPATION, VERIFICATION OF INSURANCE COVERAGE AND MEDICAL AUTHORIZATION. THIS SIGNATURE ALSO REPRESENTS THAT ALL INFORMATION PROVIDED IN THIS ATHLETIC PARTICIPATION FORM IS ACCURATE AND COMPLETE.

SIGNATURE OF ATHLETE SIGNATURE OF PARENT/GUARDIAN DATE

Educational Material for Parents and Students (Content from MDHHS Requirements)

Sources: Michigan Dept. of Health and Human Services. Created through a grant to the CDC Foundation from NOCSAE.

UNDERSTANDING CONCUSSION

Some Common Symptoms

Headache Pressure in the Head

Nausea/Vomiting Dizziness

Balance Problems Double Vision Blurry Vision

Sensitive to Light

Sensitive to Noise Sluggishness

Haziness Fogginess

Grogginess

Poor Concentration Memory Problems

Confusion “Feeling Down”

Lost Consciousness

Not “Feeling Right” Feeling Irritable

Slow Reaction Time Sleep Problems

WHAT IS A CONCUSSION?

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a fall, bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. A concussion can be caused by a shaking, spinning or a sudden stopping and starting of the head. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious. A concussion can happen even if you haven’t been knocked out. You can’t see a concussion. Signs and symptoms of concussions can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If the student reports any symptoms of a concussion, or if you notice symptoms yourself, seek medical attention right away. A student who may have had a concussion should not return to play on the day of the injury and until a health care professional says they are okay to return to play.

IF YOU SUSPECT A CONCUSSION: 1. SEEK MEDICAL ATTENTION RIGHT AWAY – DON’T HIDE IT, REPORT IT. Playing or practicing with concussion symptoms is

dangerous and can lead to a longer recovery. A health care professional will be able to decide how serious the concussion is and when it is safe for the student to return to regular activities, including sports. Ignoring symptoms and trying to “tough it out” often makes it worse.

2. KEEP YOUR STUDENT OUT OF PLAY – Concussions take time to heal. Don’t let the student return to play the day of injury and until

a heath care professional says it’s okay. A student, who returns to play too soon, while the brain is still healing, risks a greater chance of having a second concussion. Young children and teens are more likely to get a concussion and take longer to recover than adults. Repeat or second concussions increase the time it takes to recover and can be very serious. They can cause permanent brain damage, affecting the student for a lifetime. They can be fatal. It is better to miss one game than the whole season.

3. TELL THE SCHOOL ABOUT ANY PREVIOUS CONCUSSION – Schools should know if a student had a previous concussion. A student’s

school may not know about a concussion received in another sport or activity unless you notify them.

SIGNS OBSERVED BY PARENTS: • Appears dazed or stunned • Is confused about assignment or

position • Forgets an instruction

• Can’t recall events prior to or after a hit or fall

• Is unsure of game, score, or opponent • Moves clumsily

• Answers questions slowly • Loses consciousness (even briefly) • Shows mood, behavior, or personality

changes

CONCUSSION DANGER SIGNS: In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. A student should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

• One pupil larger than the other • Is drowsy or cannot be awakened • A headache that gets worse • Weakness, numbness, or decreased

coordination • Repeated vomiting or nausea

• Slurred speech • Convulsions or seizures • Cannot recognize people/places

• Becomes increasingly confused, restless or agitated

• Has unusual behavior

• Loses consciousness (even a brief loss of consciousness should be taken seriously.)

HOW TO RESPOND TO A REPORT OF A CONCUSSION:

If a student reports one or more symptoms of a concussion after a bump, blow, or jolt to the head or body, s/he must be kept out of athletic activity the day of the injury. The student shall only return to activity (practice, scrimmage or competition) with written unconditional permission from an MD, DO, Physician’s Assistant or Nurse Practitioner. During recovery, rest is key. Exercising or activities that involve a lot of concentration (such as studying, working on the computer, or playing video games) may cause concussion symptoms to reappear or get worse. Students who return to school after a concussion may need to spend fewer hours at school, take rests breaks, be given extra help and time, spend less time reading, writing or on a computer. After a concussion, returning to sports and school is a gradual process that should be monitored by a health care professional. Remember: Concussion affects people differently. While most students with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer. To learn more, go to www.cdc.gov/concussion. Concussion Educ. Materials & Acknowledge Form (May 2016)

Parent and Student Must Sign Consent & Waiver on MHSAA Physical Form Acknowledging Awareness

This portion below may be substituted for the signatures on the MHSAA Physical Form

CONCUSSION AWARENESS

EDUCATIONAL MATERIAL ACKNOWLEDGEMENT FORM

By my name and signature below, I acknowledge in accordance with Public Acts 342 and 343 of 2012 that I have received and reviewed the Concussion Fact Sheet for Parents and/or the Concussion Fact Sheet for Students provided by ________________________________________________________ Sponsoring Organization

___________________________________ Participant Name Printed ___________________________________ Participant Name Signature ___________________________________ Date

___________________________________ Parent or Guardian Name Printed ___________________________________ Parent or Guardian Name Signature ___________________________________ Date

Return this signed form to the participant’s MHSAA member school. The school should keep this document on file for five years following the student’s high school graduation. Participants and parents please review and keep the educational materials available for future reference.