2019-2020 Extra-Curricular Activities

Eligibility & Student Participation Policy LCHS & LCMS

Please review the attached policy, complete, initial and sign each required page. This packet must be turned in to the school office (NOT your coach) prior to student participation in ANY extra-curricular activity. This packet must be on file with current physical before student may practice for any athletic activity. Proof of medical/health insurance is required. You may purchase school insurance online at www.studentinsurance-kk.com. Each sport has a separate Inherent Risk Form. Please sign all in which your student may or plans to participate.

LCHS Fees

ASB Fee $30.00 Football Fee $100.00

All other activity fees $50.00

LCMS Fees ASB Fee $30.00

Activity Fee $40.00

La Conner School District Official Use Only

Extra-Curricular Eligibility ASB

Student Name _______________________________________________ Last First M.I. Activity Fee

Home Address:______________________________________________ Physical good through _________________

______________________________________________ Medical Release

Risk Assessment (Sport specific) Track _____ Cheer____ Insurance

FB____ VB_____ Soccer _____ BKB _____ Wresting ______ Eligibility Code

Knowledge Bowl _____ BB/SB ______ Concussion/SCA Form (completion of this (form April – August will carry through the upcoming school year)

False information may result in the loss of extra-curricular eligibility and the forfeiture of team competitions.

1. Do you reside within the La Conner School District? Yes_____ No _____ 2. Do you reside with your parents? Yes_____ No _____ 3. Are you currently enrolled in at least four (4) subjects? Yes _____No _____ 4. Were you enrolled as a full-time student and pass all your classes last semester? Yes _____No _____ 5. Have you experienced any truancy issues last semester? Yes _____No _____ 6. Are you a foreign exchange student? Yes _____No _____ 7. Are you a new student in the La Conner School District? Yes _____No _____ 8. Have you repeated any grade or withdrawn from school at any

time since the start of 7th grade? Yes _____No _____

WARNING: Participation in interscholastic athletics can be dangerous, involving multiple risks of injury. Such injuries can range from abrasions, bruises and sprains to catastrophic injuries resulting in crippling conditions, paralysis, brain damage, and even fatality. Severe injuries can impair a student’s ability to earn a living, engage in social and recreational activities and to generally enjoy life. Careful consideration should be given to the risks and dangers associated with interscholastic athletics before making a decision to participate.

The La Conner School District requires private insurance for all students participating in interscholastic activities and must be in place prior to any athletic practice/event. A student insurance plan is available for purchase through the school offices. Parents/guardians are responsible for securing medical insurance coverage for their student and for any costs of medical treatment that may be incurred as a result of the student’s extra-curricular activities participation. Should any personal insurance information change during the school year, it is the responsibility of the parent/guardian to notify the District immediately before any extra-curricular participation may continue.

Participation in an interscholastic activity such as athletics or Knowledge Bowl, or representing LCHS through ASB, band, choir or drama, is a privilege that carries a corresponding responsibility for exemplary conduct. Students are expected to abide by all school and extra-curricular policies as published by the school. Please review the attached LCSD Eligibility Code.

We acknowledge that we have READ, UNDERSTAND AND WILL ABIDE BY the above information and the attached LCSD Eligibility Code, Concussion Information Sheet and Risk Assessment for each activity in which my child participates, which we also return signed and dated, and grant permission for the above-named student to participate in interscholastic athletics/activities.

X_________________________________________________________________X__________________________________________________ Student signature Date Parent/Guardian signature Date

La Conner School District Medical Emergency Authorization Name of Student Participant _________________________________________ As parent/legal guardian, I authorize a qualified physician to examine the above-named student and in the event of any injury, to administer emergency care and arrange for any consultation by a specialist, including a surgeon, he or she deems necessary to insure proper care of any injury. Every effort will be made to contact a parent or guardian to explain the nature of the problem prior to any involved treatment. A district staff member will remain with ill/injured student until a parent/guardian is present.

Parent/Guardian Signature __________________________________________________________________Date________________________

Home/Cell phone ______________________________/_____________________________________

Emergency contact name (other than parent) ____________________________________________ phone ____________________________________________

Medical Insurance Company_______________________________________Policy number ________________________________________________________

Family Physician __________________________________________________________Phone _____________________________________________________

Known allergies ________________________________________Current medications___________________________________ Rev 05/19

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La Conner School District Extra- Curricular Student Participation Policy This policy applies to all students participating in any extracurricular activities sponsored by the La Conner School District and the Washington Interscholastic Activities Association (WIAA). These groups include but are not limited to sport teams, sport team support personnel, cheerleaders, ASB and class officers, academic teams as well as band, chorus and drama participants. At the beginning of each season, the teacher/coach shall review the requirements of the La Conner Extra-curricular Policy with all athletes/participants on his/her team or class roster. Attendance at this meeting will be required and a record of attendance kept on file in the athletic office of La Conner High School/Middle School Students and parents are required to read and sign this document and meet WIAA requirements. Philosophy The community of La Conner is proud of its athletic and activities programs. We encourage all students to be involved, while keeping in mind that participation in these programs is a privilege. La Conner students participating in sports and other school sponsored activities must demonstrate consistently high standards of academic performance as well as positive ethical and legal behaviors both inside and outside the school. Terms of Enforcement The Athletic Director, principals and coaches shall enforce this policy from the beginning date of a season or activity to the beginning date of the next season or activity. For example an athlete who participates in a fall sport or activity is held to this policy from the first turnout of the fall till the first turnout of the next sport or activity in which he/she chooses to participate. Washington Interscholastic Activities Association (W.I.A.A.) Requirements

1) Prior to the first practice session, and in order to ensure the ongoing physical welfare of the athletes, it is imperative that evidence be given to the Athletic Director of the following:

A) Student physical fitness exam by a qualified health professional B) Proof of health insurance C) Signed Sudden Cardiac Arrest Information Form

D) Signed Concussion Information Form E) Signed Inherent Risk Form(s) – these are required for each individual sport 2) Additional W.I.A.A. rules must be followed regarding eligibility, previous semester requirements, enrollment requirements, transfer, sportsmanship, season length and the appropriate use of school equipment. W.I.A.A. requirements are covered in detail in the W.I.A.A. handbook available for review in the Athletic Director’s office or on the W.I.A.A. website. 3) All ASB and participation fees must be paid prior to first competition.

Accommodations/Modifications Under 504 Plans and I.D.E.A. Modifications or accommodations to this policy may be made for any students eligible for services under Section 504 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA) or for any student otherwise identified. A committee consisting of the following individuals: coach, teachers(s), counselor, principal and/or the director of special services or their designees will determine any modifications/ accommodations to procedures for eligibility to this policy. This group will discuss the nature of the handicapping condition and design appropriate modifications or accommodations. The fundamental principle to guide decisions is that all who participate must maintain the essential character of the sport/activity and of this policy. The Athletic Director and principal will oversee and evaluate the implementation of each accommodation plan. School Attendance and Athletic Events/Activities Students must attend at least one half of a school day in order to participate in the same day extracurricular event or activity, any partial absence must be excused under the school attendance policy as defined in the student handbook. Students with three or more unexcused tardies in any two-week period will not be eligible (see below). In the case of extreme unforeseen circumstances, exceptions to this rule may be considered at the discretion of the building principal and/or Athletic Director

Academic Ineligibility School sponsored activities must support and not compete with the academic focus of the school. To ensure that students are meeting their academic responsibilities:

1) The principal and/or Athletic Director will conduct academic eligibility checks for all participants in school-sponsored activities/events. These checks will be completed every two weeks during the sport/activity season according to a published calendar. The principal or athletic director will notify students, parents and coaches of ineligibility due to academic deficiencies. Reversal of ineligibility is the responsibility of the individual student and requires approval by the principal/athletic director. Eligibility checks will be based on current semester grades. 2) Conditional academic ineligibility from school-sponsored activities will be instituted for any student who falls below a 2.0 grade point average. Consequences: any student with less than a 2.0 in the current semester will be required to document two hours of before or after school study time each week with teachers and/or approved support staff. This will be required until the student’s current semester GPA is greater than 2.0. 3) Ineligibility from competition (and team travel) will result if the student:

A) Receives an “F” grade in any class. B) Has 3 or more unexcused tardies in any two-week period. C) Has been assigned to In-School or Out-of-School Suspension

4) The suspension becomes effective at 1:00 p.m. on the Tuesday following the Friday grade check and lasts seven calendar days. In order to regain eligibility, the student must prove that he/she has met the academic standards set forth above by bringing a printout of current grades to the principal or athletic director. Providing that he/she has met the standard he/she will regain eligibility. Consequences: A student ineligible for any of the above reasons A-C will miss a minimum of one contest at his/her “regular completion level” for any ineligibility. In addition, the ineligible student will be required to document two hours of before or after school study time each week with teachers and/or approved support staff. This will be required until the student’s current semester GPA is greater than 2.0. 5) If extremely difficult extenuating circumstances occur (for example extended illness or family emergency) the principal may approve and monitor a student-initiated action plan developed by the student and teacher. When the principal judges that adequate progress has been made the student may have eligibility re-instated.

Ineligibility Due to Illegal Substance Use La Conner School District recognizes that chemical use and dependency are serious medical and legal issues that affect school performance, student safety and often require outside intervention. The following specific expectations apply:

1) Abstain from drinking any alcoholic beverages in and out of school. 2) Abstain from using any form of tobacco in and out of school. 3) Abstain from using all controlled substances, illegal drugs, legend drugs and steroids

Consequences for Use of Marijuana, Tobacco and Alcohol Criteria for violations: Students, who have, in the judgment of the principal, used, shared or delivered marijuana, tobacco, or alcohol will be subject to the following sanctions:

First Violation: Ineligible for competition or scheduled activities for a minimum of 14 days. Required steps to regain eligibility: 1) The student will undergo mandatory assessment through an outside agency at his/her own expense. 2) The student and parent guardian will sign a “release of information form” allowing the school access to the recommendations of the evaluation and proof of treatment. 3) The student and parent/guardian will share the evaluation and treatment recommendations with the principal. Should the student fail to follow through on the recommendations he/she will be restricted from further participation in the activity until the recommendations are being followed to the satisfaction of the principal. Second Violation: Suspension from all extracurricular activities for the remainder of the school year.

Required steps to regain eligibility: 1) The student will undergo mandatory assessment through an outside agency at his/her own expense. 2) The student and parent guardian will sign a “release of information form” allowing the school access to the recommendations of the evaluation and proof of treatment. 3) The student and parent/guardian will share the evaluation and treatment recommendations with the principal. Should the student fail to follow through on the recommendations he/she will be restricted from further participation in the activity until the recommendations are being followed to the satisfaction of the principal.

Consequences for Use of Controlled Substances, Anabolic Steroids, Illegal Drugs and/or Legend Drugs Criteria for violations: Students who have, in the judgment of the principal, used, shared or delivered controlled substances, anabolic steroids, illegal drugs and/or legend drugs will be subject to the following sanctions: (Note: The following outlines the accumulative consequences for students in grades 9-12 as defined in section 18.22.2 in the W.I.A.A. handbook)

First Violation A participant shall be immediately ineligible for interscholastic competition in the current sport or activity for the remainder of the season. Required steps to regain eligibility: 1) The student will undergo mandatory assessment through an outside agency at his/her own expense. The student and parent guardian will sign a “release of information form” allowing the school access to the recommendations of the evaluation and to proof of treatment. The student and parent/guardian will share the evaluation and treatment recommendations with the principal. 2) The student is urged to seek help for his/her substance use problem using community resources (these may include counseling services, Alcoholics Anonymous, Narcotics Anonymous, etc.) Utilization of treatment may allow the student to have eligibility reinstated in the athletic program, pending recommendation by the school eligibility board. (See below) 3) Ineligibility shall continue until the next season in which the student chooses to participate. In order to be eligible to participate in the next season or activity, the student shall present his/her plan of improvement to the school eligibility board consisting of the athletic director, principal and a coach to request approval to participate. The board shall make the final decision on the action to be taken in the student’s case. The school principal shall have final authority as to the student’s eligibility for participation. 4) The student is required to undergo at least one random drug test during the remainder of the school year. Failure of the random drug test will constitute a second violation of this code. Second Violation A participant shall be ineligible for extracurricular activities and competitions for a period of one calendar year from the date of the second violation. Third Violation A participant shall be permanently ineligible for extracurricular activities and competitions.

Note: Sale or delivery of controlled substances, illegal drugs and/or legend drugs will constitute a step 2 violation of the activities code. Engaging in Criminal Activity: (excluding using, supplying and possessing illegal drugs and alcohol)

First Violation: Ineligible for a minimum of 14 days Second Violation: Ineligible for the remainder of the season Third Violation: Ineligible permanently for participation in activities and competitions.

Inter-local Law Enforcement/School Communication Student participants waive all rights precluding all shared communication between the La Conner Schools, the Skagit County Sheriff’s Department, the Swinomish Tribal Police and other law enforcement officials. This is intended to hold students accountable for illegal behavior under the provisions of this activity participation policy and to assist school officials in fair enforcement of the policy.

Appeals of Ineligibility Appeals should be submitted to the principal and/or Athletic Director in a letter outlining procedural errors or mitigating circumstances. The decision of the principal may be appealed to the superintendent for resolution and finally the Board of Directors. Coach/Advisor Expectations

1) While ineligible student participation in practice will be solely at the discretion of the coach or advisor. Students suspended from one activity during a season may not participate in another activity in the same season. 2) Coaches/advisors may set rules augmenting this activities code. The athletic director and/or coaches at the start of the season will review these coaches’ rules. Students are expected to abide by the coaches/advisor’s rules as well as the activities code during the season.

Sportsmanship W.I.A.A. policy prohibits unsportsman-like conduct during contests and events.

First Violation: Student participants exhibiting such behavior will be removed from the game and suspended from the following contest. Second Violation: Suspension for the remainder of the season.

DETACH AND RETURN THE BOTTOM PORTION TO THE SCHOOL OFFICE. PLEASE

RETAIN THE POLICY FOR YOUR RECORD.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I have read, understand and intend to abide by the rules governing extracurricular activity eligibility in the La Conner School District. Student Name (printed): Student Signature Date I have read and understand the requirements and consequences pertaining to the student for whom I am responsible. Parent/Guardian Signature: Date

Board Approved June 2016

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LA CONNER SCHOOL DISTRICT Concussion Information Sheet

Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 6/15/2009

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and in most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away. Symptoms may include one or more of the following:

• Headaches • “Pressure in head” • Nausea or vomiting • Neck pain • Balance problems or dizziness • Blurred, double, or fuzzy vision • Sensitivity to light or noise • Feeling sluggish or slowed down • Feeling foggy or groggy • Drowsiness • Change in sleep patterns

• Amnesia • “Don’t feel right” • Fatigue or low energy • Sadness • Nervousness or anxiety • Irritability • More emotional • Confusion • Concentration or memory problems

(forgetting game plays) • Repeating the same question/comment

Signs observed by teammates, parents and coaches include:

• Appears dazed • Vacant facial expression • Confused about assignment • Forgets plays • Is unsure of game, score, or opponent • Moves clumsily or displays incoordination • Answers questions slowly • Slurred speech • Shows behavior or personality changes • Can’t recall events prior to hit • Can’t recall events after hit • Seizures or convulsions • Any change in typical behavior or personality • Loses consciousness

LA CONNER SCHOOL DISTRICT Concussion Information Sheet

Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 6/15/2009

What can happen if my child keeps on playing with a concussion or returns too soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athletes will often fail to report symptoms of injuries. Concussions are no different. As a result, education of administrators, coaches, parents and students is the key to student-athlete’s safety.

If you think your child has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new “Zackery Lystedt Law” in Washington now requires the consistent and uniform implementation of long and well-established return-to-play concussion guidelines that have been recommended for several years:

“a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time”

and “…may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.

You should also inform your child’s coach if you think that your child may have a concussion. Remember it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out. RETURN TO PARTICIPATION PROTOCOL If you child has been diagnosed with a concussion they MUST follow a progressive return to participation protocol (under the supervision of an approved health care provider) before full participation is authorized. The return to play protocol may not begin until the participant is no longer showing signs or symptoms of concussion. Once symptom free, the athlete may begin a progressive return to play. This progression begins with light aerobic exercise only to increase the heart rate (5-10 minutes of light jog or exercise bike) and progresses each day as long as the child remains symptom free. If at any time symptoms return, the athlete is removed from participation.

SSB 5083 ~ SCA Awareness Act

1.  RECOGNIZE                                          Sudden  Cardiac  Arrest x� Collapsed  and  unresponsive x� Abnormal  breathing x� Seizure-like  activity

2.  CALL  9-1-1 x� Call  for  help  and  for  an  AED

3.    CPR x� Begin  chest  compressions x� Push  hard/  push  fast                  

(100  per  minute)

4.    AED x� Use  AED  as  soon  as  possible

5.    CONTINUE  CARE x� Continue  CPR  and  AED  until                      

EMS  arrives

Be Prepared! Every Second Counts!

 

What  is  sudden  cardiac  arrest?    Sudden  Cardiac  Arrest  (SCA)  is  the   sudden  onset  of  an    abnormal  and  lethal  heart  rhythm,  causing  the  heart  to  stop   beating  and  the  individual  to  collapse.  SCA  is  the  leading  cause  of  death  in  the  U.S.  afflicting  over  300,000  individuals  per  year.  

SCA  is  also  the  leading  cause  of  sudden  death   in  young  athletes  during  sports

What  causes  sudden  cardiac  arrest?    SCA  in  young  athletes  is  usually  caused  by  a  structural  or  electrical  disorder  of  the  heart.  Many  of  these   conditions  are  inherited  (genetic)  and  can  develop  as  an  adolescent  or  young  adult.  SCA  is  more  likely  during  exercise  or  physical  activity,  placing   student-athletes  with  undiagnosed  heart  conditions  at  greater  risk.  SCA  also  can  occur  from  a  direct  blow  to  the  chest  by  a  firm  projectile  (baseball,  softball,  lacrosse  ball,  or  hockey  puck)  or  by  chest  contact  from  another  player   (called  “commotio  cordis”).

While  a  heart  condition  may  have  no  warning  signs,  some  young  athletes  may  have  symptoms  but  neglect  to  tell  an  adult.  If  any  of  the  following  symptoms  are  present,  a  cardiac  evaluation  by  a  physician  is  recommended:

·  Passing  out  during  exercise ·  Chest  pain  with  exercise ·  Excessive  shortness  of  breath  with  exercise ·  Palpitations  (heart  racing  for  no  reason) ·  Unexplained  seizures ·  A  family  member  with  early  onset  heart  disease  or  sudden  death  from  a  heart   condition  before  the  age  of  40

How  to  prevent  and  treat  sudden  cardiac  arrest?  Some  heart  conditions  at  risk  for  SCA  can  be  detected  by  a  thorough  heart  screening  evaluation.  However,  all  schools  and  teams  should  be  prepared  to  respond  to  a  cardiac  emergency.  Young   athletes  who  suffer  SCA  are  collapsed  and  unresponsive  and  may  appear  to  have  brief  seizure-like  activity  or  abnormal  breathing  (gasping).  SCA  can  be  effectively  treated  by  immediate  recognition,  prompt  CPR,  and  quick  access  to  a  defibrillator  (AED).   AEDs  are  safe,  portable  devices  that  read  and  analyze  the  heart  rhythm  and  provide   an  electric  shock  (if  necessary)  to  restore  a  normal  heart  rhythm.  

Remember,  to  save  a  life:  recognize  SCA,  call  9-1-1,  begin  CPR,     and  use  an  AED  as  soon  as  possible!

Center For Sports Cardiology www.uwsportscardiology.org

Sudden Cardiac Arrest Information Sheet for

Student-Athletes, Coaches and Parents/Guardians

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LA CONNER SCHOOL DISTRICT

PHYSICAL EXAMINATION UPDATE

(Statement For Continued Participation) Name Phone Address Street City State Zip School Grade 8 9 10 11 12 (circle one) WIAA Regulation - PHYSICAL EXAMINATION - Prior to the first practice for participation in interscholastic athletics in a middle level school and prior to participation in a high school, a student shall undergo a thorough medical examination and be approved for interscholastic athletic competition by a medical authority licensed to perform a physical examination. This physical examination must include, but not necessarily be limited to: A. Documentation of a detailed review of the student’s medical history with special attention to presence or absence of cardiovascular/pulmonary risks and/or previous significant injury and rehabilitation therefrom. B. Documentation of satisfactory examination of the cardiopulmonary system. C. Documentation of satisfactory sport specific orthopedic screening examination. D. A written statement by the examiner as to the fitness of the student to undertake the proposed athletic participation, together with suggestion for activity modification if necessary.

******************************************************* EXAMINER'S CERTIFICATION: Date of last complete physical examination _____ I hereby certify that the above-named individual's physical condition is adequate to participate in supervised interscholastic activities NOT CROSSED OUT BELOW: BASEBALL BASKETBALL CROSS COUNTRY DANCE/DRILL FOOTBALL

GOLF GYMNASTICS SOCCER SOFTBALL SPIRIT SWIMMING TENNIS

TRACK VOLLEYBALL WRESTLING Other

Date Examiner's Signature Examiner's Name (Print)

MEDICAL AUTHORITIES LICENSED TO GIVE PHYSICAL EXAMINATIONS

1. Medical Doctor (MD) 4. Medics - Physician Assistant (P.A.) 2. Doctor of Osteopathy (D.O.) 5. Naturopaths (N.D.) 3. Certified Nurse Practitioner (CRN)

! 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 ! InfectionsOther: _______________________________________________

3. Have you ever spent the night in the hospital?

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No5. 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 No13. 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 No17. 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 No26. 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 ONLY52. 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

Type text here

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! 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).

EXAMINATIONHeight Weight ! Male ! Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected ! Y ! NMEDICAL NORMAL ABNORMAL FINDINGSAppearance• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)Eyes/ears/nose/throat• Pupils equal• HearingLymph nodesHeart a

• Murmurs (auscultation standing, supine, +/- Valsalva)• Location of point of maximal impulse (PMI)Pulses• Simultaneous femoral and radial pulsesLungsAbdomenGenitourinary (males only)b

Skin• HSV, lesions suggestive of MRSA, tinea corporisNeurologic c

MUSCULOSKELETALNeckBackShoulder/armElbow/forearmWrist/hand/fingersHip/thighKneeLeg/ankleFoot/toesFunctional• 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

! Preparticipation Physical Evaluation CLEARANCE FORM

Name ___ ____________________________________________________ Sex "#M "#F Age _________________ Date of birth _________________

"#Cleared for all sports without restriction

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

___________________________________________________________________________________________________________________________

"#Not cleared

"#Pending further evaluation

"#For any sports

"#For certain sports _____________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________

Recommendations _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type) ___________________________________________________________________________________ Date ________________

Address _________________________________________________________________________________________ Phone _________________________

Signature of physician _____________________________________________________________________________________________________, MD or DO

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Other information _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

©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.

Compare and Choose Low Option Accident Only High Option Accident Only

Maximum Benefit: $25,000 (For Each Injury) $25,000 (For Each Injury)

Deductible: $0 $0

Inpatient

Room & Board: Up to $150 per day/Semi-private room rate

80% of Reasonable Charges/Semi-private room rate

Hospital Miscellaneous: $600 maximum per day $1,200 maximum per day

Registered Nurse: 75% of Reasonable Charges 100% of Reasonable Charges

Physician’s Visits:(Benefits are limited to one visit per day and do not apply when related to surgery)

$40 first day/$25 each subsequent day $60 first day/$40 each subsequent day

Outpatient

Day Surgery Miscellaneous: $1,000 maximum $1,200 maximum

Physician’s Visits:Benefits are limited to one visit per day and do not apply when related to surgery or physiotherapy)

$40 first day/$25 each subsequent day

$60 first day/$40 each subsequent day

Outpatient Physical Therapy:(Benefits are limited to one visit per day)

$30 first day/$20 each subsequent day/5 days maximum

$60 first day/$40 each subsequent day/5 days maximum

Emergency Room Services:(Treatment must be rendered within 72 hours from the time of the injury)

$150 maximum $300 maximum

X-Rays: $200 maximum $600 maximum

Diagnostic Imaging Services: $300 maximum $600 maximum

Laboratory: $50 maximum $300 maximum

Prescription Drugs: $75 maximum $200 maximum

Injections: No Benefits No Benefits

Orthopedic Braces & Appliances: $75 maximum $140 maximum

Inpatient and/or Outpatient

Surgery Fees:(Limited to primary procedure per injury)

$1,000 maximum $1,200 maximum

Anesthetist: 20% of Surgery Allowance 25% of Surgery Allowance

Assistant Surgeon: 20% of Surgery Allowance 25% of Surgery Allowance

Ambulance: $300 maximum $800 maximum

Consultant: $200 maximum $400 maximum

Dental Treatment due to Injury to Teeth:(For Injury to sound, natural teeth only)

$10,000 maximum per policy term $10,000 maximum per policy term

Replacement of Eye Glasses, Contact Lenses or Hearing Aids that are broken as a result of a Covered Injury:

100% of Reasonable Charges 100% of Reasonable Charges

Durable Medical Equipment: No Benefits No Benefits

Maternity: No Benefits No Benefits

Complication of Pregnancy: No Benefits No Benefits

2019-2020 Student Accident CoverageServiced by: K&K Insurance Group, Inc. Phone: 855-742-3135

Remember to visit our website for faster enrollment: www.studentinsurance-kk.com Online Enrollment—Secured Accident Coverage can be purchased any time throughout the year.

ACCIDENT ONLY COVERAGE: The Policy provides benefits for loss due to a covered Injury up to the Maximum Benefit of $25,000 for each Injury. Provided that treatment by a qualified, licensed Physician begins within 60 days from the date of Injury, benefits will be paid for Covered Medical Expenses incurred within 52 weeks from the date of Injury up to the Maximum Benefit per service as shown below.

SCHEDULE OF BENEFITS: Maximum Benefits Paid As Specified Below. Medically Necessary and Reasonable Charges are based on the 75th percentile.

Expenses for the following are not covered: Prosthetic Devices, Mental and Nervous Disorders, Home Health Care, Injections.

This policy contains an excess provision. Benefits will not be paid under the Basic Accident Medical Expense for Covered Expenses to the extent that they are collectible under another Health Care Plan.

Details of these benefits may be found in the Master Policy on file at the School District. NOTE: This is a brief summary of the benefits and not a contract. A Master Policy has been provided to your school district that contains all of the provisions, limitations and exclusions and qualifications of the insurance benefits. The Master policy is the contract and will govern and control the payment of benefits.

Facts about the Policy1. WHO IS ELIGIBLE: students of the policyholder

who make the required premium contribution for the coverage selected are eligible. Student status continues after graduation and between school years unless the person enrolls at a different school district.

2. The Master Policy on file with the school district is a non-renewable policy.

3. This is a limited benefit policy.4. COVERAGE EFFECTIVE DATE: A person’s coverage

takes effect at the later of the date his or her completed application and premium is received by the company or the effective date of the policy issued to his or her school or school district.

5. COVERAGE TERMINATION DATE: Coverage ends on the earlier of the date his or her coverage has been in force for twelve months or the first day of the next school year.

All coverage ceases if the policyholder cancels the policy or when person ceases to be eligible.

Termination of coverage for any reason will not affect a claim which occurs before coverage ends.

6. LATE ENROLLMENT: Coverage may be purchased at any time during the school year. There is no premium reduction for any individual who enrolls late in the year

7. CANCELLATION: Coverage under the Policy will not be cancelled, and accordingly, premiums may not be refunded after acceptance by the Company. However, a pro-rata refund of premium shall be made in the event a Covered Person enters the Military Service.

8. STUDENT TRANSFER: The policy continues to be in force anywhere in the world if the Covered Person should relocate prior to the expiration of coverage.

Enroll online at:www.StudentInsurance-kk.com or by mail using attached enrollment form.1. Complete and detach the enrollment form.2. Make check or money order payable to

Nationwide Life Insurance Company. Do not send cash. The Company is not responsible for cash payments.

3. Write your child’s name on your check or money order.

4. Mail completed enrollment form with payment back to:

K&K Insurance Group, P.O. Box 2338 Fort Wayne, IN 46801-23385. Your cancelled check, credit card billing, or

money order stub will be your receipt and confirmation of payment.

6. Keep this brochure for future reference. Individual policies will not be sent to you.

Privacy PolicyWe know that your privacy is important to you and we strive to protect the confidentiality of your nonpublic personal information. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic and procedural safeguards to ensure the security of your nonpublic personal information.

Administered by:K&K Insurance Group, P.O. Box 2338, Fort Wayne, IN 46801-2338

PLEASE NOTE - FOR COVERAGE PLANS LISTED BELOW Coverage Effective Date: A person’s coverage takes effect at the later of the date his or her completed application and premium is received by the company or the effective date of the policy issued to his or her school or school district. Coverage Termination Date: Coverage ends on the earlier of the date his or her coverage has been in force for twelve months or the first day of the next school year. All coverage ceases if the policyholder cancels the policy or when the person ceases to be eligible. Termination of coverage for any reason will not affect a claim which occurs before coverage ends.

Low Option High Option

24-Hour Accident (Students & Employees) Around-the-clock/anywhere in the world. Before, during and after school. Weekends, vacation and all summer including summer

school. School sponsored and extracurricular sports excluding High School Football. $105.00 $154.00

24-Hour Accident (Summer Only Coverage, Students Only) Summer begins on the first day after the school year ends. Summer ends the first day of the next school year.

$36.00 $48.00

At-School Accident (Students & Employees) During the regular school term, on school premises while school is in session. Direct and uninterrupted travel to and from home and

scheduled classes. School Sponsored and supervised activities and sports excluding High School Football. Travel to and from school sponsored and supervised activities and sports while in a school furnished or approved vehicle.

$29.00 $37.00

High School Football (Full Year) Play or practice of regularly scheduled football. Consult your Athletic Department for enrollment instructions.

$171.00 $284.00

High School Football (Spring Only Rates) For new players who participate in spring training and not already insured under Football Coverage. Sports seasons are defined by

your state high school athletic association.$74.00 $120.00

High School Football and At-School Accident (Covers all athletics) $200.00 $321.00

High School Football and 24-Hour Accident (Covers all athletics) $276.00 $438.00

Choose Your Coverage Plan: One-Time Payment For Accident Coverage

STUDENT INSURANCE CARD

Student’s Name If premium has been paid, the student whose name appears

above has been insured under a Policy issued to:

School District: Accident Only Coverage: q24-HOUR q24-HOUR (Summer Only Coverage)qAT-SCHOOL qFOOTBALL qFOOTBALL (Spring Only)

Paid by Check # Amount Paid: Date Paid:

Policy # Underwritten by: Nationwide Life Insurance Company

Claims Questions: K&K Insurance Group, Inc.1712 Magnavox Way • Fort Wayne, IN 46801 • 800-237-2917

!Cut out card and retain for your records

1731(AOS_MB_ENG_03/19)

Life $10,000Both arms or both legs $10,000Both hands and both feet $10,000One arm and one leg $10,000One hand and one foot $10,000Either both hands or both feet $10,000Speech and hearing in both ears $10,000The sight of both eyes $10,000The sight of one eye and either one hand or one foot $10,000Either one arm or one leg $7,500Either one hand or one foot $5,000Speech or hearing in both ears $5,000Sight of one eye $5,000Hearing in one ear $2,500Both the thumb and index finger of one hand $2,500

Policy Exclusions and Limitations for Accident Only CoveragesThe following exclusions apply to any and all Benefits and any applicable Riders, unless otherwise specifically referenced. We will not pay Benefits for:

1. An Injury or Loss that is: a. caused by war or any act of war, declared or

undeclared, whether civil or international, or any substantial armed conflict between organized forces of military nature (which does not include acts of terrorism);

b. caused while the Insured is serving full-time active duty (more than 31 days) in any Armed Forces;

c. caused by participating in a riot or violent disorder; d. the result of an Insured’s taking part in committing

or attempting to commit a felony, or engaging in any unlawful act or illegal occupation, or committing or provoking an unlawful act;

e. the result of the Insured being under the influence of any drug, narcotic, intoxicant or chemical (unless prescribed by a Physician and taken according to the Physician’s instructions) as defined by the law of the jurisdiction in which the Accidental Injury occurred. Conviction is not necessary for determination of being “under the influence.”; or

f. intentionally self-inflicted, including suicide or attempt thereof, while sane or insane.

2. An Injury or Loss that is the result of travel or flight (including getting in or out, on or off) in any aircraft except solely as a fare-paying passenger in a commercial aircraft, or as a passenger in a Policyholder chartered aircraft, provided such aircraft has a valid and current airworthiness certificate and is operated by a duly licensed or certified pilot, and while such aircraft is being used for the sole purpose of transportation and such travel is listed as a Covered Activity in the Schedule of Benefits.

3. Any Accident where the Insured is the operator and does not possess a current and valid motor vehicle operator’s license (except in a Driver’s Education Program).

4. An Accident that occurs while: a. participating in any hazardous activities, including the

sports of snowmobile, ATV (all terrain or similar type wheeled vehicle), personal watercraft, sky diving, scuba diving, skin diving, hang gliding, cave exploration, bungee jumping, parachute jumping or mountain climbing;

b. riding, driving, or testing a motorized vehicle used in a race or speed contest, sport, exhibition work or test driving. Motorized Vehicle for purposes of this provision

means any self-propelled vehicle or conveyance, including but not limited to automobiles, trucks, motorcycles, ATV’s, snow mobiles, tractors, golf carts, motorized scooters, lawn mowers, heavy equipment used for excavating, boats, and personal watercraft. Motorized Vehicle does not include a Medically Necessary motorized wheelchair, unless such activity is specifically listed as a Covered Activity in the Schedule of Benefits.

5. Medical or surgical treatment, diagnostic or preventative care of any Sickness, except for treatment of pyogenic infection that results from an Accidental Injury or a bacterial infection that results from the Accidental ingestion of contaminated substances.

6. Any Heart or Circulatory Malfunction, whether or not known or diagnosed, except as may be otherwise covered under the Policy or unless the immediate cause of such malfunction is external trauma.

1. Expenses Incurred for services or treatment rendered by a Physician, Nurse or any other Provider who is:

a. employed or retained by the Policyholder, or its subsidiaries or affiliates;

b. the Insured, or the Insured’s Family Member. 2. Expenses Incurred for charges which the Insured would not

have to pay if he/she did not have insurance or for which no charge is made.

3. Expenses Incurred for charges which are in excess of Reasonable Charges.

4. That part of medical expenses payable by any automobile insurance Policy without regard to fault.

5. Expenses Incurred for any treatment that is considered to be experimental by the American Medical Association (AMA) or the American Dental Association (ADA).

6. Expenses Incurred for the examination, prescription,

purchase, or fitting of eyeglasses, contact lenses, or hearing aids, unless Injury has caused impairment of sight or hearing or unless repair or replacement of existing eye glasses, contact lenses or hearing aids is necessary as a result of a covered Injury.

7. Expenses Incurred for new, or repair or replacement of, dentures, bridges, dental implants, dental bands or braces or other dental appliances, crowns, caps, inlays or onlays, fillings or any other treatment of the teeth or gums, except as a result of Injury up to the Dental Maximum shown in the Schedule of Benefits, if applicable.

8. Expenses Incurred for personal comfort or convenience items including, but not limited to, Hospital telephone charges, television rentals, or guest meals.

9. Expenses Incurred for or in connection with Custodial Care, unless otherwise specified in the Schedule of Benefits.

10. Expenses Incurred for supervision of an anesthetist. 11. Expenses Incurred for Durable Medical Equipment rental in

excess of the purchase price. 12. Expenses Incurred for subsequent repairs and replacement

of prosthetic devices. 13. Expenses Incurred for any condition covered by any

Workers’ Compensation Act, Occupational Disease law or similar law.

Additional exclusions for the Accident Medical Expense Benefit and any applicable Riders: We will not pay Benefits for:

Accidental Death & Specific Loss Benefits:The Aggregate Limit is $500,000 and is the maximum amount payable for claims incurred for all Insureds under the Policy which are caused by any one Incident that occurs when the Policy is in force. If this limit is not sufficient to pay the total of all such Claims, then the Benefit payable to any one Insured will be determined in proportion to our total aggregate limit of liability. This Aggregate Limit of Liability applies only to Accidental Death and Specific Loss Benefits.

Injury A bodily injury which is: 1. directly and independently caused by specific Accidental

contact with another body or object; 2. a source of loss that is sustained while the Insured Person

is covered under this Policy and while he or she is taking part in a Covered Activity.

For all Benefits, Injury includes Heart and Circulatory Malfunction, subject to the following conditions: 1. Malfunction must occur before age 65 while the Insured is

taking part in a Covered Activity; and

2. The symptom(s) of such malfunction(s) is (are) first medically treated while the Policy is in force with respect to the Insured and within 48 hours of having taken part in a Covered Activity; and

3. Such Insured has not, within one year prior to the date of participation in the Covered Activity, been medically diagnosed with, or received any medication for, any myocardial infarction, angina pectoris, coronary thrombosis, hypertension, heart attack, or a cerebral vascular incident.

For the Accident Medical Expense Benefit, Injury also includes repetitive motion injuries resulting from participation in a Covered Activity. Repetitive motion injuries are injuries such as, but not limited to, strains, sprains, hernias, tennis elbow, tendonitis, bursitis, and muscle tears. The repetitive motion injury must be diagnosed by a Physician and occur within 30 days of participation in a Covered Activity.

All Injuries sustained in one Accident, including all related conditions and recurrent symptoms of these Injuries will be considered as one Injury.

Accident Only Definitions:

Accident Only Coverage Plans Low Option High Option

24-HOUR q$105.00 q$154.00

24-HOUR Summer Only q$36.00 q$48.00

AT-SCHOOL q$29.00 q$37.00

HIGH SCHOOL FOOTBALL COVERAGE Full Year q$171.00 q$284.00

HIGH SCHOOL FOOTBALL COVERAGE Spring Only For New Players

q$74.00 q$120.00

HIGH SCHOOL FOOTBALL and AT-SCHOOL Covers all athletics

q$200.00 q$321.00

HIGH SCHOOL FOOTBALL and 24-HOUR Covers all athletics

q$276.00 q$438.00

Student Insurance Plan Options — Check Your Selection:

Complete this section only if you wish to pay with a Credit CardFull name as it appears on cardFirst Name: MI: Last Name: Billing Address (if different than above)Street # Address Apt #

City: State: Zip:

Card Number: Expiration Date: Month: Year: Cardholder signature:

Company does not issue refunds nor accept responsibility for cash payments. (Rejection of check or credit card by bank for any reason, will invalidate insurance.)

Enroll online for quicker service at www.StudentInsurance-kk.com or complete and mail this form

Enrollment Form (School Year 2019-2020)

Student’s Last Name:

Student’s First Name:

Student’s Middle Name: Date of Birth:

Street Address:

City: State: Zip:

Name of School District (required):

Name of School:

Grade Level: qPre-K/Headstart qKindergarten/Elementary qMiddle School qHigh School/Above

Signature of Parent or Guardian:

Date: Email Address: Phone Number:

Enclose check for total payment payable to: Nationwide Life Insurance Company. Checks, money orders, or credit cards accepted. DO NOT SEND CASH TOTAL ENCLOSED: $ 1731(AOS_MB_ENG_03/19)

Mail this completed form with payment back to: K&K Insurance Group, P.O. Box 2338, Fort Wayne, IN 46801-2338

!

LA CONNER SCHOOL DISTRICT INFORMED CONSENT FORM RE: FOOTBALL

Student Name: ______________________________________ Birth Date: __________

School: ____________________________________________ Grade: _____________

We accept and understand that the sport of football involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport. We accept and understand that certain activities such as the act of tackling carry with them a greater inherent risk of injury.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________

We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________

I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________

In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________

I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________

Page 1 of 2

!

Page 2 of 2 INFORMED CONSENT FORM RE: FOOTBALL

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE.

___________________________________ _______________________________ ____________ Student name (please print) Student signature Date

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE.

___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

!

Page 1 of 2

LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: VOLLEYBALL !Student Name: ______________________________________ Birth Date: __________ School: ____________________________________________ Grade: _____________ We accept and understand that the sport of volleyball involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________ We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________ I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________ In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________ I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________

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Page 2 of 2 INFORMED CONSENT FORM RE: VOLLEYBALL

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE. ___________________________________ _______________________________ ____________ Student name (please print) Student signature Date HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE. ___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

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LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: SOCCER !Student Name: ______________________________________ Birth Date: __________ School: ____________________________________________ Grade: _____________ We accept and understand that the sport of soccer involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport. We accept and understand that certain activities such as slide tackling and heading the ball carry with them a greater inherent risk of injury.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________ We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________ I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________ In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________

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Page 2 of 2 INFORMED CONSENT FORM RE: SOCCER

I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________ HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE. ___________________________________ _______________________________ ____________ Student name (please print) Student signature Date HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE. ___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

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LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: CHEERLEADING !Student Name: ______________________________________ Birth Date: __________ School: ____________________________________________ Grade: _____________ We accept and understand that the sport of cheerleading involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport. We accept and understand that certain activities such as tumbling and stunting carry with them a greater inherent risk of injury.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________ We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________ I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________ In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________

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Page 2 of 2 INFORMED CONSENT FORM RE: CHEERLEADING

I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________ HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE. ___________________________________ _______________________________ ____________ Student name (please print) Student signature Date HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE. ___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

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LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: BASKETBALL !Student Name: ______________________________________ Birth Date: __________

School: ____________________________________________ Grade: _____________

We accept and understand that the sport of basketball involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________

We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________

I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________

In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________

I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________

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Page 2 of 2 INFORMED CONSENT FORM RE: BASKETBALL

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE.

___________________________________ _______________________________ ____________ Student name (please print) Student signature Date

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE.

___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

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LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: WRESTLING !Student Name: ______________________________________ Birth Date: __________ School: ____________________________________________ Grade: _____________ We accept and understand that the sport of wrestling involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________ We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________ I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________ In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________ I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________

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Page 2 of 2 INFORMED CONSENT FORM RE: WRESTLING

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE.

___________________________________ _______________________________ ____________ Student name (please print) Student signature Date

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE.

___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

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LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: BASEBALL/SOFTBALL

Student Name: ______________________________________ Birth Date: __________

School: ____________________________________________ Grade: _____________

We accept and understand that the sport of baseball/softball involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport. We accept and understand that certain activities such as batting, fielding and sliding carry with them a greater inherent risk of injury.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________

We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________

I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________

In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________

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Page 2 of 2 INFORMED CONSENT FORM RE: BASEBALL/SOFTBALL

I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE.

___________________________________ _______________________________ ____________ Student name (please print) Student signature Date

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE.

___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

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LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: GOLF !Student Name: ______________________________________ Birth Date: __________ School: ____________________________________________ Grade: _____________ We accept and understand that the sport of golf involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________ We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________ I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________ In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________ I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________

Page 2 of 2 INFORMED CONSENT FORM RE: GOLF

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE.

___________________________________ _______________________________ ____________ Student name (please print) Student signature Date

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE.

___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date

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LA CONNER SCHOOL DISTRICT

INFORMED CONSENT FORM RE: TRACK AND FIELD !Student Name: ______________________________________ Birth Date: __________

School: ____________________________________________ Grade: _____________

We accept and understand that the sport of track and field involves certain inherent risks, dangers and hazards that may cause serious personal injury, including death, severe paralysis or brain injury necessitating long term care and significantly impairing enjoyment of life or life activities. We accept and understand that the above-described injuries and other injuries, including but not limited to: concussions; serious neck and spinal injuries potentially resulting in complete or partial paralysis; brain damage; blindness; serious injury to all internal organs; serious injury to all bones, joints, ligaments, muscles and tendons; contusions; dislocations; sprains; strains; and fractures, may occur as a result of participating in this sport. We accept and understand that certain activities such as high jumping, participating in throwing events such as javelin, shot put and discus and pole vaulting carry with them a greater inherent risk of injury.

We understand that the inherent risks of this sport cannot be eliminated without jeopardizing the essential qualities of the sport. We have reviewed all of these risks and we understand and appreciate them and still desire to participate in the activity. (Student Initial)________ (Parent Initial)________

We certify that (Student Name) __________________________________has no medical or physical conditions which could interfere with or compromise his/her safety in participating in this activity. (Student Initial)________ (Parent Initial)________

I authorize qualified emergency medical professionals to examine, and in the event of an injury or serious illness, to administer emergency medical care to the above-named student. (Parent Initial)________

In the event it becomes necessary for school district staff to obtain emergency medical care for the above-named student, we understand that neither the staff member nor the school district assumes financial liability for the expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. (Student Initial)________ (Parent Initial)________

Page 2 of 2 INFORMED CONSENT FORM RE: TRACK AND FIELD

I certify that my household has sufficient medical insurance to facilitate any necessary medical care or resultant care for any injury that may be sustained by the above-named student. (Parent Initial)________

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND WISH TO PARTICIPATE.

___________________________________ _______________________________ ____________ Student name (please print) Student signature Date

HAVING READ AND INITIALED THE STATEMENTS ABOVE, I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS VOLUNTARY SCHOOL DISTRICT ATHLETIC PROGRAM. BY SIGNING BELOW, I CERTIFY THAT I HAVE READ THE ABOVE, UNDERSTAND ITS CONTENT AND GIVE MY PERMISSION FOR MY STUDENT TO PARTICIPATE.

___________________________________ _______________________________ ____________ Parent/guardian name (please print) Parent/guardian signature Date