Football paperwork packet 2013

7/27/2019 Football paperwork packet 2013

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SAN RAMON VALLEY UNIFIED SCHOOL DISTRICT

699 Old Orchard Drive, Danville, CA 94526

VOLUNTARY ACTIVITIES PARTICIPATION FORM

ACKNOWLEDGMENT AND ASSUMPTION OF POTENTIAL RISK

I authorize myself/my son/daughter, to

participate in the activities of .I understand and acknowledge that these activities, by their very nature, pose the potential risk ofserious injury/illness to individuals who participate in such activities.

I understand and acknowledge that participation in these activities is completely voluntary.

I understand and acknowledge that in order to participate in these activities, my son/daughter and I

agree to assume liability and responsibility for any and all potential risks that may be associated withparticipation in such activities.

I understand, acknowledge, and agree that the San Ramon Valley Unified School District, itsemployees, officers, agents, or volunteers shall not be liable for any injury/illness suffered by myself,my son/daughter which is incident to and/or associated with preparing for and/or participating inthis activity.

The undersigned agrees to defend, indemnify and hold harmless the San Ramon Valley UnifiedSchool District, its Board of Trustees, officers, agents and employees, individually and collectively,from and against all costs, losses, claims, demands, suits, actions, payments and judgments, including

legal and attorney fees, arising from personal or bodily injuries, property damage or otherwise,regardless of and however caused, brought or recovered against any of the above that may arise forany reason from or during or be alleged to be caused by the undersigneds (use/occupancy ofDistricts facilities, furniture or equipment, or nature of activity).

I acknowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATIONFORM and that I understand and agree to its terms.

_______________________________________________ ________________________Parent/Guardian Date

_______________________________________________ ________________________Student Signature Date

A signed VOLUNTARY ACTIVITIES PARTICIPATION FORM must be on file before aparticipant will be allowed to participate in the above extra-curricular activities.

ES:ATHL:11609

Revised: 3/14/2012


4/12

CIF BYLAW 524

ANDROGENIC / ANABOLIC STEROIDS

______________________________________Print Name of Student-Athlete

As a condition of membership in the CIF, all schools shall adopt policies

prohibiting the use and abuse of androgenic/anabolic steroids. Allmember schools shall have participating students and their parents, legalguardian/caregiver agree that the athlete will not use steroids without thewritten prescription of a fully licensed physician (as recognized by theAMA) to treat a medical condition (Bylaw 524).

By signing below, both the participating student/athlete and the parents,legal guardian/caregiver hereby agree that the student shall not useandrogenic/anabolic steroids without the written prescription of a fullylicensed physician (as recognized by the AMA) to treat a medicalcondition. We also recognize that under CIF Bylaw 200.D., there could be

penalties for false or fraudulent information. We also understand that theSan Ramon Valley Unified School District policy regarding the use ofillegal drugs will be enforced for any violations of these rules.

________________________________________ ____________________Signature of Athlete Date

________________________________________ ____________________Signature of Parent/Caregiver Date


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A third offense will result in a twelve (12) month period of suspension from extracurricular activities from the date of the infraction.

Students found to be selling such controlled substances shall be removed from the extracurricular activities for a twelve (12) month

period from the date of the infraction and are subject to discipline under Education Codes 48900 and 48915.

Athletes/students with substance abuse problems are encouraged to talk to their coach/advisor, athletic director, or other school

official. Athletes/students who come forward asking for assistance with their dependency problem, prior to involvement in an incidentwhich requires disciplinary action, will not be subject to disciplinary action as a result of their disclosures related to the request for

assistance.

Should a participant become involved in an incident which requires disciplinary action either during or upon completion of a

rehabilitation program, he/she will be disciplined in accord with the directives set forthin this policy/procedure.Tobacco Products: A first offense will result in a one-week suspension from extracurricular activities/team competition. A secondoffense will result in a suspension from the extracurricular activity/team competition for three weeks.

Theft

Any student guilty of theft of school property or the property of other students or adults at school will be suspended from theextracurricular activities/team competition for three weeks and will be subject to the SRVUSD discipline code. A second offense shall

result in removal from extracurricular activities for one calendar year and subject to the SRVUSD discipline code and Education Code

48900.

Competition ConductAny student who initiates or participates in a physical assault on an official, opposing coach/advisor, spectator, or opposing competitor

shall be subject to the disciplinary consequences prescribed under NCS/CIF.

Participation during the Period of Athletic SuspensionDuring the time of the athletic suspension, an athlete shall participate in practice in order to return to the team after the suspension, but

may not participate in the scheduled competitive events during the time of the suspension.

Dismissal from an Extracurricular Activities for Failure to Follow RulesThe coach/advisor shall establish rules, which shall be approved by the schools athletic director, or activities director, oradministrative designee. Dismissal of a student from the extracurricular activity shall be preceded by a conference with the student,

the students coach or advisor, and the athletic director or activities director to discuss the reason(s) for the dismissal.

Grade Point Average Appeal ProcessA high school student who fails to achieve a 2.0 grade point average may appeal for probation for one quarter. To qualify for this

probation, the students parent(s) or guardian must submit a written appeal to the principal delineating a significant upheaval in the

students life that has caused his grades to fall. This upheaval would include, but not be limited to, parentaldivorce, a death in the

family, serious illness or injury to the student, drug or alcohol rehabilitation, or a serious family problem. Failure to achieve a 2.0 GPA

during the probationary quarter would render the student ineligible during all subsequent quarters until he/she raises his/her GPA to2.0 for a quarter.

The principal shall establish a selected site review board consisting of the following certified school personnel: an administrator,athletic or activities director, counselor, and a teacher not currently teaching, coaching or advising the student under consideration.

The appeals board shall be convened within five(5)school days of the filing of the appeal by a parent/guardian and will render adecision within five (5) school days following the date of the appeal.

If the student had a subsequentfailure to achieve a 2.0 grade point average, the appeal process would be conducted by EducationalServices and would require evidence of significant upheaval as defined above.

Student Name: _____________________________________ School: ____________________________________________

Student Signature:__________________________________ Parent Signature: _____________________________________

Date: ____________________________________________ Date: __________________________________________ ____


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Monte Vista High School

Concussion Information Sheet

Adapted from the CDC and the 3rd

International Conference on Concussion in Sport

Document created 5/20/2010

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. Youcant see a concussion and 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 fullyappear. 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 Dont 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 Cant recall events prior to hit Cant recall events after hit Seizures or convulsions Any change in typical behavior or personality Loses consciousness


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Monte Vista High School

Concussion Information Sheet

Adapted from the CDC and the 3rd

International Conference on Concussion in Sport

Document created 5/20/2010

What can happen if my child keeps on playing with a concussion or returns to 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 aconcussion 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 prolongedrecovery, or even to severe brain swelling (second impact syndrome) with devastating and even

fatal consequences. It is well known that adolescent or teenage athlete will often under report

symptoms of injuries. And concussions are no different. As a result, education of administrators,coaches, parents and students is the key for student-athletes 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 medicalclearance. Close observation of the athlete should continue for several hours. The new CIF

Bylaw 313 now requires implementation of long and well-established return to play concussion

guidelines that have been recommended for several years:

A student-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 for the remainder ofthe day.

and

A student-athlete who has been removed may not return to play until the athlete is

evaluated by a licensed heath care provider trained in the evaluation and management ofconcussion and received written clearance to return to play from that health care

provider.

You should also inform your childs coach if you think that your child may have a concussion

Remember its better to miss one game than miss the whole season. And when in doubt, the

athlete sits out.

For current and up-to-date information on concussions you can go to:

http://www.cdc.gov/ConcussionInYouthSports/

_____________________________ _____________________________ _____________Student-athlete Name Printed Student-athlete Signature Date

_____________________________ ______________________________ _____________

Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date
http://www.cdc.gov/ConcussionInYouthSports/http://www.cdc.gov/ConcussionInYouthSports/


9/12

SAN RAMON VALLEY UNIFIED SCHOOL DISTRICT699 Old Orchard Drive, Danville, CA 94526

2012-13 VOLUNTEER CLEARANCE FORM

Dear School Volunteer:

Thank you for your interest in volunteering at our school. Volunteers are an integral aspect of a greatschool/district. The San Ramon Valley Unified School District has instituted the following guidelines for all

who wish to volunteer their time at our schools. This includes field trips, classroom and office support, librarysupport and any other volunteer support that may involve direct contact with students at a school.

The district expects that all volunteers follow the guidelines listed below:

All volunteers must view the districtsparent volunteer orientation video prior to volunteering on campus.The video can be accessed on the district website at: http://www.srvusd.net

All volunteers will check in at the office and wear a school-issued badge before going onto campus. All volunteers are expected to practice professionalism: arrive on time, turn off cell phones, dress

appropriately, etc.

In order to ensure safety and minimize distractions to the learning environment, please do not bring infantsor non school-age children to school with you when you are volunteering in the classroom. Volunteers are

asked to make arrangements for off-campus child care. Volunteers are to use staff restrooms only. Confidentiality of information obtained through your volunteer efforts must be maintained. Respect the privacy of everyone in the classroom. This includes materials you may see on the students or

teachers desks (i.e. test scores, graded papers, notes, etc.). When addressing student behavior: ask politely twice, then inform the teacher. School trip drivers must have on file an approved driver form (annually). The school reserves the right to revoke volunteer privileges at any time.We thank you for your willingness to help us help all students succeed. Adherence to these guidelines will help

ensure that all students learn in a safe, secure environment.

By signing this form, I represent that I have not been convicted of a felony, and that I am not a registered sex

offender as defined by Megans Law, California Penal Code Section 290. I agree to allow the school to keep acopy of my drivers license/personal identification on file (information will not be used for any other purpose).

School: I have viewed the districts volunteer orientation videoPrint Name: __________________________________________________________________________

Last First Middle

Volunteer Signature: ________________________________________ Date: ___________________

Student Name(s): __________________________ Grade/Teacher:(if parent/guardian) Last First

__________________________ Grade/Teacher:Last First

For Office Use Only: Copy of picture ID attached Received by: _____________________________Training completed Date: _________________________


10/12

ES:STU:11037REVISED: 11/8/11Effective: 1/01/12


SCHOOL TRIP PERMISSION/EMERGENCY INFORMATION

School Name____________________________________ Teachers Name _______________________School Trip Destination __________________________________________________________________

Departure Date _____________ Time:________am/pm Return Date_____________ Time: __________ am/pm

TRANSPORTATION: Walking____ Private Vehicle (volunteer drivers) ____ District ____ Commercial ____

If by private car, I understand that seat belts and/or car seats are required by law to be worn/used by all passengers. I further understandthat safety considerations and California State Law require that no child ride in the front passenger seat of my vehicle. I also understandthat children MUST be secured in an appropriate child passenger restraint system (car seat or booster seat) until they reach eight (8)

years of age or are 4' 9" in height or taller. A child who is 4 9 or taller may be properly restrained by a seat belt.

INFORMATION: Education Code Section 35330 authorizes the governing board of any school district to conduct field trips or

excursions for students in connection with courses of instruction of school related social, educational, cultural, athletic or schoolband activities to and from places in the state, any other state, the District of Columbia, or a foreign country. Field trips orexcursions may be connected with such courses of instruction or such school activities that further the students education and

participation is voluntary. As a voluntary event, no special attendance credit is given for participation, and an alternative activityat school will be provided if my child does not participate.

PARENT/GUARDIAN TO COMPLETE EMERGENCY INFORMATION:Student _______________________________________ Parent/Guardian______________________________

Home # ______________________ Work #_____________________ Cell # __________________________

PLEASE CHECK THE APPROPRIATE STATEMENT REGARDING STUDENTS HEALTH:_____ My child has no known health problems._____ My child has the following health problems: _______________________________________________

____________________________________________________________________________________

(Please identify any medication that the child may need during the course of this trip)

PLEASE CHECK #1 OR #2 BELOW TO INDICATE DESIRED ACTION IN THE EVENT OF ACCIDENT

OR EMERGENCY:_____1. In the event of accident or emergency, when a parent/guardian is unavailable, I hereby authorize a

representative of the school to make such arrangements as he/she considers necessary for my child to receivemedical/hospital care, including necessary transportation. Under such circumstances, I further authorize the

physician the named below to undertake such care and treatment of my child as he/she considers necessary. In the

event said physician is not available at any time, I authorize such care and treatment to be performed by any licensed

physician or surgeon. THE UNDERSIGNED PARENT/GUARDIAN FULLY UNDERSTANDS HE/SHE IS

RESPONSIBLE TO PAY ALL COST INCURRED AS A RESULT OF THE FOREGOING.

Physicians name ___________________________________ Phone # _____________________________

Medical Insurance Name (Kaiser, etc) ___________________ Medical # ____________________________

_____ 2. I do not choose the above statement and desire the following action to be taken: _______________

________________________________________________________________________________________

WAIVER: California law provides as follows: All persons making the field trip or excursion shall be deemed to have waived all claims

against the district or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or

excursion. (Education Code Section 35330) I acknowledge that as a condition of my childs participation, I agree this waiver of all

claims shall be extended to any and all claims against the school, its employees and volunteers, the district, its governing board, theindividual members thereof, and all other district officers, agents and employees. Further, I agree to indemnify and hold harmless the

school, its employees and volunteers, the district, its governing board, the individual members thereof, and all other district officers,

agents and employees for any injury, harm, accident, illness, death, loss, liability, cost, expense or claim of any type whatsoever

(including attorneys fees) or damage to personal property occurring during or by reason of this excursion/field trip event.

I understand that participation in this field trip involves a certain degree of risk. I have carefully considered the risk involved and

consent for my child/myself to participate in the field trip.

Additionally, I agree to participate as a Volunteer Chaperone for this event. My Volunteer Clearance Form is

on file in the school office.

My signature below authorizes my child to participate in the field trip:

PARENT/GUARDIAN SIGNATURE___________________________________ DATE ________________(Original Form to be carried by person transporting student)

Teacher to return original form to school office after field trip.


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Activity/Sport

Drivers License #: ________________________________ Expiration date: __________________

Year/Make of Auto _____________________________ Vehicle License # ________________

Drivers License #: ________________________________ Expiration date: __________________

Year/Make of Auto _____________________________ Vehicle License # ________________

Insurance Carrier/Agent ______________________________ Phone # _____________________

B.I. & P.D. Limits ___________________________________ Policy # _____________________

Exp. Date ______________ Vehicle Capacity_________________________________________

Driving Restrictions_______________________________________________________________

Student's Name __________________________Student's Name __________________________

I represent that I am not a registered sex offender as defined by Megan's Law, California Penal Code Sec. 290

Driver#1 Signature Date

Driver#2 Signature Date

Administrative Approval Date

NOTE:

#1Driver's Name __________________________ Birth Date __________ Phone# _________

#2Driver's Name __________________________ Birth Date __________ Phone# _________

Teacher's Name _________________________Teacher's Name _________________________

San Ramon Valley Unified School District

PERSONAL AUTOMOBILE USE

PERMISSION FORM

Danville, CA

* Your signature confirms that you have the minimum insurance required and that you

understand and will comply to the above.

I understand that seat belts and/or car seats are required by law to be worn/used by all passengers. I further

understand that safety considerations and California State Law require that no child ride in the front

passenger seat of my vehicle. I also understand that children MUST be secured in an appropriate child

passenger restraint system (car seat or booster seat) until they reach eight (8) years of age or are 4' 9" inheight or taller. A child who is 4' 9" or taller may be properly restrained by a seat belt.

If you drive your personal automobile while on school business and you are involved in an accident, by law your own insurance

policy is used first. The District liability policy would be used only after your liability policy limits have been exceeded. The

District does not cover, nor is it liable for, comprehensive and collision coverage to your vehicle.

I certify the above information is correct and that the required insurance coverage is in-force. I understand

that I must have liability insurance coverage meeting the District's minimum requirement and agree to advise

the District, in writin , of an chan es in the above information.

District Insurance REQUIREMENT

MINIMUM Insurance Limits of $100,000/$300,000 Bodily Injury and $25,000 Property

* Please submit a copy of your Driver's License and Proof of Insurance Card with form.

STRIBUTION: White-School; Yellow-Driver BU:BU: 10100 (2part NCR)Revised:

Effective


12/12

White Bond ES:ATHL 11602

Revised: 09-09-03


699 Old Orchard Drive, Danville, California 94526

PARENT/STUDENT CONSENT AND WAIVER OF LIABILITY CAMP PARTICIPATION

PARTICIPANTS NAME: _______________________________________________

ADDRESS: ___________________________________________________________

SCHOOL: ___________________________________________________________

GRADE: _____ AGE: ______

NAME OF CAMP: ____________________________________________________

I hereby give my consent for the above named student to compete and participate in the above referenced

Camp. I, the undersigned, hereby release and discharge the both the organizers and operators of the Camp andthe San Ramon Valley Unified School District, their officers, employers, agents, servants and volunteers (herein

collectively referred to as (Camp/District') from all liability arising out of or in connection with the above

described activity or all liabilities associated with any and all claims related to such activity that may be filed on

behalf of or for the above named minor. For the purposes of this agreement, liability means all claims, demands,

losses, causes of action, suits or judgments of any and every kind that occurs during the above described activity

and that results from any cause including the active or passive conduct and/or negligence of the Camp/District.

I acknowledge on my behalf and on the behalf of the above named minor that there are risks that are

inherent in the above-described activity, including the risk of serious injury that may occur through the conduct

of other participants, coaches, Camp/District, including conduct that may not be part of the ordinary risks of the

activity itself. For example, injury may occur through conduct that is not authorized by the rules and regulationsof the activity. This release and waiver as set forth in the above paragraph shall also apply to this type of

conduct and any resulting injury.

I also represent that the above name participant has undergone a medical examination by a licensed

physician within one year preceding the date this document is signed, is in good health, and fully able to

participate in the activities provided by the camp, including activities which are strenuous in

nature.

I have carefully read this waiver and release of liability and fully understand its terms and

condition and understand that by signing this document that I have given up substantial rights for the

named participant/minor and myself.

_____________________________________ __________________________________Parent/Guardian Signature Date Parent/Guardian Print Name

________________________________________

Participants Signature Date

Documents

Football paperwork packet 2013