Orcutt Academy High School Pre-Participation Physical Evaluation Student Health History Form

(Note: This form is to be filled out by the student and the parent prior to seeing the medical examiner. The medical examiner may keep a copy of this form in the chart).

Exam Date: Name: Birth Date: Age: Email: Gender: Grade: Address: City: Phone (H): (Work) (Cell) Sport(s): Emergency Contact: Phone: Relationship:

Medicines and Allergies: Please list the prescription and over-the-counter medicines and supplements (herbal and nutritional-including energy drinks/ protein supplements) that you are currently taking: ______Do you have any allergies? Yes No If yes, please identify specific allergies below: Medicines Pollens Foods Stinging Insects Please mark an "X" in "Yes" or "No" box to all questions, if you do not know the answer, please circle the number. GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in any sport for 26. Do you cough, wheeze, or have difficulty breathing during or after

any reason? exercise? 2. Do you have any ongoing medical conditions? If so, please identify below: 27. Have you ever used an inhaler or taken asthma medicine?

Asthma / Anemia / Diabetes / Infections / Other: ______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 3. Have you ever spent the night in the hospital? (males), your spleen, or any other organ? 4. Have you ever had surgery? 30. Do you have groin pain or a painful bulge or hernia in the groin area? HEART HEALTH QUESTIONS ABOUT YOU Yes No 31. Have you had infectious mononucleosis (mono) within the past month? 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 32. Do you have any rashes, pressure sores, or other skin issues? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest

during exercise? 33. Have you had a herpes (cold sores) or MRSA (staph) skin infection? 7. Does your heart ever race or skip beats (irregular beats) during exercise? 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, 8. Has a doctor ever told you that you have any heart problems? If yes, circle all that apply. prolonged headaches or memory problems? 36. Do you have a history of seizure disorder or epilepsy? High Blood A Heart Murmur 37. Do you have headaches with exercise? Pressure A Heart Infection 38. Have you ever had numbness, tingling, or weakness in your arms or legs

High Cholesterol Other: ______after being hit or falling? 39. Have you ever been unable to move your arms or legs after being hit or

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, falling?

echocardiogram) 40. Have you ever become ill while exercising in the heat? 10. Do you get lightheaded or feel more short of breath than expected 41. Do you get frequent muscle cramps when exercising?

during exercise? 42. Do you or someone in your family have sickle cell trait or disease? 11. Have you ever had an unexplained seizure? 43. Have you had any problems with your eyes or vision? 12. Do you get more tired or short of breath, quicker than your friends during 44. Have you had an eye injury?

exercise? 45. Do you wear glasses or contact lenses? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 46. Do you wear protective eyewear, such as goggles or a face shield? 13. Has any family member or relative died of heart problems or had an 47. Do you worry about your weight? unexpected or unexplained sudden death before age 50 (including 48. Are you trying to gain or lose weight? Has anyone recommended that

drowning, unexplained car accident or sudden infant death syndrome)? you do? 14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan 49. Are you on a special diet or do you avoid certain types of foods? syndrome, arryhthmogenic right ventricular cardiomyopathy, long QT 50. Have you ever had an eating disorder? syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic 51. Do you have any concerns that you would like to discuss with a doctor? polymorphic ventricular tachycardia? 52. Do you have or someone in your family with Down Syndrome or 15. Does anyone in your family have a heart problem, pacemaker, or Dwarfism? implanted defibrillator? FEMALES ONLY Yes No 16. Has anyone in your family had unexplained fainting, unexplained 52. Have you ever had a menstrual period? seizures, or near drowning? 53. How old were you when you had your first menstrual period? BONE AND JOINT QUESTIONS Yes No 54. How many periods have you had in the last 12 months? 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that Explain "yes" answers below or on the backside of the paper: caused you to miss a practice or 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? 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?

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Student Signature: ______Parent/Guardian Signature: ______Date: ______

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Orcutt Academy High School Parent / Student Athlete Authorization Form

THE STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN INTERSCHOLASTIC ATHLETICS UNTIL THIS FORM HAS BEEN SIGNED AND RETURNED TO THE SCHOOL

I hereby authorize the release and disclosure of the pre-participation physical evaluation clearance form of: ("Student") ______, as described below, to ("School") ______.

The information described below may be released to the School Principal or Assistant Principal, Athletic Director, Coach, Athletic Trainer, Physical Education Teacher, School Nurse and/or other members of the School's administrative staff as necessary to evaluate the student's eligibility to participate in school sponsored activities. Including, but not limited to interscholastic sports programs, physical education classes, or other classroom activities.

The personal health information of a student, other than the clearance form; may be released and disclosed. It includes the records of the evaluation, diagnosis, and treatment of injuries, which the Student incurred while engaging in school sponsored activities, including but not limited to practice sessions, training and competition; and other records as necessary to determine the Student's physical fitness to participate in school sponsored activities.

The personal health information described above may be released or disclosed to the school by the student's personal physician or physicians. A physician or other health care professional maybe retained by the school to perform physical examinations. This to determine the student's eligibility to participate in certain school sponsored activities. In addition, to provide treatment to students injured while participating in such activities. Whether or not such physician, other health care professionals are paid for their services, volunteer their time to the school, any other EMT, hospital, physician or other health care professional who evaluates, diagnoses, treats an injury or other condition incurred by the student while participating in school sponsored activities.

I understand that the school has requested this authorization to release or disclose the personal health information described above to make certain decisions about the student's health and ability to participate in certain school sponsored and classroom activities, and that the school is a not a health care provider or health plan covered by federal HIPAA privacy regulations, and the information described below may be re-disclosed and may not continue to be protected by the federal HIPAA privacy regulations. I also understand that the school is covered under the federal regulations that govern the privacy of educational records, and that the personal health information disclosed under this authorization may be protected by those regulations.

I also understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of this authorization; however, the student's participation in certain school-sponsored activities may be conditioned on the signing of this authorization.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by a health care provider in reliance on this authorization, by sending a written revocation to the school principal (or designee) whose name and address appears below.

Name of Principal: Rhett Carter School Address: 610 Pinal Ave, Orcutt, CA 93455

This authorization will expire when the student is no longer enrolled as a student at the School.

NOTE: IF THE STUDENT IS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN TO BE VALID. IF THE STUDENT IS 18 YEARS OF AGE OR OVER, THE STUDENT MUST SIGN THIS AUTHORIZATION PERSONALLY.

Student’s Signature: ______Student’s Birth Date: ______Parent/Guardian’s Name (please print): ______Parent/Guardian Signature: ______Date: ______I am the Student's (check one): Parent ______Legal Guardian______

The original is kept with the school and a copy is given to student’s parent/guardian if requested

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Orcutt Academy High School Pre-Participation Physical Evaluation Physical Examination Form to be completed by the Doctor

Athlete’s Name Date of Birth ______PHYSICIAN REMINDERS 1. 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, or use condoms? • Do you consume energy drinks? 2. Consider reviewing questions on cardiovascular symptoms (questions 5-14). EXAMINATION Height Weight □ Male □ Female BP ( / ) Pulse ( / ) Vision: R 20/ L 20/ Corrected □ Y □ N MEDICAL NORMAL ABNORMAL Appearance Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyper laxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat Pupils equal Hearing Lymph nodes Heart Murmurs (auscultation standing, supine, +/- Valsalva) Location of the point of maximal impulse (PMI) Pulses Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only) Skin HSV, lesions suggestive of MRSA, tinea corporis Neurologic MUSCULOSKELETAL Neck Back Shoulder / Arm Elbow / Forearm Wrist / Hand / Fingers Hip / Thigh Knee Leg / Ankle Foot / Toes Functional Duck walk, single leg hop *Consider ECG, echocardiogram, or referral to cardiology for abnormal cardiac history or exam *Consider GU exam if in private setting. Having third part present is recommended *Consider cognitive or baseline neuropsychiatric testing if a history of significant concussion

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Orcutt Academy High School Pre-Participation Physical Evaluation Clearance Form to be completed by the Doctor

Name Sex Age Date of Birth (Please print)

Cleared without restriction

Cleared, with recommendations for further evaluation or treatment for:

Not Cleared for:

All Sports

Certain Sports:

Reason:

Recommendations:

____ I have examined the above-named student and completed the pre-participation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. 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 explained to the athlete (and parents/guardians).

Name of physician (print) Date

Address Phone

Signature of physician MD or DO

2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

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Orcutt Academy High School Athletic Department Athlete’s Code of Discipline

The goal of athletic participation is to provide a rewarding co-curricular experience for all students. All participants must commit to exemplary conduct and behavior as a representative of the school, district, and community.

As a participant in Orcutt Academy High School Athletics, I agree to the following: 1. To recognize that athletes involved in activities which reflect negatively upon themselves, the team or the school is subject to suspension from athletics;

2. To understand that hazing is defined as any act of forcibly involving fellow students in inappropriate, demeaning, or potentially dangerous acts (as in an initiation rite). Hazing is a form of intentional harassment and is considered a serious violation of our Code of Conduct;

3. To meet the minimum academic requirements established by the Board of Directors of the Orcutt Academy High School and California Interscholastic Federations (CIF) for eligibility;

4. To recognize that suspension for offenses to Education Code 48900 will result in competition ineligibility during the time of suspension;

5. To recognize that sport specific standards of behavior and appropriate consequences may be set by the head coach of each individual sport;

6. To recognize that a student/athlete who has unlawfully possessed, used, offered to sell, sold, or otherwise furnished, or been under the influence of, any controlled substance, alcoholic beverage, or an intoxicant of any kind, including androgenic/anabolic steroids, or unlawfully possessed, offered, arranged, or negotiated to sell any drug paraphernalia, while on school grounds, during school, or during or while going to, coming from or attending a school sponsored event, while going to or coming from school, during the lunch period whether on or off school grounds, shall receive the consequences listed below;

First Offense: *6 months or more suspension from athletic competition Second Offense: Suspended from athletics for one calendar year, regardless of the substance Third Offense: Lifetime suspension from the athletic program, regardless of the substance

*Any offense occurring outside the student’s athletic season, including summer will result in the suspension being applied to the next sport he/she participates in. Any offense occurring during the student’s athletic season may result in suspension for the balance of the season. Any time left on the suspension will be applied to the student’s next season of sport.

If a suspended athlete so chooses, he/she may have his/her suspension reviewed, and possibly have the time of the suspension cut in half upon enrollment and completion of an acceptable substance abuse counseling program.

7. To recognize a student/athlete involved in any activity during the time school is not in session, which results in an arrest and/or conviction, shall receive the consequences listed above.

Any athletic suspension may be subject to a review by the principal, athletic director, head-coach and/or coaches’ council.

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Orcutt Academy High School Athletic Department Athlete’s Code of Discipline

Parent Grievance Procedure The grievance procedure is intended to be a process whereby concerns of alleged mistreatment of student-athlete can be addressed professionally and in a timely manner.

Legitimate grievance issues: 1. Failure to provide due process in disciplinary actions 2. Failure to provide an equitable opportunity to compete for a position/team 3. Mistreatment of athletes (verbal and/or physical) 4. Any violation of an adopted code/policy

Non-legitimate grievances “Out of bounds” for discussion: 1. Playing time 2. Position of athlete 3. Game strategy 4. Win/loss record 5. Other athletes, coaches, parents, or teachers

It is the school’s intent that problems be resolved before coming to a formal grievance procedure.

1. Parent shall make contact with the coach in question to discuss a grievance. Please make an appointment that is outside of school, practice, or game time. Parents should not make contact during class time, scheduled practices, or games.

2. If necessary, the student athlete in question shall be present.

3. If a grievance cannot be resolved in initial meeting, the following steps may be necessary: a. A meeting with the Athletic Director or Principal and other involved parties.

My parent(s)/guardian(s) and I have read the above and fully understand the regulations. We understand the responsibilities being taken on by being a member of the team. We agree to abide by the policies and rules described therein. We realize failure to comply may result in suspension and / or expulsion from the team. As parent(s) / guardian(s), we understand that the school district and coach(s) will take all means necessary to create a safe environment in which to play, however we understand there is some risk involved for accident or injury, and therefore hold them harmless should such an incident arise.

I/we agree to allow my/our child to participate in the OAHS Sports Program and will support my/our child in this sports endeavor. By signing this agreement, we agree to the policies and rules.

Athlete (print name, sign, & date): ______

Parent (print name, sign, & date): ______

This Code of Discipline must be signed and be on file before a student participates in an athletic event in the Orcutt Academy High School.

A copy of this signed form is kept on file in the Athletic Director’s office at Orcutt Academy High School on an annual basis.

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Orcutt Academy High School Athletic Department Athlete’s Code of Ethics

Athletics is an integral part of the school’s total education program. All school activities, curricular and extracurricular, in the classroom and on the playing field, must be congruent with the school’s stated goals and objectives established for the intellectual, physical, social, and moral development of the students. It is within this context that the following Code of Ethics is presented.

As an athlete, I understand that it is my responsibility to: 1. Place academic achievement as the highest priority. 2. Show respect for teammates, opponents, officials, and coaches. 3. Respect the integrity and judgment of game officials. 4. Exhibit fair play, sportsmanship, and proper conduct on and off the playing field. 5. Maintain a high level of safety awareness. 6. Refrain from the use of profanity, vulgarity and other offensive language and gestures. 7. Adhere to the established rules and standards of the game to be played. 8. Respect all equipment and use it safely and appropriately. 9. Refrain from the use of alcohol, tobacco, illegal and non-prescriptive drugs, anabolic steroids or any substance to increase physical development or performance that is not approved by the United States Food and Drug Administration, Surgeon General of the United States or American Medical Association. (See…Athletic Code of Discipline). 10. Know and follow all state, section and school athletic rules and regulations as they pertain to eligibility and sports participation. 11. Win with character, lose with dignity. 12. Agree not to use androgenic/anabolic steroid without the written prescription of a fully licensed physician (as recognized by the AMA) to treat a medical condition. 13. Show good sportsmanship and understand that the highest potential of sports is achieved when competition reflects the six pillars of character: trustworthiness, respect, responsibility, fairness, caring, and good citizenship. 14. Consistently demonstrate integrity, observe, and enforce the spirit as well as the letter of the rules. 15. Understand that participation in the school sports program is a privilege, not a right. To earn that privilege, student-athletes must abide by the rules and conduct themselves, on and off the field, as positive role models who exemplify good character.

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Orcutt Academy High School Athletic Department Athlete’s Code of Ethics

Athlete’s Bill of Rights pursuant to Education Code 271 The following list of rights, which are based on the relevant provisions of the federal regulations implementing Title IX of the Education Amendments of 1972 (20 U.S.C. Sec. 1681 et seq.), may be used by the department for purposes of Section 270: a) You have the right to fair and equitable treatment and you shall not be discriminated against based on your sex. b) You have the right to be provided with an equitable opportunity to participate in all academic extracurricular activities, including athletics. c) You have the right to inquire of the athletic director of your school as to the athletic opportunities offered by the school. d) You have the right to apply for athletic scholarships. e) You have the right to receive equitable treatment and benefits in the provision of all of the following: 1) Equipment and supplies 2) Scheduling of games and practices 3) Transportation and daily allowances 4) Access to tutoring 5) Coaching 6) Locker rooms 7) Practice and competitive facilities 8) Medical and training facilities and services 9) Publicity f) You have the right to have access to a gender equity coordinator to answer questions regarding gender equity laws. g) You have the right to contact the State Department of Education and the California Interscholastic Federation to access information on gender equity laws. h) You have the right to file a confidential discrimination complaint with the United States Office of Civil Rights or the State Department of Education if you believe you have been discriminated against or if you believe, you have received unequal treatment based on your sex. i) You have the right to pursue civil remedies if you have been discriminated against. j) You have the right to be protected against retaliation if you file a discrimination complaint.

My parent(s) / guardian(s) and I have read the above and fully understand the contents. We understand the responsibilities being taken on by being a member of the team. We agree to abide by the policies and rules described therein. We realize failure to comply may result in suspension and / or expulsion from the team. As parent(s) / guardian(s), we understand that the school district and coach(s) will take all means necessary to create a safe environment in which to play, however we understand there is some risk involved for accident or injury, and therefore hold them harmless should such an incident arise.

I/we agree to allow my/our child to participate in the OAHS Sports Program and will support my/our child in this sports endeavor. By signing this agreement, we agree to the policies and rules.

Athlete (print name, sign & date): ______

Parent (print name, sign, & date): ______

A copy of this signed form is kept on file in the Athletic Director’s office at Orcutt Academy High School on an annual basis.

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Orcutt Academy High School Delta PT Athletic Training Program by San Luis Sports Therapy Athlete’s Concussion Injury Management Protocol

Based on recommendations of CDC, NATA, NFHSS, CIF, 3rd International Consensus Statement

1. ImPACT testing will be utilized to establish baseline cognitive scores, and again in the event of a concussion; procedures are reviewed annually with AT staff by Program Director.

a. Baseline testing will be done prior to contact practices at the beginning of the athletic season. Baseline testing is good for two years.

b. Per the ImPACT’s company guidelines, post-concussion testing is recommended within 48-72 hours after injury. Test is repeated once the athlete is asymptomatic, or at weekly intervals. If case is mild and return to play is eminent, test may be performed twice in a week, but never more than this.

c. Results may be interpreted by team physician, family physician, neurologist or neuropsychologist

d. If the athlete does not have a baseline on record, they may still be given a post-injury test, as results can be compared to ImPACT’s large normative database

e. Parents will be provided contact information for neurologists and neuropsychologists in the area

f. Final return-to-play clearance must come from an MD and/or neuropsychologist.

2. Any athlete suspected of having a concussion will be removed from play immediately, and not allowed to return to play the same day.

3. All athletes sustaining any type of head injury, regardless of severity, must be evaluated and the SCAT3 Evaluation form must be completed (see document #5, Appendix A).

4. Each athlete with suspected concussion also must be released to a parent or adult who will sign the Home Care Instruction form (see document #6, Appendix A)

5. Testing and Return to play guidelines will follow the fourth International Conference on Concussion in Sport Consensus Statement. In order to be returned to play, the athlete must have no physical symptoms, no cognitive symptoms, and a written MD clearance.

6. Athletic Trainer will follow up daily with injured athlete, utilizing the Graded Symptom Checklist

7. Graded Return To Play Guidelines will be followed in all cases of confirmed head injury: a. One day at each phase b. If no return of symptoms during, or day after, may progress to next phase c. If any physical or cognitive symptoms, during or day after, go back to previous phase d. Minimum time to return to full contact = 5 days Bike: Introducing movement, without jarring of brain Run: Movement, with addition of brain ‘bounce’ Agility: Adds element of decision-making to movement In Red: In drills, no contact (‘in-red jersey’); processing information, while moving No Restrictions: Pre-practice exam, watch during practice, post-practice exam

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Orcutt Academy High School Athletic Department Athlete’s Concussion Home Care Instructions

Your student athlete may have sustained a concussion on ______. To help ensure that his/her injury is managed appropriately, please follow these important recommendations:

1. Please remind athlete to report to the Athletic Training Room on ______for a follow-up evaluation.

2. Athlete must obtain physician evaluation & written clearance. Be sure to discuss ANY medication use with physician.

3. Please review the items outlined on the following Symptom Checklist. If any of these problems develop prior to his/her follow-up evaluation, please call the Athletic Trainer, your family physician, or the local emergency medical system. Otherwise, you may follow these instructions: Symptoms may include: Symptoms not readily apparent: ● Blurred vision ● Abnormal vision, hearing, smell and/or taste ● Dazed or vacant expression ● Difficulty concentrating ● Difficulty with balance/coordination ● Excessive fatigue ● Dizziness ● Hypersensitivity to light and/or noise ● Inability to recognize people or places ● Increasing irritability ● Increasing confusion ● Numbness in the arms or legs ● Intense headache ● Pupils becoming unequal in size ● Nausea or repeated vomiting ● Academic and/or Cognitive difficulties, ● Slurred speech or inability to speak (memory, recall, concentration, learning, etc.)

SYMPTOMS THAT REQUIRE IMMEDIATE MEDICAL ATTENTION: ● Intense Headache ● Nausea or repeated vomiting

● Loss of, fluctuating or decreasing level of consciousness ● Seizures ● Post-concussion symptoms that worsen, do not improve, increase in number, or begin to interfere with athlete’s daily activities (i.e. sleep, cognition, behavioral change) It is OK to: There is NO NEED to: ● Use Tylenol for headache ● Check eyes with a flashlight ● Use icepack on head/neck as needed for comfort ● Wake up frequently (unless instructed) ● Eat a carbohydrate-rich diet ● Stay in bed ● Go to sleep ● Test reflexes ● Rest from mental activity (no strenuous activity or sports)

DO NOT: ● Drink Alcohol ● Drive a car or operate machinery ● Engage in physical activity that makes symptoms worse (ex: exercise, weight lifting, PE, sports) ● Engage in mental activity that makes symptoms worse (ex: school, job, homework, computer games) ● Return to strenuous/contact activity until symptom free, & with a written MD or DO clearance

If the athlete experienced loss of consciousness (LOC), prolonged periods of amnesia, or was still experiencing significant symptoms at bedtime; awaken the athlete during the night to check on deteriorating signs and/or symptoms: such as, decreased level of consciousness or increasing headache. These may indicate a more serious head injury or late-onset complication, and require immediate medical attention.

In accordance with CA State Law, athlete’s MUST provide a copy of physician’s written clearance to the Athletic Trainer in order to return to any physical activity!

Recommendations provided to: ______Athlete: ______In person _____By phone#: ______Date: ______Time: ______Athletic Trainer: ______Athletic Trainer phone #: ______

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Orcutt Academy High School Athletic Department Athlete’s Consent for Medical Treatment

I hereby authorize the Orcutt Academy High School athletic training/medical staff, contracted by San Luis Physical Therapy, to evaluate and/or treat said athlete/minor, including use of electrical modalities, for the purpose, of attempting to manage any injuries received while he/she is a participant at Orcutt Academy High School. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk on behalf of myself and said minor. I acknowledge that no warranty is being made as to the results of any treatment.

______Athlete Name (PRINT)

______Athlete Signature Date

______Parent Signature Date

SAN LUIS PHYSICAL THERAPY & ORTHOPEDIC REHABILITATION PRIVACY & SECURITY COMPLIANCE NOTICE San Luis Physical Therapy and Orthopedic Rehabilitation, in compliance with certain laws, have taken reasonable and comprehensive steps towards the protection of the privacy and security of your personal health information. Such information may include oral, written, telephone, facsimile and/or other electronic communication of protected health information (PHI). Complete information regarding Privacy and Security Practices is available to all patients upon individual request and such information is entitled “Statement of Privacy and Security Practices”.

Individual Patient Rights: You have rights with respect to the following:  To read and understand this privacy and security notice prior to treatment  To request a copy of “Statement of Privacy and Security Practices”  To expect that all protected health information be utilized only for the following purposes: - Treatment (including contacting you with regards to appointment and other treatment related communication) - Payment - Health Care operations - Mailing or other communication with you in the form of announcements and/or newsletters  To request a copy of your personal health information  To request revision of inaccuracies in your personal health information  To restrict how your personal health information is used and disclosed except as noted above

Further Information/Concerns: Please express any concerns you may have regarding any violation of your privacy rights, and other privacy and security issues to the San Luis Physical Therapy and Orthopedic Rehabilitation Compliance Officer. Any concerns reported will not result in retaliation or retribution.

Compliance Officer: Kelly Sanders 805 Aerovista, Suite # 201 San Luis Obispo, CA 93401 Email: [email protected] Phone: (805) 788-0805, Ext#216

You also have the right to report any concerns regarding your privacy rights to the Secretary of the US Health and Human Services Department. The Department can be contacted at http://www.hhs.gov/ocr/hipaa or by calling (415) 437-8310.

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Orcutt Academy High School Athletic Department Parent’s Contract

We recognize that a healthy athletic experience requires support from parents. We have agreed to honor these core principles and support our student-athletes in this process.

 We will give consistent encouragement and support to our children regardless of the degree of success, the level of skill or time on the field.

 We will stress the importance of respect for coaches through discussions with our children and highlight the critical nature of being a team player and contributing to the team success.

 We will attempt to attend school and parent meetings outside of sports seasons to meet coaches and school officials and learn firsthand about expectations of participation in interscholastic sports.

 We will agree to abide by the rules governing the conduct of athletes while modeling these principles for our children.

 We will ensure balance in our children by encouraging excellence in the classroom and excellence in the sport.

 We will leave coaching to coaches and will NOT criticize the coaches, the strategies, or the team performance. We will agree to avoid putting pressure on our children about playing time or performance.

 We will allow our children to participate in the athletic program, and if appropriate, be transported by the district to and from competitions.

 We understand that there is an element of risk associated with all athletic competitions and that the district cannot guarantee that students will not be injured, despite a commitment to provide for every participant’s health and welfare.

California Education Code Section 32221.5 32221.5. A School district that elects to operate an interscholastic athletic team or teams shall include the following statements, printed in boldface of prominent size, in offers of insurance coverage that are sent to members of school athletic teams:

“Under state law, school districts are required to ensure that all members of school athletic teams have accidental injury insurance that covers medical and hospital expenses. This insurance requirement can be met by the school district offering insurance or other health benefits that cover medical and hospital expenses. Some Pupils may qualify to enroll in no-cost or low-cost local, state, or federally sponsored health insurance programs. Information about these programs may be obtained by call the toll-free telephone number.”

We know that school athletic experiences can contribute greatly to the values and ethics of each player and those positive athletic experiences teach important life skills, encourage teamwork, help shape character, and improve citizenship.

Parent (print name, date, & signature): ______

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San Luis Sports Therapy Parent ImPACT Letter

Dear Parent/Guardian,

Orcutt Academy High School will be utilizing an innovative concussion management program foor our student-athletes. ImPACT (Immediate Post Concussion Assessment and Cognitive Testing) is an online, computerized exam that each athlete takes prior to the athletic season. Baseline testing will be performed at the school, supervised by the athletic trainer.

In the event that the athlete is believed to have suffered a concussion during competition, the exam is repeated, and the data is compared to the baseline test. Post-concussion tests are taken under the same conditions as the baseline: at the school, supervised by the athletic trainer. The information is then used as a tool to assist the athletic training staff and treating physicians in determining the extent of the injury, monitoring recovery, and in making safe return to play decisions.

Developed by doctors at the University of Pittsburgh Medical Center, this software system is utilized throughout professional and amateur sports. 28 NFL teams, 18 MLB teams, Major League Soccer, US Lacrosse, Professional Hockey, Major/Minor League Baseball Umpires, USA Olympic Hockey, USA Ski Team, Swedish Soccer, Canadian Hockey; South African, New Zealand and USA Rugby, US Armed Forces, 350+ Clinical Centers, 350+ Colleges & Universities, and over 1200 High Schools across the country are currently using the ImPACT system. As a result, it has quickly become the ‘gold stanndard’ in recognizing and managing head injuries. Additional information can be found at www.impacttest.com.

The exam takes approximately 25 minutes, and is set up as a ‘video game’ type format. It tracks neurocognitive information such as memory, reaction time, brain processing speed and concentration. For example, in one part of the exam, a dozen common words appear one at a time on the screen for about one second each. The athlete is later asked which words were displayed. It is a simple exam and most who take it enjoy the challenge of the test.

This program has been made possible by Sierra Vista Regional Medical Center, and the San Luis Sports Therapy Athletic Training Program, in an on-going effort to assure that the health and safety of high school athletes remains a top priority. If you have any questions, pleaase feel free to use the contact information listed below.

Sincerely,

Andrew Boortz, ATC Stacey J. Ritter, MS, ATC Athletic Trainer, OAHS Director of Sports Medicine & Athletic Training San Luis Sports Therapy San Luis Sporrts Therapy [email protected] [email protected] (805)305-4409 (805) 788-0805 x235

PERMISSION SLIP Foor use of the Immediate Post-Concussion Assessment and Cognitivve Testing (ImPACT)

I have read and understood the above information and give permisssion for my son/daughter to participate in the ImPACT Concussion Management Program.

PRINT Name of Athlete ______Sport(s) ______

Signature of Athlete ______Date ______

Signature of Parent ______Date ______Tel #:______www.sierravistaregional.com www.slsportstherapy.com www.impacttest.com

1 | Page Updated 4/25/2016

Orcutt Academy High School Athletic Department Press Release Authorization

I give my permission for Orcutt Academy to post my/my student’s name, photograph, and where applicable, athletic statistics on the Orcutt Academy website and MaxPrep.

In addition, I also release this information for publication in school newsletters and/or general media press releases or features.

I release Orcutt Academy from any legal liability rising from this action and give permission without reservation or limitation.

______Print Student Name Student Signature Date

______Print Parent/Guardian Name Parent/Guardian Signature Date

1 | Page Updated 4/25/2016

Orcutt Academy High School 2016 - 2017 Coaches Contact Information

Last First Sport Season Cell Email Name Name Cheer All Year Eckenrode Katey 805-714-0760 [email protected] Cheer Assistant All Year Moore Megan 805-478-5798 [email protected] Dance All Year Lane Jennifer 805-598-2312 [email protected] Football Fall May Doug 805-878-7634 [email protected] Assistant Football Fall Lyon Ted 805-868-3131 [email protected] Assistant Football Fall Lyon Shane Girls Golf Spring McManus James 805-458-2901 [email protected] Girls Golf Spring Birch Raul 805-268-4561 [email protected] Girls Varsity Tennis Fall Lopez Art 805-448-3947 [email protected] Girls Varsity Tennis Fall Hull Stephanie [email protected] Girls Varsity Tennis Fall Childs Tara 805-714-8886 [email protected] Girls JV Tennis Fall Herrera Michele [email protected] Girls JV Tennis Fall Stitt Jennie [email protected] Girls Var Volleyball Fall Girls JV Volleyball Fall Boys Cross Country Fall Fabing Roger 805-315-3786 [email protected] Girls Cross Country Fall Girls Var Basketball Winter Avila Danny 805-878-1523 [email protected] Girls Var Basketball Asst Winter Fierros Gilbert 805-896-3936 [email protected] Girls JV Coach Winter Loera Fernando 805-878-2783 [email protected] Boys Var Basketball Winter Black Darrell 805-406-3250 [email protected] Var Basketball Asst Winter Dell'Armo John 805-938-8550 [email protected] Boys JV Basketball Winter Smalley Ryan 805-345-0838 Boys Varsity Soccer Winter Bennett Josh 805-623-2158 [email protected] Boys Var Soccer Winter Dyson Kevin 805-268-4932 Boys JV Soccer Winter Ruiz Francisco 805-720-4333 Girls Varsity Soccer Winter Speer Brian 805-698-6905 [email protected] Girls Varsity Soccer Winter Justice Larry 805-588-0010 [email protected] Girls Varsity Soccer Winter Ryan Shawn 805-720-0717 [email protected] Girls JV Soccer Winter Boys Golf Spring White Lincoln 805-403-2498 [email protected] Boys Golf Spring Birch Raul 805-268-4561 [email protected] Boys Volleyball Spring Milton James 603-799-6406 [email protected] Boys Volleyball Spring Papworth Tim 805-863-7452 [email protected] Track Coach Spring Tosches Marc 805-714-4566 [email protected] Track Assistant Spring Krouse Stephanie 805-714-5798 [email protected] Track Assistant Spring Fabing Roger 805-315-3786 [email protected] Boys Varsity Tennis Spring Cartwright John 805-478-2011 [email protected] Swim Spring Ayers Deanna 805-287-0917 [email protected] Swim Assistant Spring Brown Bailey 805-878-8295 Swim Assistant Spring Lougee Sara 805-896-4920 [email protected] Dive Coach Spring Roux Kailey 805-598-5495 Varsity Baseball Spring Rose Jim 805-406-6906 [email protected] Varsity Softball Spring Krasner John 805-714-5159 [email protected] Var Softball Assistant Spring Santiago Paul [email protected] Var Softball Assistant Spring Dutra Deedra 805-245-7083 [email protected] JV Softball Spring

1 I Page Updated 4/25/2016 Orcutt Academy High School

Dear Business Owners:

As our 2016-2017 Sports Season rapidly approaches, our athletes have been working very hard and our expectations are very high. In order for our athletes to compete and have an opportunity for a meaningful sports experience, our students rely heavily on fundraising efforts and donations from local businesses.

The high school does receive a small athletic budget that covers the cost of coaches' stipends, CIF dues, CIF travel expenses, and official fees. This leaves facility costs, competition/tournament fees, transportation, equipment, team awards/banquets, and uniforms to be paid for by students out of funds raised or from donations received from local businesses.

As part of our fundraising efforts, we are asking local businesses to help support our sports programs. If your business would be able to help out, it would be greatly appreciated. If you have any questions, please contact our Business Office as listed below.

Thank you in advance for your generous donation and support our sports program.

GO SPARTANS!

Chad McKenzie Athletic Director

Please make check payable to OAHS. Please indicate which sport or you may donate to the General Athletic fund, which is used by all sports. Please mail check and form to the address below.

Name of Business/Sponsor:

I am enclosing a check/money order for Check Amount $ ______Check # ______Sport Team(s):

______$______/ ______$______/ ______$______

The Orcutt Academy High School is fully affiliated with the Orcutt Union School District (OUSD). The OUSD is a publicly funded local educational agency within the County of Santa Barbara. OUSD is a tax-exempt organization, as defined in the IRS Code Section 501(c)(3), organized and operates exclusively for educational purposes. Federal Tax ID #77-0074164

Attn: OAHS Business Office 610 Pinal Ave, Orcutt, CA 93455 (805) 938-8594 Office / (805) 938-8599 Fax 1 | Page Updated 4/25/2016 Dear Orcutt Academy High School Parent/Guardian:

The success and breadth of our Sports program is in large part due to donations from parents, sponsors, fundraising by teams, parent drivers, and the Athletic Boosters Club. The Academy now in the Los Padres Athletic League had an amazing year, with some of the sports making it into the CIF playoffs.

The General Charter covers the cost of a Certificated Athletic Trainer, which has been a great addition to our sports program.

The School’s Athletic Budget covers the cost of coaches’ sttipend, CIF dues, CIF Travel (some), and Official fees. This leaves uniforms, transportation, equipment, facility costs, and host of other things that can pop up during a season.

Last year, donations from parents, sponsors, and fundraising by teams helped to assist with some of these costs. We are once again asking for donations from anyone who is in a position to help. If you would like to donate to a particular sport(s), please indicate the amount that you will be donating and which sport(s). Please return the filled out form along with your check or money order payable to OAHS (the sport you want it to go to, EX: OAHS Football), and send it to the OAHS Business Office. If you do not specify a sport, then the money will go into the general athletic fundraising aaccount to be used for all sports.

Thank you in advance for your generous donation and supporting our sports program.

Sincerely,

Chad McKenzie Athletic Director

Please make check payable to OAHS. Please indicate which sport or you may donate to the General Athletic fund, which is used by all sports. Please mail check and form to the address below.

Name of Parent/Guardian: ______

Name of Student: ______

I am enclosing a check/money order for $______ck/mo #______I would like the following funds to go to the sport(s) fundraisiing account in the following amounts:

Sport ______$______, Sport ______$______,

The Orcutt Academy High School is fully affiliated with the Orcutt Union School District (OUSD). The OUSD is a publicly funded local educational agency within the County of Santa Barbara. OUSD is a tax-exempt organization, as defined in the IRS Code Section 501(c)(3), organized, and operates exclusively for educational purposes. Federal Tax ID #77-0074164

Attn: OAHS Business Office: 610 Pinal Avenue Orcutt, CA 93455 (8055) 938-8594 Fax (805) 938-8599

Orcutt Union School District

SAFETY RULES FOR DRIVERS OF VEHICLES USED TO TRANSPORT STUDENTS

It is well for all of us to recognize that while driving students, increased safety precautions should be taken. The district would appreciate your reviewing this list to insure the safest possible trip.

1. Be sure your vehicle, including brakes, lights and tires, is in good operating condition before you leave.

2. Do not allow more passengers than the vehicle is designed to accommodate. Drivers cannot legally transport more than 9 students and the vehicle cannot be designed for seating more than 10 people, including the driver.

3. Use of safety belts is required by the State of California. Each passenger must have a seat belt and belts must be used at all times when the vehicle is in motion.

4. Obey all traffic rules. Be alert. Never exceed the posted legal speed limit. Do not allow passengers to distract you while driving. Do not text or make cell phone calls while driving.

5. All doors should be locked when the vehicle is in motion.

6. Accidents, unusual incidents, or disciplinary problems shall be reported to the school Principal.

7. Accidents, claims resulting from an accident, and supporting documentation shall be reported and submitted to the Assistant Superintendent of Business at the District Office at (805) 938-8916.

WORKERS' COMPENSATION INSURANCE FOR VOLUNTEERS

Thank you for your interest in performing volunteer services for the Orcutt Union School District. Your services are welcome and appreciated.

You will be covered by the district's workers' compensation insurance while performing services for the district, providing you have submitted a completed Trip Volunteer Authorization Form. This form must be approved by the Principal/Director and the Assistant Superintendent of Business before a volunteer is authorized to receive coverage for an accident or illness which may result from volunteer service. The coverage will be in effect only for the length of service shown on the authorization form. If you will be performing services beyond the date(s) shown on the form, please notify the Principal/Director immediately.

If you should have an accident or illness due to voluntary service, report it immediately to the Principal/Director. If medical services are needed, please contact:

Workers’ Compensation Administrators 265 E. Donovan Road Santa Maria, CA 93454 (805) 922-9157

If you will be transporting students as part of your volunteer services, please make sure that the Pupil Transportation section of the Volunteer Authorization form has been completed and requirements met.

Again, thank you for your willingness to help in our schools.

c:\documents and settings\office.000\my documents\transportation\transportation volunteer\volunteer safety information.doc Orcutt Union School District VEHICLE SAFETY FORM

This form is to be completed by the school volunteer using his/her personal vehicle to transport students to a school-sponsored event.

Name of Driver(s): ______

VEHICLE NO. ______License No. ______Make/Model ______CHECK LIST _____Brake Lights _____ Head Lights _____ Seat Belts _____ Tires

I verify that the vehicle(s) noted above are/is in working order and can safely transport students.

______Print Name Signature Date

Please return this completed form to your school principal or athletic director.

c:\documents and settings\office.000\my documents\transportation\transportation volunteer\vehicle safety form.docx

Orcutt Union School District Student Name:______School Year:______TRIP VOLUNTEER AUTHORIZATION FORM

A completed form must be submitted to the Principal or Athletic Director at least 5 days prior to services being performed.

Name:______Phone:______Cell Phone: ______Last First Address: ______Volunteer Services to be Performed: ______Teacher/Coach:______Activity:______Teacher/Coach:______Activity:______Have you ever been convicted of: Any crime other than minor traffic violations ____Yes ____No Felony ____Yes ____No Child Abuse ____Yes ____No

If so, please explain in detail. Use an extra sheet of paper if necessary.______Education Code 35021 prohibits registered sex offenders from serving as volunteer aides. In accordance with Penal Code 290.4, the Department of Justice operates a “900” telephone number that the district may call to ask if an individual is a registered sex offender.

PUPIL TRANSPORTATION (Complete this section if you will be transporting students.)

The district appreciates your contribution in providing pupil transportation. However, please be advised that the school district's liability policies do not protect you. The district strongly urges you to check with your insurance carrier to determine that you have sufficient liability and personal injury coverage prior to driving and/or using any vehicle to transport students. Your insurance is primary and the district’s is secondary.

In addition to this completed form, proof of insurance and a current DMV printout must be attached. A DMV printout can be obtained from the Department of Motor Vehicles, 523 South McClelland, 1-800-777-0133.

Drivers cannot legally transport more than 9 students and the vehicle cannot be designed for seating more than 10 people, including the driver. A driver must have a seatbelt for each passenger.

Date of Trip(s) ______Destination ______Purpose of Trip(s) ______Driver's License # ______(NEED COPY) Issued by (state) ______Expiration Date ______Auto Insurance Carrier Name ______Auto Insurance Agent Name & Phone ______I will be driving: ______my own vehicle ______a rented vehicle I certify that I have not been convicted of reckless driving or driving under the influence of drugs or alcohol within the past five years. I understand that if an accident occurs, my insurance coverage shall bear primary responsibility for any losses or claims for damages. MY SIGNATURE CONSTITUTES AWARENESS OF THE SAFETY RULES AND THE COMPLETENESS AND ACCURACY OF THE STATEMENTS ON THIS FORM

Signature of Volunteer: ______Date: ______ ______Safety Rules ____ Vehicle Inspection ____ DMV Print-out Approved by: Principal/Athletic Director ____Pull Notice ____ Proof of Ins. __ID Copy ____ DOJ (if non parent)

Megan’s Law Check by______on ______(Business Ofc ______) Pull Notice to Trans_____ Added to DBase______

c:\documents and settings\office.000\my documents\transportation\transportation volunteer\trip parent volunteer authorization 9-2009.doc REVISED 9/15/09