Coconino High School

Flagstaff Unified School District Coconino High School Stacie Zanzucchi, Principal Cris Holmes, Assistant Principal 4 Steve Bonderud, Assistant Principal Eric Freas, Athletic Director / Athletic Trainer 2800 N. Izabel Street * Flagstaff, AZ 86004 * 928-773-8200 Academic Year 2015-2016 Welcome to Coconino High School - home of the Panthers! We at Coconino High School believe that athletics and activities play an important role in the lives of our students and can contribute significantly to a student's total education experience. However, participation in athletics and activities is a privilege and we expect our students to abide by policies, rules and regulations set forth by the Arizona Interscholastic Association/ABODA/AMEA as well as the Flagstaff Unified School District. Coconino High School provides students opportunities to participate in the following sports and/or activities: Year Round Fall Marching/Concert Band-Non-Cut Cross Country (Boys and Girls)-Non-Cut Dance-Cut Football-Non-Cut Cheer-Cut Golf (Boys)-Cut Choir/Orchestra Non-Cut Volleyball-Cut Winter Spring Basketball (Boys and Girls)-Cut Baseball (Boys)-Cut Soccer (Boys and Girls)-Cut Softball (Girls)-Cut Wrestiing-Non-Cut Sand Volleyball (Girls)-Cut Tennis (Girls)-Non-Cut Track and Field (Boys and Girls)-Non-Cut Prior to participation, students and parents are required to complete the Athletic Clearance packet and pay their fees. ***For Cut Sports: $35 non-refundable fee is due upon submission of the Athletic Clearance packet The remaining $90 of the participation fee is payable upon placement on a team ***For Non-Cut Sports: $125 non-refundable fee is due upon submission of the Athletic Clearance packet. 4f The total participation fee must be paid before the end of the season or your student will not be eligible to participate in the next season of sports. The $125 per student fee is paid once per academic year and there is a family cap of $200. The Athletic Participation Fee is a NON-REFUNDABLE TAX CREDIT ELIGIBLE DONATION. The following information should help you prepare for achieving the maximum benefit from your extra-curricular experience. Clearance packets will be accepted by the Attendance Office only after all paperwork has been completed. Students will be unable to practice or play until all required documents and fees have been submitted. We thank you for your support and commitment, we hope your student will enjoy their time at CHS and grow from their experience with AIA and Coconino High School activities. CHS Athletic Clearance Form Checklist D Coconino High School Athletic Clearance Form *AII athletes must provide documentation of insurance coverage before being able to practice or participate in any sport activity, if you need to purchase insurance from the school provider, insurance packets are available in the Front Office. In order to pay for school insurance, you must have a check, money order or credit card number. Health insurance is mandatory for all athletes. Signed by both athlete and patent. D 2015-2016 Annual Pre-participation Physical Evaluation (Form 15.7-A) 2 pages • Form is to be filled out by Parent / Guardian with assistance from student athlete and signed D 2015-2016 Annual Pre-participation Physical Evaluation (Form 15.7-B) • Physical Form to be filled out by athlete's physician or medical provider • Current Physical Examination must be dated after April 1, 2014 D Mild Traumatic Brain Injury (MTBI) Concussion Form (Form 15.7-C) • Signed by both athlete and parent D Brainbook Online Concussion Education Course • www.aiaacademy.org 1. Scroll down and click on the Quick Link titled "Concussion Education: Brainbook" in the center of the page 2. Click on "Register as Student" 3. Enter all the fields in the "Name" section 4. Answer all fields in the "Student Demographic information" section 5. Click on "Register" at the bottom of the page 6. Student athletes will now be taken to the Brainbook Concussion Course to complete • Attach printed copy of the Brainbook Evaluation Certificate to packet •!• Athlete who have taken the Brainbook Exam and who already have a copy of their Brainbook Exam on file with the CHS Front Office do not need to retake the Brainbook Evaluation D Eligibility and Conduct Code for All AIA Regulated Activities • Signed by both athlete and parent D $35.00 (Cut Sport) or $125 (Non-Cut Sport) non-refundable fee (Cash, Check, Money Order or Debit/Credit Card) D Copy of Birth Certificate D Parent/Athlete Concussion Information Sheet (Signed by Athlete and Parent) If you have any questions, please contact the Attendance Office. ATHLETIC EMERGENCY INFORMATON FORM 2015~16 General Information Coconino High School School Year ^JJ^3^r Homc of thc Panthcrs °ate Cleared |*5^pF Cleared Bv Last Name First Name School ID # Gender Grade (9-12) Address Date of Birth Home Phone Citv/Zip Domicile: 1 live with (check all that apply) Mother Father Legal Guardian Other (Relationship) Father/Legal Guardian Name Mother/Legal Guardian Name Home Phone # Home Phone)1* Other # (Cell or email) Other # (Cell or email) Emergency Contact Name (if unable to reach Parent) Relationship Phone # Sport/Activity Fall Winter Spring Crosscountry Volleyball Boys' Basketball Boys' Soccer Baseball Tennis Football Marching Band Girls' Basketball Girl's Soccer • Softball Track/Field Golf Orchestra Wrestling Choir Beach Volleyball Cheer Dance Acknowledgement of Information I/We have received the CHS Athletic Information, the parent and Student Code of Conduct and have read, reviewed and understand the information and guidelines provided. We have had our questions and/or concerns regarding this information addressed by the appropriate school personnel. We agree to participation compliant with the information and guidelines provided and attest to the fulfillment of all rules and regulations outlined in those materials. Student Signature X Parent/Guardian Signature X Equipment Code I/We accept responsibility for the care and return of all athletic equipment issued to me by CHS. I understand and agree that all equipment is the property of the high school and must be returned in reasonable condition. Items lost, stolen or abused must be replaced at replacement value. If not paid in full at time of loss the amount will appear as a charge on the athlete's * student account in the bookstore. Student Signature X Parent/Guardian Signature X Consent for Treatment by Athletic Trainer I/We give our permission for the Licensed Athletic Trainer to provide treatment and rehabilitation for injuries incurred while participating in athletics, following the protocols established in conjunction with the sponsoring physician. Yes No Student Signature X Parent/Guardian Signature X FOR OFFICE USE ONLY/DO NOT WRITE IN THIS BOX "Sn FiTe: " "fiTysicaTTtvaluatibn"" " " "~ 'consent " "insu'ranTe --- """"" 'bramb'bolc" Code of Conduct/Information Acknowledgement Concussion Acknowledgement Participation Fee Paid Amount Check** / Cash / CC Date Panther Athletic Clearance Form Birth Date: / / Can not turn 19 years of age on or before Sept 1st LAST NAME FIRST NAME HOME PHONE Insurance Carrier Policy ID Number Group Number Policy Holder Name Emergency Number Physician's Name Athletic Consent Consent for Participation in Interscholastic Activities/Acknowledgement of Warning The above named student has my permission to participate in interscholastic activities and to travel with the team as a member using school approved transportation. Our permission includes but is not limited to participation in the following organized interscholastic activities; Baseball, Basketball, Cheer, Cross country, Dance, Football, Golf, Marching Band, Orchestra, Soccer, Softball, Swimming, Tennis, Track, Volleyball and/or Wrestling; realizing that such activity involves the potential for injury which is inherent in all activities. I/We acknowledge that even with the best coaching, use of the most advanced protective equipment and strict observance of rules, injuries are still a possibility. On rare occasion these injuries can be so severe as to result in total disability, paralysis, quadriplegia or even death. We acknowledge that we have read and understand this warning. Student Signature X_ Parent/Guardian Signature X_ Date Consent for Emergency Care BE IT KNOWN THAT I, the undersigned parent or guardian of the above-named student, do hereby give and grant unto any medical doctor, hospital or school athletic trainer, my consent and authorization to render such aid, treatment or care to said student as, in the judgment of said doctor, hospital or school athletic trainer may be required, on an emergency basis, in the event said student should be injured or stricken ill while participating in an interscholastic activity sponsored or sanctioned by the Arizona interscholastic Association, of which Cocnino High School is a member, or other school activity. I understand and agree that Flagstaff unified School District #land/or Coconmo High School are not financially responsible for accident of injury resulting from my student's participation in any school related activity. I will assume the responsibility for medical, health or accident insurance during the duration of my student's participation in school activities for the current year. I will notify the school if I change or cancel my policy. IT IS HEREBY UNDERSTOOD that the consent and authorization hereby given and granted are continuing and are intended by me to extend throughout the current school year. Parent/Guardian Signature .X._ Date Participation in:

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