Paperwork Must Be Complete Before Students

Sports Registration Packet

Paperwork must be complete before students can participate in try outs, practices or games. Please review all pages carefully and sign everywhere you see the arrow. Do not take packet apart. Turn in all pages. You may have an extra copy for your records.

For additional information go to: www.roseburg.k12.or.us/jolane & click the Sports Link or call 541-440-4105 Letter to Parents of Student Athletes:

All athletes are required to have a sports physical on an official OSAA form. The necessary forms are included at the end of this packet.

Physicals are good for two years.

In addition to a physical, each athlete is required to read, understand, sign and comply with the policies outlined in this packet.

Make sure you have read the entire packet and signed where indicated.

A participation fee is charged to your student’s account for every sport played. Please pay as soon as possible. These funds are crucial to the continuation of the sports program. Fees not paid by the time your student graduates or leaves the school district will be sent for collection. If your family is financially unable to pay, please contact the athletics office to discuss your options. 541-440-4105

Never give forms or fee payments directly to your coach. Paperwork goes to either the sports table at registration or to the Athletic Office during regular business hours. Payment of sports fees must be made in the school’s main office or the fee table at registration.

Student athletes will NOT be eligible to participate in try-outs, practices or games until all necessary paperwork has been approved in the school athletic office. Schedule

September/October October/December

Football Volleyball Boys Basketball Cross Country

January/February Mar/April/May

Girls Basketball Track and Field Wrestling

Updated 2/11 kb Volunteer Drivers Application This form is only needed if you want to drive students other than your own

 We cannot process your application without a copy of your VALID DRIVERS LICENSE & INSURANCE CARD  Only one application is needed for all of your students at any Roseburg Public School  A new application is needed each year We are now required to determine proof of Auto Liability insurance prior to volunteers driving our students on a field trip or some other school approved activity. Since we depend heavily on parent drivers, we are asking you to complete this form and return it to the Athletics Office as soon as possible. Our central office will do verification through the Department of Motor Vehicles. We hope that the benefit in formalizing this process outweighs any inconvenience. It is our understanding that you are equipped to transport children to a school approved activity in your private automobile. Signing this form indicates that you have properly working seat belts for all children and that you understand that your insurance company is the primary source of coverage. The district policy becomes a secondary source of coverage. Please provide the following information for our records. Remember to attach copies of your drivers license and insurance card as evidence of required insurance coverage.

Your Student’s Name______School______

______PRINT Driver’s Name Driver’s Signature Date

______PRING Driver’s Name Driver’s Signature Date

Updated 2/11 kb Joseph Lane Middle School [ ][ ][ ] Student’s first mi last name EMERGENCY INFORMATION FORM Birth Date ______Current Grade_____ Student Emergency Contact Information

Student Address:

1st Parent /Guardian Name:______

Home# Work# Cell# 2nd Parent /Guardian Name:______

Home# Work# Cell# Alternate Contact Person’s Name:

______Relationship______

Home# Work# Cell# Insurance + Medical Information

Insurance Company: Group or Policy #

Notify the athletic office immediately if your insurance or contact numbers change.

My Family Physician ______Phone ______

Known allergies: ______

Ongoing Medical Conditions: ______

Medications taken on a regular basis:

Circle the sport/s you plan on playing: Football - Volleyball - Cross Country - Girls Basketball - Boys Basketball - Wrestling - Track I give my consent for my child to participate in competitive activities; therefore, he/she may go with the coach on any regularly scheduled trip. I also give consent for the coaches to apply first aid treatment and to use their own judgment in securing emergency medical aid and ambulance service in case of injury or illness in case I cannot be reached to provide consent. While I expect school authorities to exercise reasonable precautions to avoid injury I understand that they assume no financial obligation for any injury or illness that may occur. I understand that if my child is seen for an injury we will need to provide a physician’s release before he/she can return to full participation. I also confirm that my student has adequate accident insurance as described above, effective as of this date.

Date:______Parent Signature:______Do not fill out below this line Athletic Department Red Card

Sport 1 ______Date______OK ______Sport 3 ______Date______OK ______

Sport 2 ______Date______OK ______Sport 4 ______Date______OK ______

Updated 1/11 kb Physical Expires ______SMG_____

INSURANCE REQUIREMENTS File 2/4

All the athletes in the Roseburg School District must be insured against injuries, which may occur during athletic participation. The District must be assured that the student- athlete has adequate accident coverage. The Roseburg School District cannot be financially responsible for accidental injury to student-athletes. Roseburg School District is relying on the information provided as assurance that your student has adequate accident insurance coverage that will be in effect for the duration of his/her athletic participation.

My child ______has adequate accident insurance coverage

Parent/Guardian Signature:______

Date ______

If you do NOT have insurance at this time you must obtain coverage before your student can participate, including practices, try out s, or games.

School Insurance can be purchased on-line at www.k12StudentInsurance.com at a very reasonable cost.

If you do not have computer access please contact the Athletics Office for assistance. 541- 440-4105 ______PARENT/GUARDIAN RESPONSIBILITY FOR SPORT FEES I understand that there will be a $125 fee charged for each sport my child participates in, up to a $300 maximum for my family. These participation fees go toward the salaries of referees and coaches, as well as the cost of maintaining fields, gymnasiums, equipment, uniforms and safety gear.

I understand that fees not paid, by the time my student graduates from middle school or leaves the school district, will be sent for collection. If your family is financially unable to pay, please contact the athletics office to discuss your options. 541-440-4105

Parent/Guardian Signature:______

Date ______JOSEPH LANE MIDDLE SCHOOL - ATHLETIC ELIGIBILITY POLICY

Interschool athletic competition is held to be part of the total curriculum; therefore, participation in such activities is contingent upon meeting established guidelines in an effort to insure the moral and physical health of the student athlete. In addition to regular school policies, athletes a Jo Lane Middle School are expected to conform to the following athletic code. This code is upheld the school year including school vacation periods. All students desiring to participate in interschool athletic competition must meet the following eligibility requirements: Grades  Students must be passing a minimum of five (5) classes.  A grade check will determine eligibility. Grade checks will occur approximately every two (2) weeks. A team roster will be given to each teacher to indicate those students who are receiving an “F.”  Ineligibility extends for a period of two (2) weeks unless the teacher submits documentation to both the Athletic Office then Coaches indicating grade improvement by which eligibility will be reinstated.  If the athlete is not passing five (5) classes, he/she will be ineligible to participate in competition. Unless otherwise arranged by the coach, participants are required to attend all practices during this time. Ineligible athletes will not be permitted to travel with the team to away competitions. Attendance  Students must be attending school and practice regularly.  Students must be in attendance a minimum of a ½ day (3 periods) on the day of the scheduled event/game/competition.  An athlete who continuously misses school the day before and/or after an athletic event (as determined by an attendance record review) may be suspended from further athlete competition during the sport season.  Circumstances beyond the control of the athlete may be grounds for exception to this rule as determined by the building principal(s) and/or athletic director. Behavior Students participating in interschool athletic competition must demonstrate the ability to conduct themselves in an acceptable manner in the classroom, on the court/field, and during competition. Behavioral infractions including, but not limited to, harassment, defiance, disrespect, insubordination, and/or actions deemed unsafe may result in an athletic probation contract and/or suspension from competition. Continued behavior infractions violating the athletic probation contract may result in permanent exclusion from the team. School administration and/or the athletic director will make such determination. Discipline In addition to school and district policy, the coaches shall set up guidelines for discipline expectations during their respective sport season. Athletes are subject to all disciplinary actions as outlined in Policy JFC in relation to substance abuse. In addition to JFC policy, a student athlete found:  Smoking, chewing tobacco, and/or possession will be subject to suspension based upon the athletic suspension schedule.  In possession, using, transmitting or being under the influence of alcohol, marijuana, any illegal drug, and/or prescription drug used for purpose of getting recreational intoxication shall be suspended from athletic competition for a minimum of competitive events as represented in the athletic suspension schedule. Any athlete involved in a substance abuse violation shall automatically be referred to the appropriate program provided by the school/or related agencies designated to deal with such infractions. The athlete must successfully complete the requirements of the program or be declared ineligible to participate in interscholastic competitions as a Joseph Lane Middle School representative. Any athlete cited, arrested, and/or found violating any law, which carries a misdemeanor or felony penalties, shall be suspended for minimum of competitive events as represented in the athletic suspension schedule. Athletic Suspension Schedule Basketball - 2 games - Volleyball - 2 games - Wrestling - 2 matches - Football - 1 game - Track - 1 meet Umpqua Valley League Philosophy “The UMPQUA VALLEY LEAGUE promotes a philosophy that the intensity of competition shall be tempered with the humility in victory and graciousness in defeat. The League shall always strive to achieve desirable characteristics in the athlete by maximum participation. We believe in the highest standards of conduct and scholarship. We insist on exemplary behavior and leadership from every coach, that they may serve as a positive example to our athletes. Finally we will strive to promote the growth and development of the UMPQUA VALLEY LEAGUE so that we may continue to serve the best interest of our athletes.” Eligibility Requirements You need to fill out and return the following forms to participate in any practice or game. 1. Current Physical: The physical is good for two years. If you had a new physical last year it is still on file in the athletic office; you will not need a new physical. Student’s who have not played sports will need to get a physical on the official OSAA physical form available in the office or on the osaa website www.osaa.org. 2. Health Update form: This form is required of athletes who have a physical of more than one year old. This form is required to update the school and coaches of medical concerns that have developed since the last physical. 3. Emergency & Insurance information form: This form is required of all athletes and parents and includes signatures from both. You need to update this form annually. The form will be on file in the athletic office and with your athlete’s coach for all events. It requires your insurance policy number; insurance is required for all athletes. 4. School Insurance is also available. Contact the school athletics office for information and assistance. 541-440-4105 5. Code of Conduct: Read and signed by both the student athlete and the parent. 6. Parent Participation Contract: Please retain the first page and return the second page signed by both parents/guardians and students. 7. Payment of Participation Fee: This fee is $125.00 per sport with a $300.00 family maximum for middle school sports, It is payable at the time of school registration. If your student is participating in a cut sport, you may wait until the final cut to pay the fee. The fee should be paid before the first contest. Applications for community service or delay of the sports fee are available in the athletic office. Parent Support Contract of Joseph Lane Middle School Athletics Parents please read and sign the following parent support contract for Joseph Lane Middle School Athletics,. Be supportive of the program in front of your athlete! Never be critical of coaches, players, or game officials in front of your player. Nothing can erode the intricate fabric of a team more than doubt. It can negatively affect performance, confidence, and competitive edge at the most critical times. Cheer for all players on the team; never coach the athletes or jeer the officials from the sidelines. Playing time is the sole responsibility of the athletic coach of that team. The coach is in the best position to determine the amount of time an athlete competes and should base his/her decision on the following: Practice • Attitude • Team Contribution • Ability/Skill Encourage your athlete to speak directly to coaches about sports issues! By assuming this responsibility, your athlete is claiming ownership for all aspects of the sport. If you have concerns that cannot be resolved in this manner, speak privately with the coach at an appropriate time – not right after or during a game. A secondary resource is the Athletic Director. Be part of the team’s parent network! Sports program benefit when parents work in support of the team. Be part of that effort! Interact with other parents; work to halt group related criticism, rumors, and just plain gossip! Support the Code of Conduct! Our athletes are “in-training” for life as well as sports. It is essential that parents and the school work as partners, to ensure that Joseph Lane athletes, are drug free and that our athletes are held accountable for their academic performance. Be proud of the team’s effort! Remember that winning is just “icing on the cake” The real importance of athletics lies in building solid values, pursuing individual excellence, and learning skills to work with others in a team effort These lessons last a lifetime, far longer than the glory of victory or the sting of defeat. At Jo Lane we cheer for all athletes on the court. We never do anything to discourage the athletes, coaches or officials. Spectator/Athlete Support Contract for Roseburg School District Athletics Parents please read and sign the following parent support contract for Roseburg School District Athletics. Be supportive of the program and provide positive support for your athlete. Never be critical of coaches, players, or game officials in front of your player. Nothing can erode the effectiveness of a team more quickly. Cheer for all players on the team and never coach the athletes or jeer the officials from the sidelines. It only detracts from the quality of the experience. Spectators at all sporting events hosted by or sponsored by the Roseburg School District will be informed of defined spectator seating and viewing areas as deemed appropriate by school staff. Playing time decisions are the sole responsibility of the athletic coach of that team. The coach is in the best position to determine the amount of time an athlete competes. While the coach will endeavor to make the team membership experience as fulfilling as possible, playing time is determined in large part by the coaches’ decisions as influenced by attendance, performance, attitude, team commitment, ability and effort. Encourage your athlete to speak directly to coaches about sports issues. By assuming this responsibility, your athlete claims ownership of his/her own participation. If you still have concerns please speak privately to the coach at an appropriate time, never right before, after or during a game. You may also contact the Athletic Director at 440-4105. Be part of the team’s parent network. Sports programs benefit when parents work together in support of the team. Interact positively with other parents; work to halt group related criticism and rumors. Support the Code of Conduct. Our athletes are “in-training” for life as well as sports. It is essential that parents and the school work as partners, to ensure that Roseburg District athletes, are substance-free and that our athletes are held accountable for their academic performance. Help to foster positive and healthy relationships among athletes and coaches. Talk to your athlete about relationships that may be concerning to him or to her. Bullying, intimidation and hazing have no place in our school programs. If your student reports an uncomfortable situation with others, report that to your coach or school administrator. Be proud of the team’s effort. Remember that winning is just “icing on the cake.” Your student’s participation in athletics builds values, instills a strong work ethic and teaches them to work with others. These lessons last a lifetime, far longer than the glory of victory or the sting of defeat. So cheer for all athletes on the court and never do anything to discourage the players, coaches or officials. Roseburg Public School policies are designed to maintain a positive environment for our student athletes and spectators. The district reserves the right at any time, to eject or deny attendance to any guest of the district for any reason that district administration determines is sufficient. Spectators who: Inappropriately address, threaten, or harass a coach, player or official before, during or after the game Use insulting or profane language Substantially interfere with the orderly operation of the game Encroach upon the playing area without consent of officials Engage in tumultuous, threatening or violent behavior WILL BE EJECTED FROM THE EVENT Police may be contacted to determine if a crime has been committed. Suspension of spectator privileges from all Roseburg School District events ranging from one game up to one calendar year will be determined by the administrators of the schools involved.. After the suspension period, the offending spectator must agree to a Contract of Expected Behavior as a condition of reinstating spectator privileges. When a participant in an event relies for transportation on a spectator who has been ejected they will be directed to meet at the edge of campus.

Game officials, who are “calling” the game or contest, have the authority to halt the game indefinitely, in order to preserve safety and order. Further, game officials have the authority to eject any player or spectator as described by Oregon Revised Statutes. Joseph Lane Middle School File 3/4

Spectator/Athlete Support Contract – Code of Conduct

Parent/Guardian

I ______, parent/guardian of Joseph Lane parent/guardian

Middle School athlete ______, have read Athlete and understand the Roseburg Public School’s Spectator Code of Conduct. I agree that I am responsible for complying with these expectations and I understand the consequences for failure to comply with these rules and responsibilities.

Athlete

I ______, an athlete of Joseph Lane Middle Athlete

School, have read and understand the Roseburg Public School’s Spectator Code of Conduct. I agree that I am responsible for complying with these expectations and I understand the consequences for failure to comply with these rules and responsibilities.

Parent/Guardian Signature: ______Date:______

Athlete Signature: ______Date:______

Permission for Use of Pictures

I hereby give Roseburg School District permission to use photos of my student participating Jo Lane Activities. The photographs will be used for display to recognize our students (website, display case, powerlines, etc).

I, the undersigned, hereby authorize Roseburg School Dist to take and use photographs of my student for the above mentioned purposes.

Student’s Date of Birth ______

Signature of Legal Guardian:______Date ______

Revised 12/09 kb ROSEBURG CODE FOR STUDENTS PRIVILEGED TO PARTICIPATE IN EXTRA-CURRICULAR ACTIVITIES OR STUDENT LEADERSHIP (revised September 25, 1989) 1. Policy Statement: Sometimes it is risky to be a leader or an innovator, but because we care about you, we are making a very serious effort to make our school a safer and healthier place for faculty and students. District No. 4 takes the stand that we want to help students with a problem, not “catch” them, “persecute” them, or “prosecute” them, but help them. Because we care deeply about your help and happiness, we are initiating steps to help make our school a drug-free school. Because of their high visibility and leadership roles, students who are “privileged” to participate in activities such as extra- curricular school activities or student leadership are held to high standards of conduct. No student participating in interscholastic athletics, rally, or as an associated student body officer shall use alcohol, tobacco, or any other controlled substance at any time, on or off school grounds. For those who participate in “privileged” activities the following policy will apply in addition to the overall school policy already in existence. 2. Consequence of “privileged” student use of alcohol or controlled substance: First Offense During Student Career:

2.1 Any such student who is reasonably suspected of using alcohol, tobacco, or any other controlled substance shall be notified of such suspicion and granted a hearing before the appropriate administrator. Such hearing shall occur within two school days of the notification to the student and the parent of the possible infraction. Parents or guardian or counsel may attend the hearing.

2.2 If it is found, after hearing by the administrator, that probable cause exists to believe that the student has used alcohol or any controlled substance, the administrator shall make a written “adjudication” to that effect and shall impose the following sanction;

2.2.1 Suspension from the privileged activity in which the student is participating until the end of the current extra-curricular activity.

2.2.2 Appeal from an adjudication shall be to the school principal or his designee.

2.3 First Offense: Reinstatement

2.3.1 Urinalysis: Mandatory Reinstatement Upon first adjudication, a student shall be reinstated to participate in the privileged activity from which the student has been suspended by submitting to the adjudicating administrator official written proof that the student has completed an enzyme multiplied immunoassay (“EMIT”), urine test within 6 hours of the notification, and has consented to the test results being delivered to the adjudicating administrator. A negative EMIT test finding shall result in reinstatement and cancellation of the adjudication. Any other test finding shall result in the suspension continuing unless 2.3.2 is invoked. Absolutely no stigma penalty will be attached to any student who chooses not to follow.

2.3.1 1 The laboratory expense of such EMIT test shall be paid by the district.

2.3.2 Discretionary RE-admission After drug assessment, if alcohol or other drugs are involved, reinstatement may be achieved, at the discretion of the adjudicating administrator, by requiring the student to enroll in a drug/alcohol education program ; or attending regular meeting with a counselor, Impact Person, assistance person, or other designated individual; or performing a written behavior/academic contract with progress reports, or such other condition as may be imposed. 3. Student Voluntary Seeking Help: Any such student, without prior adjudication, who voluntary initiates seeking help through school personnel for problems of use of alcohol or controlled substances and also voluntarily submits to an EMIT test will not be subject to 2.1 or 2.2 above, but will proceed upon the help program set forth in 2.3.2 irrespective of the test findings. No student may benefit from section more than once. To benefit from this section, the initiatory contact by the student must have clearly occurred before the student’s drug or alcohol problem becomes the subject of criminal investigation, or suspension or expulsion from the school. 4. Subsequent Adjudication: Any such student who has been adjudicated as using alcohol or controlled substance and who is then subsequently adjudicated again at any time shall:

4.1 Be dismissed from the team, or performance in competition, or office for the remainder of the entire privileged activity for the remainder of the school year (unless 2.3.2 is invoked); and

4.2 Receive no award letter or other recognition for such activity (unless 2.3.2 is invoked); and

4.3 Not utilize athletic facilities or equipment for the duration of the school year. 5. Random Urinalysis Testing: All “privileged” students will be provided an opportunity to voluntarily participate in a Random Voluntary Drug Testing Program as follows:

5.1 Each participating student shall be assigned a number within the team or activity, and the numbers of all the participating members of a given team or activity shall be placed in a box.

5.2 At random intervals during a specific season or activity:

5.2.1 A number will be drawn at random from the box. The student having that number shall submit to a urinalysis at the Districts expense:

5.2.1.1 If the student’s EMIT tests positive then 2.3 may apply.

5.2.1.2 EMIT tests that show positive on the initial test are confirmed on a fresh portion of the original sample, using the most appropriate method for each particular drug. Confirmation methods used are Thin Layer Chromatography (TLC), Radioimmunoassy (RIA), or Gas Chromatography (GS).

5.3 The number of any participating student which has been drawn from the box will be replaced immediately with the numbers in that drawing and be among those drawn from hereafter.

6. Consequences of “Privileged Students Use of Tobacco 6.1 Policy Statement: Because of their high visibility and leadership roles and the effect of tobacco on their performance, students who are “privileged” to participate in activities such as extra-curricular activities, or student leadership shall not use tobacco in any form.

6.2 First Offense: If it is found , after a hearing by an administrator, that the probable cause exists to believe that the student has used tobacco, the administrator shall impose the following sanction:

6.2.1 Suspension from the privileged activity in which the student is participating for a period of no less than one game, or seven days. Game suspension will be the next immediate contest.

6.3 Second or Future Offense: Any such student who has been adjudicated as using tobacco and who is then subsequently adjudicated again, at any time shall:

6.3.1 Be suspended from the sport or activity for the duration of the sport or activity (unless 6.3.3 is invoked) and 6.3.2 Receive no award or letter, or other recognition for such activity (unless 6.3.3 is invoked).

6.3.3 Discretionary Re-Admission Reinstatement may be achieved, at the discretion of the adjudicating administrator, by the student enrolling in, and successfully completing a tobacco cessation program, or attending regular meetings with a counselor, or such other conditions may be imposed.

7. Stealing Any offense, Immediate suspension pending appropriate disciplinary action. 8. Other Violations of Student Conduct Policies 8.1 Any athlete, or student activities person who brings discredit upon the individual, the team, or the school, by violating any school conduct policy, will be immediately suspended pending appropriate disciplinary action.

9. Understanding

9.1 Please indicate your preference regarding involvement in the Voluntary Random Sample Drug Testing Provision of the Code of Conduct.

______YES, we want to participate ______NO, we do not want to participate

9.2 We have read, and understand, this Roseburg Code of Conduct. We agree to abide by this code.

student signature

date signature - parent/guardian

This agreement is in effect from the date of this signing until graduation.

Definitions:

Adjudication: a hearing, to hear and decide a case, a hearing officer’s decision

EMIT: Enzyme Multiplied Immunoassy Test; an excepted method of testing urine for the presence of drugs

Privileged Student: any student who takes part in a privileged extra-curricular activity such as athletics, associated student body offices

ROSEBURG SCHOOL DISTRICT’S - SAFETY LIST FOR “ FOOTBALL ” PLAYERS Football is a contact sport and injuries will occur. The coaches working in our program are well qualified, professional people. Fundamentals related to playing football will continually and repeatedly be emphasized on and off the field. The information contained within this list of rules and procedures is to inform the young men in our football program of the proper techniques to practice for maximum safety in the contact phase of the game.

Tackling, Blocking, and Running the Ball By rule, the helmet is not to be used as a “ram.” Initial contact is not to be made with the helmet. It is not possible to play the game safely or correctly without making contact with the helmet when properly blocking and tackling an opponent. Therefore, technique is most important to prevention of injuries.

Tackling and blocking techniques are basically the same. Contact is to be made above the waist but not initially with the helmet. The player should always be in position of balance, knees bent, back straight, body slightly bent forward, HEAD UP, target area as near to the body as possible with the main contact being made with the shoulder.

Blocking and tackling by not putting the helmet as close to the body as possible could result in shoulder injury such as separation or a pinched nerve in the neck area. The dangers of not following the proper techniques can be from minor to disabling to even death. The reason for following the safety rules in making contact with the upper body and helmet is that improper body alignment can put the spinal column in a vulnerable position for injury.

If the head is bent downward, the cervical (neck) vertebrae are in a bind and contact on the TOP OF THE HELMET could result in a dislocation, nerve damage, paralysis, or even death. If the back is not straight, the thoracic (mid back) and lumbar vertebrae are also vulnerable to injury with similar results if contact again is made to the TOP OF THE HELMET. Roseburg School District’s daily workouts includes isometric type exercises; the development of strength in the neck muscles is one of the best methods of preventing head injury and enabling an individual to hold his head up even after getting tired during a workout or contact.

Basic Hitting (Contact) Position and Fundamental Technique If the knees are not bent, the chance of knee injury is greatly increased. Fundamentally, a player should be in the proper hitting position at all times during the live ball play and this point will be repeated continually during practice. The danger is anything from strained muscles, to ankle injuries, to serious knee injuries requiring surgery. The rules have made blocking below the waist (outside a two-yard by four-yard area next to the football) illegal. Cleats have been restricted to know more than 1/2 inch to further help prevent in knee injuries. A runner with the ball, however, may be tackled around the legs.

In tackling, the rules prohibit initial contact with the helmet or grabbing the face mask or edge of the helmet. These restrictions were placed in the rules because of serious injuries resulting from non-compliance to these safety precautions. Initial helmet contact could result in bruise, dislocation, broken bone, head injury, internal injury such as kidney, spleen, bladder, etc. Grabbing the face mask or helmet edge could result in a neck injury which could be anything from muscle strain to a dislocation, nerve injury, spinal column damage causing paralysis or death.

The illegal play by participating athletes will not be tolerated and all players are repeatedly reminded of the dangers of unsportsmanlike acts.

Fitting and Use of Equipment Shoulder pads which are too small will leave the shoulder point vulnerable to bruises or separations; it could also be too tight in the neck area resulting in a possible pinched nerve. Shoulder pads which are too large will leave the neck area poorly protected and will slide on the shoulders making them vulnerable to bruises or separations.

Helmets must fit snugly at the contact points; Front, back, and top of head. The chin straps must be fastened and the cheek pads must be of the proper thickness. On contact, too tight a helmet could result in a headache. Too loose a fit could result in headache, a concussion, a face injury such as broken nose or cheek bone, a blow to the back of the neck causing a neck injury, possibly quite serious such as paralysis or even death.

The report does not cover all potential injury possibilities in playing football, but it is an attempt to make the players aware that fundamentals, coaching, and proper fitting equipment is important to their safety and enjoyment in playing football in one of the Roseburg School District’s schools. The above information has been explained to me and I understand the list of rules and procedures. I also understand the necessity of using the proper techniques while participating in the football program.

Athlete’s Signature______Dated______

Parent’s Signature______Dated______Health Update Form Complete ONLY if a current physical IS ON FILE at Jo Lane 1

______Grade Student Name ( Last, First, MI) Current physical means that the physical on file in the Athletics office will not be more than two years old before the end of the sport that your student will participate in.

1. Have you had any injuries for which you saw a physician since your last physical or the sport that you participated in at Jo Lane? YES NO

2. Have you been hospitalized or had any major illness for which you saw a physician since your last physical or the last sport that you participated in at Jo Lane? YES NO

3. Have you had any kind of surgery since your last physical or the last sport that you participated at Jo Lane? YES NO

4. Do you currently have any injuries or illnesses that are being treated by a physician? YES NO

5. Are you currently taking any medications on a regular or continuing basis? YES NO

6. Are you currently being treated by a physician, physical therapist, or other health care provider for any injury, illness, or surgery? YES NO If YES to any of the above please explain:

______

Parent/Guardian Name ______

Parent/Guardian Signature ______

If there is NOT a current physical on file you must take the last three pages of this packet to a Physician and have a physical done before your student can participate. This includes participation in the try out process, practices or games.

Updated 1/11 kb SUGGESTED EXAM PROTOCOL FOR THE PHYSICIAN Revised May 2010

MUSCULOSKELETAL Have patient: To check for: 1. Stand facing examiner AC joints, general habitus 2. Look at ceiling, floor, over shoulders, touch ears to shoulders Cervical spine motion 3. Shrug shoulders (against resistance) Trapezius strength 4. Abduct shoulders 90 degrees, hold against resistance Deltoid strength 5. Externally rotate arms fully Shoulder motion 6. Flex and extend elbows Elbow motion 7. Arms at sides, elbows 90 degrees flexed, pronate/supinate wrists Elbow and wrist motion 8. Spread fingers, make fist Hand and finger motion, deformities 9. Contract quadriceps, relax quadriceps Symmetry and knee/ankle effusion 10. “Duck walk” 4 steps away from examiner Hip, knee and ankle motion 11. Stand with back to examiner Shoulder symmetry, scoliosis 12. Knees straight, touch toes Scoliosis, hip motion, hamstrings 13. Rise up on heels, then toes Calf symmetry, leg strength

MURMUR EVALUATION – Auscultation should be performed sitting, supine and squaring in a quiet room using the diaphragm and bell of a stethoscope. Auscultation finding of: Rules out: 1. S1 heard easily; not holosystolic, soft, low‐pitched VSD and mitral regurgitation 2. Normal S2 Tetralogy, ASD and pulmonary hypertension 3. No ejection or mid‐systolic click Aortic stenosis and pulmonary stenosis 4. Continuous diastolic murmur absent Patent ductus arteriosus 5. No early diastolic murmur Aortic insufficiency 6. Normal femoral pulses Coarctation (Equivalent to brachial pulses in strength and arrival)

MARFAN’S SCREEN – Screen all men over 6’0” and all women over 5’10” in height with echocardiogram and slit lamp exam when any two of the following are found: 1. Family history of Marfan’s syndrome (this finding alone should prompt further investigation) 2. Cardiac murmur or mid‐systolic click 3. Kyphoscoliosis 4. Anterior thoracic deformity 5. Arm span greater than height 6. Upper to lower body ratio more than 1 standard deviation below mean 7. Myopia 8. Ectopic lens

CONCUSSION ‐‐ When can an athlete return to play after a concussion? After suffering a concussion, no athlete should return to play or practice on the same day. Previously, athletes were allowed to return to play if their symptoms resolved within 15 minutes of the injury. Studies have shown that the young brain does not recover that quickly, thus the Oregon Legislature has established a rule that no player shall return to play following a concussion on that same day and the athlete must be cleared by an appropriate health care professional before they are allowed to return to play or practice.

Once an athlete is cleared to return to play they should proceed with activity in a stepwise fashion to allow their brain to readjust to exertion. The athlete may complete a new step each day. The return to play schedule should proceed as below following medical clearance:

Step 1: Light exercise, including walking or riding an exercise bike. No weightlifting. Step 2: Running in the gym or on the field. No helmet or other equipment. Step 3: Non‐contact training drills in full equipment. Weight training can begin. Step 4: Full contact practice or training. Step 5: Game play. If symptoms occur at any step, the athlete should cease activity and be re‐evaluated by a health care provider.

581‐021‐0041 Form and Protocol for Sports Physical Examinations The State Board of Education adopts by reference the form entitled "School Sports Pre‐Participation Examination May 2010" that must be used to document the physical examination and sets out the protocol for conducting the physical examination. Medical providers conducting physicals on or after June 30, 2010 must use the form dated May 2010. NOTE: The form can be found on the Oregon School Activities Association (OSAA) Website w ww.osaa.org. Stat. Auth: ORS 326‐051 Stats. Implemented: ORS 336.479 Hist.: ODE 24‐2002, f. & cert. ef. 11‐15‐02; ODE 29‐2004(Temp), f. & cert. ef. 9‐15‐04 thru 2‐25‐05; ODE 4‐2005, f. & cert. ef. 2‐14‐05

Oregon School Activities Association 2010‐11 Handbook Forms – School Sports Pre‐Participation Examination Revised: 05/10 School Sports Pre‐Participation Examination – Part 1: Student or Parent Completes Revised May 2010

NAME: BIRTHDATE: / /

ADDRESS: PHONE: ( )

Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability. Explain any YES answers on back. Medical Provider: Please review with the athlete details of any positive answers.

YES NO Don’t Know 1. Has anyone in the athlete’s family died suddenly before the age of 50 years? 2. Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain? 3. Does the athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen? 4. Is the athlete allergic to any medications or bee stings? 5. Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint? 6. Has the athlete ever had a head injury or concussion? 7. Has the athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache? 8. Has the athlete ever suffered a heat‐related illness (heat stroke)? 9. Does the athlete have a chronic illness or see a physician regularly for any particular problem? 10. Does the athlete take any prescribed medicine, herbs or nutritional supplements? 11. Does the athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)? 12. Has the athlete ever had prior limitation from sports participation? 13. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily? 14. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension? 15. Is there a history of young people in the athlete’s family who have had congenital or other heart disease: cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome? (You may write "I don't understand these terms" and initial this item, if appropriate.) 16. Has the athlete ever been hospitalized overnight or had surgery? 17. Does the athlete lose weight regularly to meet the requirements for your sport? 18. Does the athlete have anything he or she wants to discuss with the physician? 19. Does the athlete cough, wheeze, or have trouble breathing during or after activity? 20. Are you unhappy with your weight? 21. FEMALES ONLY a. When was your first menstrual period? b. When was your most recent menstrual period? c. What was the longest time between menstrual periods in the last year? Parent/Guardian’s Statement: I have reviewed and answered the questions above to the best of my ability. I and my child understand and accept that there are risks of serious injury and death in any sport, including the one(s) in which my child has chosen to participate. I hereby give permission for my child to participate in sports / activities. I hereby authorize emergency medical treatment and/or transportation to a medical facility for any injury or illness deemed urgently necessary by a registered athletic trainer, coach, or medical practitioner. I understand that this sports pre‐participation physical examination is not designed nor intended to substitute for any recommended regular comprehensive health assessment. I hereby authorize release of these examination results to my child's school.

Signed: Date: Parent/Guardian

ORS 336.479, Section 1 (3) "A school district shall require students who continue to participate in extracurricular sports in grades 7 through 12 to have a physical examination once every two years." Section 1(5) “Any physical examination required by this section shall be conducted by a (a) physician possessing an unrestricted license to practice medicine; (b) licensed naturopathic physician; (c) licensed physician assistant; (d) certified nurse practitioner; or a (e) licensed chiropractic physician who has clinical training and experience in detecting cardiopulmonary diseases and defects.”

Oregon School Activities Association 2010‐11 Handbook Forms – School Sports Pre‐Participation Examination Revised: 05/10

School Sports Pre‐Participation Examination – Part 2: Medical Provider Completes Revised May 2010

NAME: BIRTHDATE: / /

Height: Weight: % Body Fat (optional): Pulse: BP: / ( / , /_ )

Rhythm: Regular Irregular Vision: R 20/ L 20/ Corrected: Y N Pupils: Equal Unequal

MEDICAL NORMAL ABNORMAL FINDINGS INITIALS* Appearance

Eyes / Ears / Nose / Throat

Lymph Nodes

Heart: Pericardial activity

st nd 1 & 2 heart sounds

Murmurs

Pulses: brachial / femoral

Lungs

Abdomen

Skin MUSCULOSKELETAL Neck

Back

Shoulder / arm

Elbow / forearm

Wrist / hand

Hip / thigh

Knee

Leg / ankle

Foot * Station‐based examination only CLEARANCE Cleared Cleared after completing evaluation / rehabilitation for: Not cleared for: Reason: Recommendations:

Name of Medical Provider: Date: (print or type)

Address: Phone: ( )

Signature of Medical Provider:

Oregon School Activities Association 2010‐11 Handbook Forms – School Sports Pre‐Participation Examination Revised: 05/10