CHESTERTON HIGH SCHOOL  Preparticipation Physical Evaluation HISTORY FORM Physical MUST be performed AFTER April 1st for 2019/2020 school year (Note: This form is to be fi lled out by the patient and parent prior to examination. The examiner should keep a copy of this form in the chart.)

NAME PLEASE WRITE LEGIBLY

Grade 2019/2020

X Signature of athlete ______Signature of parent/guardianX ______Date ______©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement. This form has been modifi ed by the High School Athletic Association, Inc. (IHSAA). (1 of 4) ■ PREPARTICIPATION PHYSICAL EVALUATION PHYSICAL EXAMINATION FORM (The physical exami11atio11 must be performed011 or r,fterApril 1 by r,physicir111 holdi11g r,11 1111/imited lice11se to practice 111edici11e, r,1111rse practitio11er or r,pl,ysici,111 r,ssistm,tto be validfor tl1efollowi11g scl,oolyear.) - IHSAA By-Law 3-10

NAME PLEASE WRITE LEGIBLY 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 youever 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 youever taken anabolic steroids or used any other pertormance supplement? • Have youever taken any supplements to help you gain or lose weight or improve yourpertormance? • Do you wear a seat belt, use a helmet, and use condoms? 2. Consider reviewing questions on cardiovascular symptoms (questions 5-14).

EXAMINATION Height Weight □ Male D Female BP I ( I ) Pulse Vision R 20/ L20/ Corrected DY ON MEDICAL NORMAL ABNORMAL FINDINGS Appearance • Martan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hype�axlly, myopia, MVP, aortic Insufficiency) Eyes/ears/nose/throat • Pupils equal • Hearing Lymph nodes Heart• • Murmurs (auscultation standing, supine, +/- Valsatva) • Location of point of maxima! 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 FooVtoes Functional • Duck-walk, single leg hop 'Consider ECG, echocardiogram,and referral to cardiology for abnormal cardiac history or exam. 'Consider GU exam if In private setting. Having third party present is recommended. 'Consider cognitive evaluation or baseline neurops1thialrlc testing If a hlsto,y of significantconcussion.

D Cleared for all sports without restriction D Cleared for all sports without restriction with recommendations for further evaluation or treatment for

□ Not cleared □ Pending further evaluation D For any sports □ For certain sports ------­ Reason Recommendations ------

I have examined the above-named student and completed the preparticipationphysical evaluation. The athlete does not present apparent clinical contraindications to practice and participate In the sport(s) as outlined above. A copy of the physical exam Is on record In my office and can be made available lo the school at the request of the parents. II condl· lions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem Is resolved and the potential consequences are completely r explained to the athlete (and parents/guardians). (11,e plt_Jh·trl e.rnmiuutim, 11111.�, he performed ti/I,,, 11.fler llpril/ by ttp ltylkitm lwldiug fl/I 1111/imited linmu/(I prm·tke metlkille, fl 111,rse practitioner arr, physicitm (ISSi.ttrml to be mlidfor lhefu/lowi11gJd,oo/ year.)-IHSAA J�r-Lnll' 3-10 Name of physician (print/type) (MD. DO, NP. or PAl Date ______Address ______Phone ______Signature of physician ..,(,.,_M,,,D,__, "'D""O,,.__,N..,_,Pc.c,-"'or'--'P'-'-A.,..) ______..:cli"'ce::n.:.esc:,.e.,,#______

(2 of4) ■ PREPARTICIPATION PHYSICAL EVALUATION IHSAA ELIGIBILITY RULES

INDIVIDUAL ELIGIBILITY RULES (Grades 9 through 12)

ATTENTIONATHLETE: Your school is a member of the IHSAA and follows established rules. To be eligible to represent your school in interschool athletics,you:

1. must be a regular bona fide student in good standing in the school you represent; must have enrolled not later than the fifteenth day of the current semester. 2. must have completed 10 separate days of organized practice in said sport under the direct supervision of the high school coaching staff preceding date of participationin interschool contests. (Excluding Girls -SeeRule 101) 3. must have received passing grades at the end of their last grading period in school in at least seventy percent (70%) of the maximum number of full credit subjects (or the equivalent) that a student can take and must be currently enrolled in at least seventy percent (70%) of the maximum number of full credit subjects (or the equivalent) that a student can take. Semester grades take precedence. 4. must not have reached your twentieth birthday prior to or on the scheduled date of the IHSAA State Finals in a sport. 5. must have been enrolled in your present high school last semester or at a junior high school from which your high school receives its students ... unless you are entering the ninth grade for the first time. unless you are transferring from a school district or territory with a corresponding bona fide move on the part of your parents. unless you are a ward of a court; you are an orphan, you reside with a parent, your former school closed, your former school is not accredited by the state accrediting agency in the state where the school is located, your transfer was pursuant to school board mandate, you attended in error a wrong school, you transferred from a correctional school, you are emancipated, you are a foreign exchange student under an approved CSIET program. You must have been eligible from the school from which you transferred. 6. must not have been enrolled in more than eight consecutivesemesters beginning with grade 9. 7. must be an amateur (have not participated under an assumed name, have not accepted money or merchandise directly or indirectly for athletic participation, have not accepted awards, gifts, or honors from colleges or their alumni, have not signed a professional contract). 8. must have had a physical examination between April 1 and your first practiceand filed with your principal your completed Consent and Release Certificate. 9. must not have transferred from one school to another for athletic reasons as a result of undue influenceor persuasion by any person or group. 10. must not have received in recognition of your athletic ability, any award not approved by your principal or the IHSAA. 11. must not accept awards in the form of merchandise, meals, cash, etc. 12. must not participate in an athletic contest during the IHSAA authorized contest season for that sport as an individual or on any team other than your school team. (See Rule 15-la) (Exception for outstanding student-athlete-See Rule 15-lb)

13. must not reflect discredit upon your school nor create a disruptive influence on the discipline, good order, moral or educational environment in your school. 14. students with remaining eligibility must not participate in tryouts or demonstrations of athletic ability in that sport as a prospective post-secondary school student-athlete. Graduates should refer to college rules and regulations before participating. 15. must not participate with a student enrolled below grade 9.

16. must not, while on a grade 9 junior high team, participate with or against a student enrolled in grade 11 or 12. 17. must, if absent five or more days due to illness or injury, present to your principal a written verification from a physician licensed to practice medicine, stating you may participate again. (See Rule 3-11 and 9-14.) 18. must not participate in camps, clinics or schools during the IHSAA authorized contest season. Consult your high school principal for regulations regarding out-of-season and summer. 19. girls shall not be permitted to participate in an IHSAA tournament program for boys where there is an IHSAA tournament program for girls in that sport in which they can qualify as a girls tournament entrant.

This is only a brief summary of the eligibilityrules.

You may access the IHSAA Eligibility Rules (By-Laws) at www.ihsaa.org Please contact your school officialsfor further informationand before participatingoutside your school.

CONTINUE TO PAGE 4 ON BACK OF THIS FORM (Consent & Release Certificate - on back or next page)

(3 of 4) ■ PREPARTICIPATION PHYSICAL EVALUATION CONSENT & RELEASE CERTIFICATE

I. STUDENT ACKNOWLEDGMENT AND RELEASE CERTIFICATE A. I have read the IHSAA Eligibility Rules (next page or an back) and know of no reason why I am not eligible to represent my school in athletic com­ petition. B. If accepted as a representative, I agree to follow the rules and abide by the decisions of my school and the IHSAA. C. I know that athletic participationis a privilege. I know of the risks involved in athletic participation, understandthat serious injury, and even death, is possible in such participation, and choose to accept such risks. I voluntarily accept any and all responsibility for my own safety and wel­ fare while participating in athletics, with full understanding of the risks involved, and agree to release and hold harmless my school, the schools involved and the IHSAA of and from any and all responsibility and liability, including any from their own negligence, for any injury or claim resulting from such athletic participation and agree to take no legal action against my school, the schools involved or the IHSAA because of any accident or mishap involving my athletic participation. D. I consent to the exclusive jurisdiction and venue of courts in Marion County, Indiana for all claims and disputes between and among the IHSAA and me, including but not limited to any claims or disputes involving injury, eligibility or rule violation. E. I give the IHSAA and its assigns, licensees and legal representatives the irrevocable right to use my picture or image and any sound recording of me, in all forms and media and in all manners, for any lawful purposes.

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE PROVISION. (to be signed by student)

Date: ------=X�student Signature: �X�) ______

Printed: ______

II. PARENT/GUARDIAN/EMANCIPATED STUDENT CONSENT, ACKNOWLEDGMENT AND RELEASE CERTIFICATE

A. Undersigned, a parent of a student, a guardian of a student or an emancipated student, hereby gives consent for the student to participate in the following interschool sports not marked out: Boys Sports: , , Cross Country, Football, Golf, Soccer, , , Track, Wrestling. Girls Sports: Basketball, Cross Country, Golf, , Soccer, , Swimming, Tennis, Track, . B. Undersigned understands that participation may necessitate an early dismissal from classes. C. Undersigned consents to the disclosure, by the student's school, to the IHSAA of all requested, detailed financial (athletic or otherwise), scholas­ tic and attendance records of such school concerning the student. D. Undersigned knows of and acknowledges that the student knows of the risks involved in athletic participation, understands that serious injury, and even death, is possible in such participation and chooses to accept any and all responsibility for the student's safety and welfare while par­ ticipating in athletics. With full understanding of the risks involved, undersigned releases and holds harmless the student's school, the schools involved and the IHSAA of and from any and all responsibility and liability, including any from their own negligence, for any injury or claim resulting from such athletic participation and agrees to take no legal action against the IHSAA or the schools involved because of any accident or mishap involving the student's athleticparticipation. E. Undersigned consents to the exclusive jurisdiction and venue of courts in Marion County, Indiana for all claims and disputes between and among the IHSAA and me or the student, including but not limited to any claims or disputes involving injury, eligibility, or rule violation. F. Undersigned gives the IHSAA and its assigns, licensees and legal representatives the irrevocable right to use any picture or image or sound re­ cording of the student in all forms and media and in all manners, for any lawful purposes. Please check the appropriate space: 0 The student has school student accident insurance. 0 The student has football insurance through school. 0 The student has adequate family insurance coverage. 0 The student does not have insurance.

X Company: ______}(p olicy Number: ______I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE PROVISION. (to be completed and signed by all parents/guardians, emancipated students; where divorce or separation, parent with legal custody must sign)

X Date: ______Parent/Guardian/Emancipated Student Signature:_C_X ______) _

Printed: ______

Date: ______Parent/Guardian Signture:-'(_X_)______

Printed: ______CONSENT & RELEASE CERTIFICATE Indiana High School Athletic Association, Inc. 9150North Meridian St., P.O. Box 40650 File In Officeof the Principal Indianapolis, IN 46240-0650 Separate Form Required for Each School Year DLC: 6/24/2016 FORMD-7/11 g:/prlnting/forms/schools/1617physlcalform.lndd (4of4) CONCUSSION and SUDDEN CARDIAC ARREST ACKNOWLEDGEMENT AND SIGNATURE FORM FOR PARENTS AND STUDENT ATHLETES

Student Athlete's Name (Please Print): ______

Sport Participating In (Current and Potential): ______

School: ______Grade: ______

IC 20-34-7 and IC 20-34-8 require schools to distribute information sheets to inform and educate student athletes and their parents on the nature and risk of concussion, head injury and sudden cardiac arrest to student athletes, including the risks of continuing to play after concussion or head injury. These laws require that each year, before beginning practice for an interscholastic sport, a student athlete and the student athlete's parents must be given an information sheet, and both must sign and return a form acknowledging receipt of the information to the student athlete's coach.

IC 20-34-7 states that an interscholastic student athlete, in grades 5-12, who is suspected of sustaining a concussion or head injury in a practice or game, shall be removed from play at the time of injury and may not return to play until the student athlete has received a written clearance from a licensed health care provider trained in the evaluation and management of concussions and head injuries, and at least twenty-four hours have passed since the injury occurred.

IC 20-34-8 states that a student athlete who is suspected of experiencing symptoms of sudden cardiac arrest shall be removed from play and may not return to play until the coach has received verbal permission from a parent or legal guardian for the student athlete to return to play. Within twenty-four hours, this verbal permission must be replaced by a written statement from the parent or guardian.

Parent/Guardian - please read the attached fact sheets regarding concussion and sudden cardiac arrest and ensure that your student athlete has also received and read these fact sheets. After reading these fact sheets, please ensure that you and your student athlete sign this form, and have your student athlete return this form to his/her coach.

As a student athlete, I have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptom�. of sudden cardiac arrest.

(Signature of Student Athlete) (Date)

I, as the parent or legal guardian of the above named student, have received and read both of the fact sheets regarding concussion and sudden cardiac arrest. I understand the nature and risk of concussion and head injury to student athletes, including the risks of continuing to play after concussion or head injury, and the symptoms of sudden cardiac arrest.

(Signature of Parent or Guardian) (Date)

Updated April 2016 SUDDEN CARDIAC ARREST A Fact Sheet for Parents

How can I help my child prevent a sudden FACTS cardiac arrest? Sudden cardiac arrest is a rare, but tragic event Daily physical activity, proper nutrition, and that claims the lives of approximately 500 adequate sleep are all important aspects of life­ athletes each year in the . Sudden long health. Additionally, parents can assist cardiac arrest can affect all levels of athletes, in student athletes prevent a sudden cardiac all sports, and in all age levels. The majority of arrest by: cardiac arrests are due to congenital (inherited) • Ensuring your child knows about any heart defects. However, sudden cardiac arrest family history of sudden cardiac arrest can also occur after a person experiences an (onset of heart disease in a family illness which has caused an inflammation to the member before the age of 50 or a heart or after a direct blow to the chest. sudden, unexplained death at an early age) • Ensuring your child has a thorough pre­ WARNING SIGNS season screening exam prior to There may not be any noticeable symptoms participation in an organized athletic before a person experiences loss of activity consciousness and a full cardiac arrest (no pulse • Asking if your school and the site of and no breathing). competition has an automatic defibrillator {AED) that is close by and Warning signs can include a complaint of: properly maintained • Chest Discomfort • Learning CPR yourself • Unusual Shortness of Breath • Ensuring your child is not using any • Racing or Irregular Heartbeat non-prescribed stimulants or • Fainting or Passing Out performance enhancing drugs • Being aware that the inappropriate use of prescription medications or energy EMERGENCY SIGNS - Call EMS (911) drinks can increase risk If a person experiences any of the following • Encouraging your child to be honest signs, call EMS (911) immediately: and report symptoms of chest • If an athlete collapses suddenly during discomfort, unusual shortness of competition breath, racing or irregular heartbeat, or • If a blow to the chest from a ball, puck feeling faint or another player precedes an athlete's complaints of any of the warning signs of sudden cardiac arrest What should I do if I think my child has • If an athlete does not look or feel right warning signs that may lead to sudden cardiac and you are just not sure arrest? 1. Tell your child's coach about any previous events or family history 2. Keep your child out of play 3. Seek medical attention right away

Developed and Reviewed by the Indiana Departmentof Education's Sudden Cardiac Arrest Advisory Board {1-7-15) SUDDEN CARDIAC ARREST A Fact Sheet for Student Athletes

FACTS How can I help prevent a sudden cardiac Sudden cardiac arrest can occur even in arrest? athletes who are in peak shape. Approximately Daily physical activity, proper nutrition, and 500 deaths are attributed to sudden cardiac adequate sleep are all important aspects of life­ arrest in athletes each year in the United States. long health. Additionally, you can assist by: Sudden cardiac arrest can affect all levels of • Knowing if you have a family history of athletes, in all sports, and in all age levels. The sudden cardiac arrest {onset of heart majority of cardiac arrests are due to congenital disease in a family member before the {inherited) heart defects. However, sudden age of 50 or a sudden, unexplained cardiac arrest can also occur after a person death at an early age) experiences an illness which has caused an • Telling your health care provider during inflammation to the heart or after a direct blow your pre-season physical about any to the chest. Once a cardiac arrest occurs, unusual symptoms of chest discomfort, there is very little time to save the athlete, so shortness of breath, racing or irregular identifying those at risk before the arrest occurs heartbeat, or feeling faint, especially if is a key factor in prevention. you feel these symptoms with physical activity WARNING SIGNS • Taking only prescription drugs that are There may not be any noticeable symptoms prescribed to you by your health care before a person experiences loss of provider consciousness and a full cardiac arrest {no pulse • Being aware that the inappropriate use and no breathing). of prescription medications or energy drinks can increase your risk Warning signs can include a complaint of: • Being honest and reporting symptoms • Chest Discomfort of chest discomfort, unusual shortness • Unusual Shortness of Breath of breath, racing or irregular heartbeat, • Racing or Irregular Heartbeat or feeling faint • Fainting or Passing Out What should I do if I think I am developing EMERGENCY SIGNS - Call EMS (911) warning signs that may lead to sudden cardiac If a person experiences any of the following arrest? signs, call EMS {911) immediately: 1. Tell an adult- your parent or guardian, • If an athlete collapses suddenly during your coach, your athletic trainer or your competition school nurse • If a blow to the chest from a ball, puck 2. Get checked out by your health care or another player precedes an athlete's provider complaints of any of the warningsigns 3. Take care of your heart of sudden cardiac arrest 4. Remember that the most dangerous thing • If an athlete does not look or feel right you can do is to do nothing and you are just not sure

Developed and Reviewed by the Indiana Department of Education's Sudden Cardiac Arrest Advisory Board (1-7-15) SAFE BRAIN. STRONGER FUTURE.

This sheet has information to help protect your teens from concussion or other serious brain injury.

What Is a Concussion? How Can I Spot a A concussion is a type of traumatic brain injury-or TBl­ Possible Concussion? caused by a bump, blow, or jolt to the head or by a hit to the Teens who show or report one or more of the signs and body that causes the head and brain to move quickly back symptoms listed below-or simply say they just "don't feel and forth. This fast movement can cause the brain to bounce right" after a bump, blow, or jolt to the head or body-may around or twist in the skull, creating chemical changes in the have a concussion or other serious brain injury. brain and sometimes stretching and damaging the brain cells. Signs Observed by Parents

How Can I Help Keep 0 Appears dazed or stunned My Teens Safe? • Forgets an instruction, is confused about an assignment or Sports are a great way for teens to stay healthy and can help position, or is unsure of the game, score, or opponent them do well in school. To help lower your teens' chances of ' Moves clumsily getting a concussion or other serious brain injury, you should: • Answers questions slowly ' Help create a culture of safety for the team. • Loses consciousness (even briefly) o Work with their coach to teach ways to lower the • Shows mood, behavior, or personality changes chances of getting a concussion. • Can't recall events or a hit or fall o Emphasize the importance of reporting concussions and prior to after taking time to recover from one. Symptoms Reported by Teens o Ensure that they follow their coach's rules for safety and ' Headache or "pressure" in head the rules of the sport. • Nausea or vomiting o Tell your teens that you expect them to practice good sportsmanship at all times. ' Balance problems or dizziness, or double or blurry vision

• When appropriate for the sport or activity, teach your 0 Bothered by light or noise teens that they must wear a helmet to lower the chances ' Feeling sluggish, hazy, foggy, or groggy of the most serious types of brain or head injury. There • Confusion, or concentration or memory problems is no "concussion-proof" helmet. Even with a helmet, it is important for teens to avoid hits to the head. • Just not "feeling right," or "feeling down"

Talk with your teens about concussion. Tell them to report their concussion symptoms to you and their coach right _away. Some teens think concussions aren't serious or worry that if they report a concussion they will lose their position on the team or look weak. Remind them that it'sbetter to miss one game than the whole season. While most teens with a concussion feel better within a What Should I Do couple of weeks, some will have symptoms for months or longer. Talk with your teens' healthcare provider if their If My Teen Has a concussion symptoms do not go away or if they get worse Possible Concussion? after they return to their regular activities. As a parent, if you think your teen may have a concussion, you should:

1. Remove your teen from play. Rian ahead. What do you want your teen to know about concussion? 2. Keep your teen out of play the day of the injury. Your teen should be seen by a healthcare provider and only return to play with permission from a healthcare What Are Some More Serious provider who is experienced in evaluating for concussion. Danger Signs to Look Out For? 3. Ask your teen's healthcare provider for In rare cases, a dangerous collection of blood (hematoma) may form written instructions on helping your on the brain after a bump, blow, or jolt to the head or body and can teen return to school. You can give squeeze the brain against the skull. Call 9-1-1, or take your teen to the the instructions to your teen's school emergency department right away if, after a bump, blow, or jolt to the nurse and teacher(s) and return-to-play head or body, he or she has one or more of these danger signs: instructions to the coach and/or athletic • One pupil larger than the other trainer.

" Drowsiness or inability to wake up Do not try to judge the severity of the injury • A headache that gets worse and does not go away yourself. Only a healthcare provider should assess a teen for a possible concussion. You • Slurred speech, weakness, numbness, or decreased coordination may not know how serious the concussion • Repeated vomiting or nausea, convulsions or seizures (shaking or is at first, and some symptoms may not twitching) show up for hours or days. A teen's return " Unusual behavior, increased confusion, restlessness, or agitation to school and sports should be a gradual process that is carefully managed and • Loss of consciousness (passed out/knocked out). Even a brief loss of monitored by a healthcare provider. consciousness should be taken seriously

Teens who continue to play while having concussion symptoms or who return to play too soon-while the brain is still healing-have a greater chance of getting another concussion. A repeat concussion that occurs while the brain is still healing from the first injury can be very serious, and can affect a teen for a lifetime. It can even be fatal.

Revised January 2019 CONCUSSION FACTS

• A concussion is a brain injury that affects how your brain works. CONCUSSION SIGNS AND SYMPTOMS • A concussion is caused by a bump, blow, or jolt to the head or body. Concussion symptoms differ with each person and with each • A concussion can happen even if you haven't been injury, and may not be noticeable for hours or days. knocked out. Common symptoms include:

• If you think you have a concussion, you should not • Headache return to play on the day of the injury and until a • Confusion health care professional says you are 01< to return to • Difficulty remembering or paying attention play. • Balance protblems or dizziness • Feeling sluggish, hazy, foggy, or groggy • Feeling irritable, more emotional, or "down" • Nausea or vomiting • Bothered by light or noise • Double or blurry vision • Slowed reaction time • Sleep problems • Loss of consciousness

During recovery, exercising or activities that involve a lot of concentration (such as studying, working on the computer, or playing video games) may cause concussion symptoms to reappear or get worse.

WHY SHOULD I REPORT MY SYMPTOMS?

• Unlike with some other injuries, playing or practicing with concussion symptoms is dangerous and can lead to a longer recovery and a delay in your return to play.

• While your brain is still healing, you are much more [ INSERT YOUR LOGO] likely to have another concussion.

• A repeat concussion in a young athlete can result in permanent damage to your brain. They can even be fatal. WHAT SHOULD I DO IF I THINI< I HAVE A CONCUSSION?

DON'T HIDE IT. REPORT IT. Ignoring your symptoms and trying to "tough it out" often makes symptoms worse. Tell your coach, parent, and athletic trainer if you think you or one of your teammates may have a concussion. Don't let anyone pressure you into continuing to practice or play with a concussion. GET CHECl(ED OUT. Only a health care professional can tell if you have a concussion and when it's 01< to return to play. Sports have injury timeouts and player substitutions so that you can get checked out and the team can perform at its best. The sooner you get checked out, the sooner you may be able to safely return to play. TAl

"IT'S BETTER TO MISS ONE GAME, THAN THE WHOLE SEASON."

JOIN THE CONVERSATION AT l+www.facebook.com/CDCHeadsUp

Content Source: CDC's Heads Up Program. Created through a grantfor to the CDC Foundation from the National Operating Committee on Standards Athletic Equipment (NOCSAE). Agreement

Co-Curricular and Extracurricular Activities Code of Conduct

As a student participantin activities at ChestertonHigh School, I recognizeand accept the factthat my participation is a privilege-an opportunityfor illyto make a significantcontribution to my school, my community, and my personal development. Representing Chesterton High School in these activities places many responsibilities upon me as an individual. As a participant,I recognize manypeople are giving hours of time and a great deal of financialsupport to provide ·co-cmricular and extracmricular activities program for me. Inconsideration of this, I agree to live by and conduct myself in accordance withthe followiJ?.g throughout the calendar year.

1. I will conduct myself so as to reflect respect for myself, my fellow students, my school, my family and my community at all times in all places. 2. I '!'fill keep myself mentally and physically prepared so that I can contribute my best efforts and benefit my fellow participants, my school, my community, and myself. 3. I will refrain from using tobacco, alcohol, and other drugs, and abide by the requirements of the Positive Life Program rules as outlined in the student handbook. 4. I will not participate in any form of hazing. 5. I will abide by any.additional school rules and my sponsor/coach rules.

My parent(s)/guardian(s) and I have read and understand theChesterton High School co/ex:tracunicular code of conduct and thePositive LifePro gram expectations associated withtlie privilege of participating inco/extracunicular actiyities. We are expected to attend the informational meetings �ssociated with these activities. Ifthere is a violation of this agreement, as stated above, we lillderstandthe penalties and consequences as outlined in the student handbook.

Date--- --�'--- Student ID:------Grade---- Student Name (pleaseprilJt) ______Address------

Activities------

Parent(s)/Guardian(s) Signature______

Student Signatme______

It is mandatory that each student who participates in a"privileged activity" andhis/.her parent/ guardian sign and returnthe drug-testing consent formprior to participationin any privileged activity. Failure to comply willresult in nonparticipation. (SectionI, E, f, 1.)

PositiveLife Program-Amended by theDuneland School Board; May 9, 1997 Revised:5/5/03, 5/3/04, 4/7/08 A TS Electronic Medical Records

NEW High School Athletes: (complete a// steps below)

1. Type duneland2.atsusers.com into a web browser.

2. Athlete ID (first time only): Type in the word new Password (first time only): Type in the word new

3. Organization: Chesterton HS Fifi out any-appropriate sports All highlighted areas MUST be filled out!

Athlete ID: Student ID# issued by Dune/and- please obtain this from your child or Skyward Password: anything you can remember (we suggest a last name)

*If your child has any medical alerts, allergies or medications that are not on the lists, please just type them in. Jj there are no medical alerts, allergies or medications, type in the word none.

4. Click SAVE ATHLETE INFO on the bottom left of the page: several tabs will then appear towards top.

5. Scroll up to the top of the page and click Contacts Tab: Please click the "add" button and fill in all highlighted areas for emergency contact information.

Please add both parents (as applies) separately. Make sure to click the check mark in the bottom left cornerto save the information.

Please also add AT LEAST ONE contact that does not reside in the same household (ie. Close relative, friend, neighbor) as the other contacts who can be contacted if a parent is not able to be reached.

Returning Athletes: Log in using your student ID and password* Once logged in1 please review your athlete information and update contact info if needed. At this time1 also update any new medical information or medications.

*If you forgot your password please click the link and fill out info. The database is: atsduneland

Please contact us if you have any trouble getting set up on ATS!

Thank you again,

Marnee Flinn-Smith [email protected]

Bernie Stento [email protected] 9/13/16