Melbourne High School Athletics

ALL FORMS AND INFORMATION SHEETS IN THIS PACKET ARE REQUIRED FOR PARTICIPATION IN CONDITIONING, WEIGHT TRAINING, TRYOUTS, PRACTICES OR CONTESTS DURING THE 2014-2015 SCHOOL YEAR!

NO SUBSTITUTE FORMS CAN BE ACCEPTED!!!

Dear Parent/Guardian,

Florida State Statutes mandates that every student athlete must have a Pre-participation Physical Evaluation (EL2), Consent and Release from Liability form (EL3) and a Consent and Release from Liability Certificate for Concussion and Heat-Related Illness (EL3CH) completed each school year. The FHSAA requires a copy of the student athlete’s original birth certificate to be on file in the MHS Athletic Dept. office. In addition Brevard Public Schools also requires the athlete and parent to sign the Parent Permission and Responsibility Statement for Off Campus Extra-Curricular Athletics form. Finally Melbourne High School requires each student athlete and their parent/guardian to sign our Athlete Code of Conduct and the Parent/Guardian/Spectator Code of Conduct. Melbourne High School respectfully requests that the physical be completed after June 1st each year in order to be valid for the entire school year. That helps (and you) make sure that your son/daughter has a valid physical throughout the entire school year (August thru May). You may get the physical evaluation completed by the Physician/Physician Assistant/Nurse Practitioner of your choice after June 1st to be valid for the entire school year. Also, please make sure that after they sign at the bottom of page #2 on the EL2 that they also clearly print their name, address and date of the physical on the appropriate lines. Please remember that Florida State Statute mandates that physicals are only valid for 365 days. Florida State Statutes also requires every athlete to have health insurance coverage in order to participate. Please be sure to include the insurance company name and policy number for your family health insurance plan on page #1 on the EL3 form. If you need to purchase insurance coverage so that your child can participate, BPS has entered into an agreement with School Insurance of Florida that offers athletic and school insurance coverage plans for all students. You can access their plans and fee schedule at their website located at www.schoolinsuranceofflorida.com. Their toll free number is 1-800-432-6915. Please note that some of the plans only provide for football coverage (fall, spring and summer conditioning). A separate plan would need to be purchased to cover any other sport other than football. Also, please make sure the plan you select covers summer conditioning if your child participates in a sport that has summer activities. I encourage you to consider purchasing this reasonably priced coverage even if your child is covered by your own family health plan. It will help pay towards some of your out of pocket deductibles up to certain limits.

In closing you will need to complete and turn in all the forms in this packet BEFORE your child can participate in athletic tryouts, conditioning, practices and weight training (including summer). I appreciate, in advance, your cooperation with completing this packet as requested. Please do not hesitate to contact me at [email protected] if you have any questions.

Sincerely, Fred Keeney Athletic Director

APPLICATION FOR F.H.S.A.A. ELIGIBILITY

Instructions: Part 1: Read carefully. Please Print. Complete all questions. The form will be returned if all questions are not answered completely. PLEASE GIVE YOUR BIRTH CERTIFICATE NAME!!!

Part II: MAKE SURE EVERYTHING IS CHECKED OFF ------PART I: BIRTH CERTIFICATE NAME

(Last Name) (First Name) (Middle Name) (Jr,Sr,II)

DATE OF BIRTH ____/____/____ CIRCLE ONE: MALE FEMALE HOME ADDRESS: (Street)

(City/Zip)

HOME PHONE: EMERGENCY PHONE:

PARENT(S)/GUARDIAN(S) NAME:

**PARENTS EMAIL:

CURRENT YEAR IN SCHOOL: 9 10 11 12

SCHOOLS ATTENDED LAST YEAR:

Did you play a sport at MHS last year? ___ Yes ___ No Are you currently living in the Melbourne High School District? ___ Yes ___ No If not do you have an out of area form on file? ______

IF YOU ARE ATTENDING MHS FOR THE FIRST TIME. HAVE YOU EVER PLAYED ON A CLUB/TRAVEL/LEAGUE TEAM COACHED BY ANYONE ON THE MHS COACHING STAFF? YES NO

If yes, name of MHS Coach:

Dates of Participation:

Parent/Player Checklist ------PART II:

EL2 Physical EL3 Parent Permission EL3CH Concussion

Athlete Code of Conduct Transportation Waiver Birth Certificate

Parent Code of Conduct Vehicle Statement of Insurance MELBOURNE HIGH SCHOOL

STUDENT – ATHLETE CODE OF CONDUCT AND ELIGIBILITY REQUIREMENTS

Sport: ______Coach:______

Printed Name of Student Athlete: ______Year:______

Philosophy The Melbourne High School Athletic Program strives to develop a well rounded student-athlete. We view student-athletes as an extension of the classroom where life-lessons are learned. Sportsmanship, scholarship and physical development are promoted and developed through a wide variety and level of interscholastic sports.

Student Eligibility  All students who participate in athletic activities are required to have an annual medical evaluation. Student-athletes must submit a valid medical evaluation, insurance and parent/player agreement form before being allowed to participate in practice or contests.  A student-athlete who has a grade point average of less than 2.0 at the end of a semester shall automatically be ineligible to participate in athletic contests and practices during the next semester.  A student who is ineligible for any reason may not try out, practice, or play during the period of ineligibility.  Unexcused absences, chronic tardiness to class or discipline problems may result in declaring a student-athlete ineligible at any time.  Student-athletes must be in attendance a minimum of four (4) hours of instruction time to be considered present each day. Student athletes are expected to present in order to participate in practice and contests. Field trips are part of the school program and are considered excused absences.  Athletes who are enrolled in physical education class must actively participate in class on the day of a practice or contest.  Participation in athletic activity will not be permitted when a student is serving a suspension. A suspension ends the next school day morning after the last day of a suspension. Hazing and initiation  Hazing and initiations are not allowed as they are against Brevard County Schools Policy, FHSAA and State of Florida Law.  Hazing is defined but not limited to; To persecute or harass with meaningless, difficult or humiliating tasks. To initiate by exacting humiliating performances from or playing rough practical jokes upon.  Initiation is defined but not limited to; A ceremony, ritual, test or period of instruction with which a new member is admitted. Student- Athlete Standards 1. Maintain academic and scholastic eligibility according to MHS and FHSAA policies. 2. Display behavior that will add to the good name of the Melbourne High Athletic Department. 3. Maintain good school and community relations. 4. Comply with all school rules and policies. 5. Display good sportsmanship at all times. 6. Dress appropriately at all times. All student- athletes are expected to follow their coach’s guidelines on dress. 7. Follow any additional team specific standards. 8. If a student/Athlete quits a team during a season- they will not be permitted to try-out or play for another until the season of the previous team is over this includes playoffs.

Alcohol/Tobacco/Controlled Substances Policy The use of alcohol, tobacco, illegal drugs and controlled substances including steroids is an extremely serious health issue. Such use places the quality of life for the student-athlete in jeopardy. If the student-athlete is using alcohol, tobacco or drugs he/she is placing herself/himself at risk and may compromise the safety of team members. Mandatory discipline action will occur when a student is determined to be in violation of school policy related to the use of alcohol, tobacco, illegal drugs and controlled substances including steroids. If the illegal use, distribution or possession of alcohol or drugs is verified, he/she will be subject to suspension, exclusion, police referral and expulsion. Care of Team Equipment, Uniforms and Locker Rooms  All athletic gear is on loan to the athlete and he/she is personally responsible for its care and return.  Lost uniforms and equipment must be reported immediately and if not found the athlete will be charged the replacement cost for it.  It is the student-athlete’s responsibility to maintain a neat locker room.  Only players are allowed in the locker rooms

At no time will I be in the gym, locker room, hallways, weight room or any other part of the gym without direct supervision of my coach. I will meet my coach only at the place designated by the coach.

Your signature below indicates that you have read all parts of the agreement. Failure to comply with the above guidelines may result in the student-athlete’s suspension or dismissal from the team.

Signature of Student Date

Signature of Parent/Guardian Date

Printed Name of Parent/Guardian

School Board of Brevard County, Florida Parent Permission and Responsibility Statement For Off Campus Extra- Curricular Athletics

Melbourne High School School Name Date

All Athletic Teams Student Name Name of Sport(s)

Activity/Event: On and Off Campus Practices, Games, Conditioning and all other events pertaining to Melbourne High. (List the extra-curricular sports, anticipated contest dates and off campus practice locations or attach the schedule for both to this form)

Fred Keeney (321) 952-5880 School Athletic Director Phone Number

Transportation Being Provided (Check all that apply)

- Walking - School Bus - Commercial Carrier (bus) - Privately Owned Vehicle - Lease Vehicle - County Vehicle - None - Other

Drivers of Private or Leased Vehicles (Check all that apply) - Listed Volunteer - Register Volunteer - Teacher or Staff Member - Other

Type of Activity (Check all that apply)

- Interscholastic game or competition - Interscholastic practice - Other

Parents should direct questions concerning the athletic activity to the school Athletic Director or the following Coach:

Name: Telephone: ( ) - Cell: ( ) -

PARENTAL AUTHORIZATION AND ACKNOWLEDGEMENT OF RISKS: 1. I understand that participation in athletics is voluntary, that it is not required and that it exposes my child to some risk(s). 2. When the school does not provide transportation, the parent or guardian and student are responsible for transportation to and from the off campus athletic activity. 3. The parent or guardian and student understand that the school district, its officers, agents or employees are not responsible for the student during the time he/she is traveling to or from the off campus activity, unless the school is providing transportation. 4. The parent or guardian and student will assume the liability for the student’s participation in the off-campus activity and will indemnify and hold harmless the Florida High School Athletic Association and the School Board of Brevard County harmless for any injury, accident or property loss involving the student during the entire course of the extra-curricular athletic activity. 5. Parent or guardian permission for the student to participate in the above activities may be withdrawn by written notification to the principal or by a change in the student’s schedule approved by the principal or designee. 6. I understand that my child will be involved in athletics off school property: therefore, neither the School Board of Brevard County or its employees and volunteers, will have any responsibility for the condition or use of any non school property. 7. I certify that my child is in good health and may participate, but in the event of medical emergency, I/We authorize the coach in charge of the off campus athletic activity to seek emergency medical treatment for my child at my expense. 8. Some trips may include or have the potential for participation in swimming or other water based activities. Risks and dangers in water may arise from foreseeable or unforeseeable causes. Your signature signifies permission for your child to participate in these activities when supervised by a sponsor(s) and that you will indemnify/hold the School Board of Brevard County harmless for any accident or injury, and hereby assume all risks and dangers and all responsibility for any injury, loss, and/or damage that may occur while your child is engaged in the water related activity(ies). 9. I/We have read and understand the information above and accept the designated responsibilities. I hereby grant participation in all aspects of this trip. - Granted - Denied - Granted with following exceptions:

Student Signature (Required) Date Parent/Guardian Signature (Required) Date

SCHOOL BOARD OF BREVARD COUNTY, FLORIDA STATEMENT OF INSURANCE ON PRIVATE VEHICLES Required by F.S. 234.03(4)

School Year: ______

School: Melbourne High School Date:

The School Board of Brevard County, Florida requires proof of insurance coverages in force on all private vehicles used for the transportation of school sponsored groups on all in-county and out-of-county trips. The groups that may be transported include, but not limited to, students, coaches, sponsors, faculty and chaperones. This form is to be completed for each private vehicle used for the transportation of school sponsored groups. It is valid for the school year in which it is filed. If the insurance policy expires or is cancelled during the school year, a new statement must be submitted.

DRIVER INFORMATION

Driver’s Name: Age:

Address: Telephone:

Florida Driver’s License: Type: Number:

VEHICLE INFORMATION Vehicle must meet Acceptable Vehicle Types (Subject to requirements of F.S. 234.02). See attached list.

Vehicle Make: Year: Model:

License Tag:

INSURANCE INFORMATION

Name of Insured: Policy Number:

Insurance Company:

Policy Period: To

Yes No This policy provides for Personal Injury Protection in a sum not less than $10,000.00.

Insurance Agent:

Address: Telephone:

I certify that insurance policies, subject to their terms, conditions and exclusions are at present in force with the company indicated and that the information above is correct.

Signature of Owner/Insured Date

The above information has been verified.

Principal’s Signature or Designee Date

MELBOURNE HIGH ATHLETICS Parent/Guardian & Spectator Code of Conduct

The role of the parent in the education of a student is important. You have a major impact on your student/athlete’s attitude about academics and athletics. The leadership role you take in sportsmanship will help influence your child and our community for years to come. As a parent and/or spectator: 1. I (and my quests) will be a positive role model for my child and encourage sportsmanship by showing respect at contests and by demonstrating positive support for all players, coaches, officials and spectators at every game, practice or other sporting events. 2. I realize that athletics are part of the classroom and the benefits of involvement go beyond the final score. 3. I will encourage our students to perform their best just as we would with their classwork. 4. I will participate in positive cheers that encourage our players and discourage any cheers that would direct that focus including those that taunt and intimidate opponents, their fans and officials. 5. I will learn, understand and respect the rules of the game and the officials who administer them. 6. I will respect the task our coaches face and support their efforts to educate our young people. 7. Respect our opponents as students and acknowledge their efforts. 8. I will respect the coaches and game officials and will never question, discuss or confront them at the field and will arrange to speak with coaches at an agreed upon time and place. 9. I recognize the importance of my responsibilities as a parent/guardian. 10. I agree to abide by all requests from school and district administrators.

Student Name:

Parent Signature: