SNOHOMISH SCHOOL DISTRICT ATHLETICS Welcome to Snohomish School District Athletics. The required forms for athletic participation include the attached five pages:

1 – Athletic Emergency & Clearance Form 2 – Athletic Eligibility Form 3 – Athletic/Activity Code 4 – Concussion Form 5 – Physical Examination Form

Please note that the physical examination form is valid for 24 months from the physician’s signed date of the exam. However, an exam must be valid for the duration of the entire sport season in order to tryout/begin a sport. All other forms must be filled out yearly, signed, and turned into your school’s athletic office prior to try outs/first practice for each sport.

MISSION STATEMENT All high school students are encouraged to participate in the co-curricular and extra-curricular programs at the high school level. It is the responsibility of all students to make learning a top priority and to be accountable for their work and personal conduct at all times. To remain eligible to participate, all students will demonstrate, through their work and attitude that they are working to their fullest potential. Students will exemplify good character in the classroom and in co-curricular and extra-curricular activities.

ATHLETIC ACADEMIC STANDARDS Students are expected to maintain satisfactory academic performance in all school courses. Athletes cannot compete unless they are continually enrolled in and passing a minimum of five classes. A student athlete who does not maintain a “C-” grade in each class will be placed on a remediation plan and contract. This contract must be signed by the teacher and returned to the coach on a weekly basis. The student may participate as long as the teacher signs the contract verifying that satisfactory progress is being made or the student’s current grade is raised to a “C-”.

ASB CARD / PARTICIPATION FEE / MEDICAL INSURANCE Athletes must purchase an ASB Card. Additionally, a participation fee of $100 is required per sport with both individual and family caps. The athletic participation fee can be waived for students who are approved for Free/Reduced Lunch. The athletic fee is due prior to the team’s first contest and shall be paid (or Free/Reduced Lunch waiver received) by using the Athletic Fee envelope provided by the coach. Refunds will not be provided after the first contest. Lastly, current medical insurance is required for sports participation. CONTACT INFORMATION Athletic Director: Mark Albertine (360)563-7611 Athletic Director: Mark Perry (360)563-4080 Email: [email protected] Email: [email protected] Athletic Adm Asst: Leslie Bjornethun (360)563-7612 Athletic Adm Asst: Ellen Lipinski (360)563-4078 Email: [email protected] Email: [email protected]

Athletic Information Hotline – 360-563-4215 Snohomish School District Athletic Adm Asst: Trisha Palm (360)563-4210 Email: [email protected]

Revised 4/15 GREEN 2151F2 Page 1 of 2 SNOHOMISH SCHOOL DISTRICT ATHLETIC EMERGENCY & CLEARANCE FORM

ATHLETE’S NAME: (Please Print Clearly using pen)

Birth Date: ______Home Phone: ______Grade ______Male/Female (Circle One) Parent’s Name(s): ______

Address: City: Zip: ______

Parent’s Email Address: ______

Father’s Employer: Business Phone: ______

Mother’s Employer: Business Phone: ______

Father’s Cell Phone: ______Mother’s Cell Phone: ______

Emergency Contact: ______Emergency Phone: ______

Alternate Person to be Notified: ______Phone: ______

Physician of Choice: ______Phone: ______

Preferred Hospital: ______Phone: ______

Medical concerns/allergies: ______

PARENT/GUARDIAN READ AND SIGN

My child is covered by the following Insurance Company (Required): ______

If the parents and/or authorized physician named above cannot be reached at the time of an emergency, and if immediate observation or treatment is urgent in the judgement of the school authorities, do you authorize and direct the school authorities to send the pupil to the hospital or doctor most easily accessible and for such doctor to render such observation and treatment as immediately as necessary?

Yes _____ No _____ Parent/Legal Guardian Signature: ______

INSURANCE: I assume financial responsibility for medical expenses that may arise out of my child’s participation and understand that the school district does not provide medical insurance for my child.

RIDE PERMIT: I hereby give permission for my child to travel to/from athletic events or activities in transportation arranged by school officials. I also understand that through my written permission my child may be allowed to be transported by another carrier.

ATHLETIC CODE: I understand the terms of both the Athletic/Activity Code and the Athletic Eligibility Form including the Warning and Agreement to Obey Instructions. I request the Snohomish School District to permit my child/ward to participate in and/or to try out for his/her school athletic/activity team(s) and to engage in all activities related to the team, including, but not limited to, trying out, practicing, or playing/participating in the sports or activities.

Parent/Legal Guardian Signature: ______Date: ______

OFFICE USE ONLY OFFICE USE ONLY AUTHORIZATION TO PARTICIPATE IN SPORTS

This is to verify that the above mentioned student has completed all the necessary athletic/activity forms and they are on file at the school the student is currently attending. He/she is responsible for giving this completed form to the coach, at which time the student is eligible to try out/practice with the team. This form needs to be completely filled out and returned to the coach for each sports season in which the student participates.

SPORT: DATE OF STUDENT’S LAST PHYSICAL: ASB CARD:  Yes  No

AUTHORIZED STAFF SIGNATURE: _____ DATE______Revision Date: May 10, 2011

2151F2 Page 2 of 2 SNOHOMISH SCHOOL DISTRICT ATHLETIC ELIGIBILITY FORM SCHOOL: ______

ATHLETE’S NAME: ______(PRINT IN PEN ONLY)

Birth Date: ______Age: ______Home Phone: ______Grade ______Male/Female Please check yes or no to the following questions: (Circle One) Yes No □ □ Are you currently living with your parents? □ □ Do you reside within the Snohomish School District? □ □ Are you enrolled in at least 5 classes at the above school? □ □ Did you pass at least 5 full-time semester classes last semester? □ □ Are you now or have you ever been a foreign exchange student? □ □ Have you repeated a grade or withdrawn from school at any time since entering 7th grade? □ □ Did you receive an attendance variance to attend this school? If yes, what is your neighborhood school? ______□ □ Did you transfer from another school during the past two school years? If yes, were you under any conditions of ineligibility when you left your previous school? ______

List all schools student has attended in the past two school years: ______

PARENT’S NAME(s): ______

Address: ______City: ______Zip: ______

Parent’s Email: ______Athlete’s Email: ______

Mother’s Cell Phone: ______Mother’s Work Phone: ______

Father’s Cell Phone: ______Father’s Work Phone: ______

I hereby request that my child be permitted to participate in: ______(Fall Sport) (Winter Sport) (Spring Sport) WARNING AND AGREEMENT TO OBEY INSTRUCTIONS: I am aware that playing or practicing to play/participate in any sport can be a dangerous activity involving many RISKS OF INJURY. I understand that the dangers and risks of playing or practicing to play/participate in interscholastic sport(s) include but are not limited to death, serious neck and spinal injuries (which may result in complete or partial paralysis), brain damage, injury to internal organs, bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal systems. I understand that the dangers and risks of playing or practicing to play/participate in the interscholastic sport(s) may result not only in serious injury, but also in a serious impairment of my future abilities. Because of the dangers of participating in the interscholastic sport(s), I recognize the importance of following coaches’ instructions regarding playing techniques, training and other team rules, etc, and agree to obey such instructions. I further understand that by following the instructions provided by the Snohomish School District, the risk of injury described above may be reduced, but that due to the nature of the sport I have selected, there is still risk of injury regardless of the precautions taken or procedures followed. I further acknowledge that baseball, basketball, football, soccer and wrestling are sports which involve violent person-to-person contact and, therefore, the risk of injury in these sports is even greater than other sports. I understand that all sports can involve many RISKS OF INJURY, including, but not limited to, those risks outlined. I also understand that the consequences of injury may exceed the benefits afforded by my own medical insurance and acknowledge that the District has informed me of this possibility. I agree to hold harmless and indemnify the Snohomish School District, its employees, officers and agents from all claims, liability, actions or lawsuits, except for acts or omissions involving the sole negligence of the School District. INSURANCE: I assume full financial responsibility for medical expenses that may arise out of my child’s participation and understand that the Snohomish School District does not provide medical insurance for my child. RIDE PERMIT: I hereby give permission for my child to travel to/from athletic events or activities in transportation arranged by the school officials. I also understand that through my written permission my child may be allowed to be transported by another carrier. ATHLETIC/ACTIVITY CODE: I have read and understand the terms of the attached Snohomish School District Athletic/Activity Code.

______Signature of Student Date

______Signature of Parent/Legal Guardian Date Revision Date: April 21, 2015 2151F1 Page 1 of 1 (white)

SNOHOMISH SCHOOL DISTRICT ATHLETIC/ACTIVITY CODE

Participation in interscholastic athletics and activities is governed by the rules and regulations of the Interscholastic Activities Association (WIAA). The various athletic teams and activity programs within the district are considered to be an extension of the school program. Students are not only representing their teams and/or activities, but also their school. Therefore, school rules pertaining to student conduct as well as additional rules established by the coach, captains, advisors, activity group, or team must be adhered to by all participants.

SCHOOL RULES: These rules pertaining to student eligibility and conduct will be followed: a) In athletics, no changes between sports may be made after 15 days from the first turnout or after the first scheduled contest (whichever comes first). Practices accumulated in one sport may not be used toward the required number of practices in another. b) Attend practice/meeting on a regular basis. c) Attendance at school is required in at least 3 of 6 periods on days in which a student is to be involved in practice or a contest. Absences must be excused. Exceptions to this must be made with prior approval of the athletic director/advisor or principal. d) Any violation of school rules may result in the removal from athletic/activity participation for the balance of the sport/activity season; such discipline may be in addition to any other discipline, suspension, expulsion or emergency expulsion under district Policy and Procedures No. 3300-3300P. ATHLETIC FEES: All participants are required to purchase an ASB card. In addition, the Athletic Fee is due prior to the first competition. Refunds will not be given after the first competition. ACADEMICS: Students participating in co-curricular and/or extra-curricular programs are expected to maintain satisfactory academic performance in all school courses. Students are required to be continuously enrolled in and passing a minimum of five classes to be eligible to participate. A remediation plan and contract will be developed and followed for each student who does not maintain a “C-” grade in each class in order for that student to continue participation in school programs. Students will be monitored at the beginning of the program, as well as through the program in terms of academics and behavior. INITIATIONS AND HAZING: Any abusive act with the intent to “initiate”, hurt, intimidate, or humiliate another student shall be considered harassment and may result in the immediate removal from the team. Such acts may include but are not limited to traditional and non-traditional “initiation” practices, such as atomic sit ups, swirlies, wedgies, and any other humiliating act or behavior. PROHIBITED SUBSTANCES: Students will not be permitted to possess, traffic in, and/or use non prescribed or illegal drugs, alcohol, marijuana, or any form of tobacco or e-cigarette/vapor cigarette, and may not be in the presence of, or remain in the vicinity of, the use of such prohibited substances, or engage in behavior that enables others to illegally use such substances. It is the responsibility of the student-athlete or squad member to remove himself/herself immediately. Failure to immediately leave the premises will result in the same discipline as actual use. a) When a first offense involving a prohibited substance occurs, the athlete will be suspended from participation for the remainder of the season or the athlete may choose the assistance program outlined below. The athlete will not be allowed to practice for one week and removed from competition for an additional two weeks and must: i. Obtain a Substance Abuse Diagnostic Assessment from an outside agency (see school counselor for approved agencies). ii. Develop a plan for completing the recommendation of the assessment. iii. Communicate the results and recommendations of the assessment with the Athletic Director. iv. Obtain approval for reinstatement on the team from the Athletic Eligibility Board. The Board will consist of the Principal (or designee), Athletic Administrator, and two coaches. The coach of the team where the violation occurred will not be present in the meeting. b) A second offense will result in the individual being ineligible for interscholastic competition for the period of one calendar year. c) A third offense will result in the individual being permanently ineligible for interscholastic competition. d) Penalties will be carried forward to next sport season or school year in which the student competes. e) The Athletic Department may continue to monitor the athlete’s compliance with treatment expectations, even if those expectations extend beyond the applicable three week disciplinary time frame. Noncompliance with the treatment recommendations will be considered a second offense. f) Disciplinary actions regarding athletic code violations shall be progressive and cumulative over the career of the athlete.

Printed Student Name Student Signature Date

Sport Parent/Guardian Signature

Revision Date: April 21, 2015 2151F4 Page 1 of 2 Snohomish School District #201 Concussion Form

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following: • Headaches • Amnesia • “Pressure in head” • “Don’t feel right” • Nausea or vomiting • Fatigue or low energy • Neck pain • Sadness • Balance problems or dizziness • Nervousness or anxiety • Blurred, double, or fuzzy vision • Irritability • Sensitivity to light or noise • More emotional • Feeling sluggish or slowed down • Confusion • Feeling foggy or groggy • Concentration or memory problems • Drowsiness (forgetting game plays) • Change in sleep patterns • Repeating the same question/comment

Signs observed by teammates, parents and coaches include: • Appears dazed • Vacant facial expression • Confused about assignment • Forgets plays • Is unsure of game, score, or opponent • Moves clumsily or displays incoordination • Answers questions slowly • Slurred speech • Shows behavior or personality changes • Can’t recall events prior to hit • Can’t recall events after hit • Seizures or convulsions • Any change in typical behavior or personality • Loses consciousness

2151F4 Page 2 of 2

What can happen if my child keeps on playing with a concussion or returns to soon? Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.

If you think your child has suffered a concussion Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new “Zackery Lystedt Law” in Washington now requires the consistent and uniform implementation of long and well-established return to play concussion guidelines that have been recommended for several years: “a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time” and “…may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”. You should also inform your child’s coach if you think that your child may have a concussion Remember its better to miss one game than miss the whole season. And when in doubt, the athlete sits out. For current and up-to-date information on concussions you can go to: http://www.cdc.gov/ConcussionInYouthSports/

______Student-athlete Name Printed Student-athlete Signature Date

______Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date

Adopted: October 14, 2009 2151F3 Page 1 of 2 (yellow) PRE-PARTICIPATION HISTORY AND PHYSICAL EXAMINATION

Name: ______Birth Date: ______Exam Date: ______

Address: ______City: ______Zip: ______

Phone: ______Sport: ______

HISTORY Y N 1. a.   Have you had any illness/injury recently, or do you have an illness/injury now? b.   Have you had a medical problem, illness or injury since your last exam? c.   Do you have any chronic or recurrent illness? d.   Have you ever had any illness lasting more than a week? e.   Have you ever been hospitalized overnight? f.   Have you had any surgery other than tonsillectomy? g.   Have you ever had any injuries requiring treatment by a physician? h.   Do you have any organ missing other that tonsils (appendix, eye, kidney, testicle, etc)? 2.   Are you presently taking ANY medications (including birth control pill, vitamin, aspirin, etc.)? 3.   Do you have ANY allergies (medicines, bees, foods, or other factors)? 4. a.   Have you ever had chest pain, dizziness, fainting, passing out during or after exercise? b.   Do you tire more easily or quickly than your friends during exercise? c.   Have you ever had any problem with your blood pressure or your heart? d.   Have any close relatives had heart problems, heart attack or sudden death before they were age 50? 5.   Do you have any skin problems (acne, itching, rashes, etc)? 6. a.   Have you ever had fainting, convulsions, seizures or severe dizziness? b.   Do you have frequent severe headaches? c.   Have you ever had a “stinger” or “burner” or “pinched nerve”? d.   Have you ever been “knocked out” or “passed out”? e.   Have you ever had a neck or head injury. 7.   Have you ever had heat exhaustion, heat stroke, heat cramps or similar heat-related problems? 8.   Have you had asthma, or trouble breathing, or cough during or after exercise? 9. a.   Do you wear eyeglasses, contact lenses or protective eye wear? b.   Have you had any problem with your eyes or vision? 10.   Do you wear any dental appliance such as braces, bridge, plate or retainer? 11. a.   Have you ever had a knee injury? b.   Have you ever had an ankle injury? c.   Have you ever injured any other joint (shoulder, wrist, fingers, etc)? d.   Have you ever had a broken bone (fracture)? e.   Have you ever had a cast, splint, or had to use crutches? f.   Must you use special equipment for competition (pads, braces, neck roll, etc.)? 12.   Has it been more than 5 years since your last tetanus booster shot? 13.   Are you worried about your weight? 14.   FEMALES: Have you any menstrual problems? 15.   Have you any medical concerns about participating in your sport?

***** ATHLETE SHOULD NOT WRITE BELOW THIS LINE *****

EXAMINER’S COMMENTS ON ALL “YES” ANSWERS (refer to question number):

______

Revision Date: April 2012

2151F3 Page 2 of 2 (yellow)

PHYSICAL EXAMINATION

Optional STUDENT NAME: ______Urinalysis:

Body Fat % Age: ______Pulse: ______

HCT: Height: ______Blood Pressure: ______

EST VO2 Max: Weight: ______Visual Acuity: Left 20/ ____

Right 20/ ____ Audiometry:

Normal Abnormal  1. Head  ______ 2. Eyes (pupils), ENT  ______ 3. Teeth  ______ 4. Chest  ______ 5. Lungs  ______ 6. Heart  ______ 7. Abdomen  ______ 8. Genitalia  ______ 9. Neurologic  ______ 10. Skin  ______ 11. Physical Maturity  ______ 12. Spine, Back  ______ 13. Shoulders, Upper Extremities  ______ 14. Lower Extremities  ______

Assessment:  Full Participation  Limited participation (describe limitations, restrictions):

______

 Participation contraindicated (list reasons):

______

Recommendations (equipment, taping, rehabilitation, etc.):

______

EXAMINER’S PHONE: ( ) ______EXAMINER’S SIGNATURE: ______

EXAM DATE: ______PRINT EXAMINER’S NAME: ______CIRCLE ONE: MD PA ARNP ND DO

Revision Date: April 2012