Student Name (print) HENRY COUNTY ATHLETICS FORMS REQUIRING COMPLETION AND PARENTAL/GUARDIAN SIGNATURE PRIOR TO STUDENT PARTICIPATION SCHOOL YEAR 2015-2016 ‘CONTENTS OF FOLDER: ("lank” Isfor AD to check off that form Inside is signed) Henry County Schools’ Participation and Consent Form, _GHSA PPE-4 (Pre-participation Physical Evaluation) Form, GHSA By-Law 2.67: Practice Policy or Heat/Humidity Awareness Coma erirn.. Farin Please note: ‘No pages are to be removed from this booklet. Each of the above-fisted forms must be signed by the student-athlete’s parent or legal guardian. ‘* Booklet must be returned to the Schoof's Athletic Director who wil check for the required. signatures ‘+ Due to fate revisions to the Concussion Form from GHSA, its not Included in this packet.‘soHOOL. STUDENT IDE. HENRY COUNTY SCHOOL DISTRICT ATHLETICIEXTRA-CURRICULAR INFORMATION AND CONSENT FORM (horoinater"Forn) Mao ___Femate__ FST TBE oY a a ‘Teleoone (home) ote of ith Date entered 9 grace ‘Stuer rade level forthe cure echoa year FehersNape ators Wore Numeral oor Neme oer Werk Nut Student ostes wth (Names of Poron'Guarden). (WGutdan,subyat oples of Court Oda or Gua ‘Tho studnt fe domed atthe above adeeacs locatod Ih be ich echost abet (choo! must bo ‘oMMed stadt roves fon fs ove sbirss), Students found Wiopally earelied Sut off echool atundance zone could be ‘ued Telgino for GHSA competion fr ono (1) ul yor. Vos th above-namutt atudot stoned thls Homry County School or allen cne fil echéol your? Yes. No. EMERGENCY CONTACT INFORMATION. :n.9 oven! ha father or mother caret bo reach, thos parsons thoul! be contactod rgarng any stains wich any offer, agan or «employe ofthe Harry County Scho! Disc nd oho ao emergency ation Iino tse, cal Rae aan ‘es Panel Bane Ware aoe Tana Rae icine Phone Gall Pon Wak Paha WARNING: BY TS NATURE, PARTICIPATION IN INTER SCHOLASTIC ATHLETICS, INTRA SCHOLASTIC SPORTS CLUBS, OR ‘OTHER EXTRA-CURRICULAR ACTIVITIES INCLUDE A, RISK OF ILURY WHICH MAY RANGE iW SEVERITY FROW MINOR TO {Lowa TERM CATASTROPHIC, INCLUDING PERMANENT PARALYSIS FROM THE NECICDOWN OR DEATH. Parfeanls can and have te responsibly to hap rece the chance of hun, PARTICIPANTS MUST OBEY ALL SAFETY RULES, REPORT ALL PHYSICAL PROBLEMS TO THEIR COACHES ON CLUB SUPERVISORS, FOLLOW A PROPER CONDITIONING PROGRAW, AND INSPECT THEIR EQUIPMENT DAILY, sch of ie mcesgnad hereby consents forte sbove named student tc ‘Cempat in stotes Gr Senco! of th Harry County Schoo Dts} in Goatgia High Schoo Aasocktion apved spo axeeet toss OROUSED out below: xupel sia hteg Gem conty Foal ator Tice Watng Voto it pmmsies ———evieg Larosa 9) any hoo lam or spore cub af woh ho student « member an any oft foclo out twn tps. ‘Exdrai to utaigaed porn vo tho cn ct nh Fr sd nay hr Secu ubmiliod tothe Hony Counly Sshool Dee coree and understand hat ary flo Infomation my resus Be aovo- ‘ard ede bly ceding patent srs MEDICAL INFORMATION: Each of tho undorspned cores tat the modal Nelay on tho stashed form onliled GHBA's PPE-4 ‘oneaming th above-named aiden i complte and acourate. Each ct tho urderlgod underslands that is vil suv as tha asl for ‘Selsrning wheter to abeve-painad shone eligbleo compte n nidUeighschoa abc er ler etre-urlcar axles wih {ha Homy County Schete. ach ofthe undesgna ego undertads any evaluation ac rovaw conducted by te Henry Couny School Dioiet concaming eny student's medeal history le ony to datomine wheter aiden! moos olgbliy Teguremenia conesring aration in afietzs or oer exe-cunicuareciles. Ay ech evaluation or veiew by tho Henry Coutty School Dis! fs rol & textiafon ot quaraies of any halo concerring th alt, wl beg, tnecl sal, cr feos cf any sen o papal ory ‘icelaigh school alles or ere curious aly and ena toe the Place of egusr mode examinations. in cateof an emergency fect en schoo rn, da of aid ay scholar acy vie he boven auto, ik tho ophion of ary ocho aubrey prosont knmediale medical or eutjeal atrion is edvsbla, each ofthe underanod heraby granks pernlsson to said schoo! wuthattes to oblain the verses ofa piyican or cher madcal prover and lo vanspat the above Diadant ioe (oe not page) {Cea 000143 Mate: 0000 Dos: ns78501.00C) 2 aespa ox cler med! ally ks desmee adel by any echt ahs. Each of ho widened hereby gana parma, ee LesEirpyslano:aher mada prover to tel eet eanduon unseen uncaelgnod parent or guaran of he above-named oud [recon ae reqasts chords of unl each ofthe underigned requedt eens nwthg. Each of to undalgned sso hore grants Pcmision fo ery preonnal ths Henry unl Eakoo lait render any srvenlewve radial ecient et ee, emergency mada "Schaal teaent ct nt olaved by ech cna be acl lo let ia hs on ok beta of ‘cious mare slink. East of be Undersgnod undoratands ana agree tnt te tnns hart appl ay run, accent ose, ‘eda! proslom or metyency tht een a8 foul of or I conection wih ony aapeet of Hany County School Dist eto oer ‘eter pariceton or any aches fn any wy rate or Indra thereto, Ide but nat tod to yout, practic, cowstonng, Tate games and Havel Each f tho urargned lao underiande Ut easonabs oft wil be made a contet a parent (or legal {usin} ofthe bove-named siden conearing ary ert orhnolved media ean. “TRANSPORTATION PERMISSION: The Hemy County Schoo Distt doesnot prove ransportion fo senator eta-cuniculreverts Unies roid by lve. Aa su, 1a th fespanabiily of tho parereguurden to make aracgemens for wanepottion oar etre ‘ular ovenls hr which te above-named viel rey wish lo parpel, The Henry County School Dll sonal ckaakreges ‘lento ‘rom dng ot ola stions fo and ort oxta-cunicular overs, Paso o aciaed tut tho Honey County School Dstt i ot ipl er mr oven rapan and eae la ene tes. Gach of un hereby tutor eonaonte an behalf bs stent ramod above tparicipals hechosk-eponsered ie, INSURANCE INFORMATION: Each of the undersigned horeby auerzns the rleese of eny and ol aration relating to the ext. {cube or tate parttpaon of he above gamed atdet fo te mela and io al calege teers, cuca any medial nionaon eSraing ly ee Aneset any bograiea iareaon, and ary lve formafcn raed tof oda-curiusr or alte pattpaton of ‘0x ascent, not abit, alta and cond. ‘lease have the paeniaiordan INITIAL ono the fllng statment regarding Insurance coverage forth abovesaried ett frtho 215.2006 sel you: “Tho sbove-naad eudet fe sdoquaoly and curently covered by accent surance thal wil cover Ijroseusttnad while pardapatig ny son) eiharzed sty Olan, bu nota to, Valor Sonor Vary Footbal) an Fee Hae Sia asad a ee ‘One orm of tho undersianed hae pursed the Bene lan forthe above named student previed by the Hany County SeRTDT, syn Ita Insrance {ore sbove-named ser eps, oid, caeas shod, aumpended, te underlined ae 12 frmately nly tro Henry Coury Schocl Cleet aad fo emedlally bio replacement accident Iauran coverag for the above famad atten aed provide Heny County School Disc wih re are of tho Insurance company, fe aame of he Insured, ar the pb caso cn non ary, Pons Pm ene Pian ey Hy Cnty Se 3 sgrng this Form ach ofthe enderslned arrowed ed eae tat ash ofthe wndertgnod hes road and underedt fe Com and agrees to all tho trma set forth inthis Form end that ll tho Infomation goniained In this Form or otherwise Bonn sh ny Coty aol let ae and cave, Eh he nde ae een nat Troy nave foe aunty end right fo algo this Fore on behalf of the above-named student and on behalf of oi of sald atudont peents snd guerdans, and Wher hereby release and agree fo Indemny and fold the Henry County 6choo! District ard Is Eraployoon; mrebor, agont,ofiare, and drector, and tne Henry Covety Board of Education and is members, and all ofthe iezedaors and sssighe ofa of such persone and ene, harmloss from any and al cian, damage, aby, and causes of Siete Rleihor incu or unknown, whether now, previsly, or In Une furs exiting or arsing n any way docty a indlreoty asted tothe sbovemamod students partelplion I any spe, extra-curricular actly, or any ofr atv In any vay related ar Iraidontalthaveo, er many way rested to any rendering, aiomp to fener, o faire to render any medical, heath caro, of other Weatmontafany nate tothe sbovesiamed store. “Thi Form and all consents, acknowlelgmonts, aa agreements conflned heroin shallremsin iy offost unl the spect potion of Iho Form tals paront or gunrlan wisi to fevoko Io Mied in wring end auch revecction Is devoted tothe Henty County ‘Sehocl Datel nla! thao (day prior to tha affective date such consent I terminated ‘ater Psa Gian) Baie ‘Sigal af ara Garay Peer eee Sepa Tae aloe reeeeersreveraeneee elted and Updated 446-16 (ett 0000143 Mate: 0000 Der U578S01.D0C}PREPARTICICATION PHYSICAL E HISTORY FORM (te: aie or tb te pat ae! oe lyst The en eh ep i fa nde ht) iio a JATION me a Tie ae gles Peet ren el rr edhe and spencer and mora yo ae carey ng oyoutave arya? © Yes Cl Ho yes pono Mendy soci fey elo. Biase ‘Pate Great hay tah oth ost of my nwt my atone oth abo guste recone ance, eam Sea etait a, 1 sing {in oe lo Goons yur ewe we sons. ° Te |) (naa Se Te SS aan ero ry Renin dea roariopaian Ih AT ee Hane ely Weatg aa a Ta A en ar oA fee ae hr ee Fe Eben npn hw 2 lg wae Thane (oie cay weet ‘ism ne Serpents er ae it a eros avETHT ——~ | [pace nes bn Taha oy RAT 5 ioe i ner en elon 5 ie be Ih ett Ti ge RT aa aT Stee car ees to BS a SET > paper nal Tease ae ee irate 5 bts arene Errnteedease Cl ANetome rion ici? Behn” & Aston cm peer oto Eton _ te fue higmeuet Tiacatoar ood intron ee Parco OE, non ratea ns a TESo aT POTR ‘Sanind ae a ibaa TT TIAA RPO ian pea eae a Ee be pt Senpeine Tita ET re bre or an ao ein a ahr tae ot ETA tpt rie Sree 24 Hav yeh ony apo ae a a ST TY [| I ame ie Se fe Swabs ce TAD Senet sree i amie on ari geen tei oa aagonn bore ‘smc siete en tee stesso kere las Spe STORE mantic jaa aeaiya es era vee pn new Dosen po TS iano aa oni ig eae renates z smear doar Ee poe i eo eT ar ie [ot rata ohe oe ramp bt og a saa St rn nck act octans pat Sa pene ley Wn Sen ORCS Fi eps ryote al en ‘Gisteouahessatenon! serene Ft epee yon ran pea aE ly Sts atin nguleen nae Fiat wc, tr on ee ab hoped Todi a bey A le TE pairs tin ciha i i ew aaa oa i a ose et ai i slag aaa age ethene ‘Seno eds esi nabs at of oes oS8 PREPARTIOPATION PHYSICAL EVALUATION PHYSICAL EXAMINATION FORM Nase Bi eS ate ote uve meni 1. Gal ote scam tin bons ‘Devoted ga anereniee eee eas YO "aor re at tah koh Soca See ae rer atta 1 bhatt 1 Ghote auto otn ea cmarenithos tr otto tenet 1 Pate fe atin 1 eyes 1 erat pote tae Fame Sapa eRaR eS oReam aaia anne eae fpr eet ena na a een See caiiems oe eenmcomacrememeneer onan it, anu ceiemans Nerang EH EE SE ‘Sgenne tes ‘wourto a aa aaa ae aa ie ic it Meine Manan on Speen onic hati oan avo ara sco sh steamBR. PREPARTIGIPATION PHYSICAL EVALLIATION THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM Det ene Dat tet ox ae erate Shoal — so) i aeaaa STE 5 Gta a co Bh in oe od Deo prs cdg ni 0a NG vars sii 3, Dye cbs pee a era a? Dye aul ero ey byl veg ey my ck dle lar a baer eects we oad sr end i anos eo a aa frei Se ne 1c Dypuigomace Dro ged ln a ci el ely are ‘asl yun we a a eon aaa yon a se a faves Tis tas eet en katoi ae ae eo as a Tsing art Visieeeh amen nes ni feoet gph cn fasriomost nyo Sener ct uae woven ney tae roby noes eso toa ange dae peng ae ‘Sa seal pti Na SRS a aie ea ip pt mr crat ar i ni ie i ty ns ae rob acoacne® PREPARTIGIPATION PHYBIGAL EVALUATION CLEARANCE FORM ar, sa OM OF Ae. Dato 1 Coaster a spots tt ten 1 Coot at sos wetness otter rat exit or 1 totes 1 feng tater eaton 1 ernyapats {have examined the above-named student ane completed the prepatclpationphylen ovahation. The athote does ‘dinteal sontralndleation to practice end parlcpat Inthe spor) x outned above. copy et tho phyetca exams on recordin my etce ‘sud ean be sao avaabtc thodobool atthe aquest of tho parans It eoedilens arse aftr the athlete hae been eewrod fer partctaton, fe palin ay reoind to clearance unt the problems resolved and the potential coneoences ar completely explained oto ahete {en parent/guardian}. resent eppart noc eiypg) i, "pee Pec ‘mosieofpitn tn [EMERGENCY INFORTAATION Ate ‘Sa ay Hg ot ais i lo i in i Wn oh io earring ors co ete pnb oa ean ae mo wth are‘SHSA Heat Poti Athlete Name Se First Day Football Accmattzatlon: July 25, 2035 (5 days eccimattation required) Fitst Day of Practice: August 2, 2035, Fra a ta Toon the satenide poly for conducting practices and voluntary condoning workouts (including during he aac) inal spor's during times of extremely high hest and/or hurl that willbe signe by each head coach atthe begining of sary neccon and dutbotedt all pers an thel parents or guetcns. The policy shall fllow madi gldeines of the American Colege of sports Medicine in regard to: ‘The scheduling of practices at various heetfhumity levels 2. The ratio of workout time to timo alate forrest and hydration at various heat/humlty levels The heat/humlty leva that wil esu in practice being terminated {iy Ascletialy approved isrurent that measures Wet Bulb Globe Temperetue (WBGI) readlg must be ttled st each trhetce to ence tot the wien pays bel folowed propery, WBGT readings shoul be taken every hour, beaning 30 Inloutes before the beginning of practice. weer "ACTIVITY GUIDELINES AND REST BREAK GUIDELINES ‘UNDER #2.0 ttormal actities ~Provide at feast three separate rest breaks each hour of minimum | duration of 3 minutes each during workout 82.0-86.9 Use discretion for intense of prolonged exercise; watch at-risk players carefully; Provide atleast three separate rest breaks each hour of @ minioum of four minutes duration ‘ach. 87.0-89.9 ‘Maximum practice time Is two hours. For Football: players restricted to helmet, ‘shoulder pads, end shorts during practice, ll protective equipment mast be removed for conditioning ectivites f the WBGT rises to ths evel during practice, players may continue to work out wearing footbol pants without changing to shorts. Focal mers: Provide atleast four separate rest breaks each hour with a minimum duration of four ‘minutes each 90.0-82.0 ‘Maximum length of prectice fs one hour, For Football no protective equipment may be ‘worn duting practice and there may be no conditioning actkles, EorAllSnorts: There rust be 20 minutes of rest breaks distributed during the hour of practic. over 92, No outdoor workouts; Cancel exercise; delay practices until a cocler WEGT level is reach {c) Practices are dofined asthe period of ime that a participant engages in a coach-supervised school-approved sport oF conditioning-telated activity Practices are timed from the tims the players report tothe fold until they leave. Wa practices interrupted for @ weathor ~related reason, the “clock” on that practie wil stop andl wil hegin again when the practice resumes. (d) Conditioning activites include such things as weight traning, wind sprints, timed runs for distance ete, and may be apart ofthe practice time or inckided in “voluntary workouts” (e) A WALK THROUGH Is not part of the practice time regulation, and may lst no longer than one hour, This activity may not Involve conditioning activities or contac dls, No protective equipment may be wom during @ walethrough, and no full'speed dels may beheld. 9 Rest breaks may not be combined with any other type of activity and players must be glen uniimited acces ta hydration. These breaks must beheld In a “cool zone” where players are out of direct sunlght. ‘PENALTIES: Schools violating the heat policy shall be fined a minimum of $500.00 and a maximum of $2,000.00, Date: are iguanas teetsetseeteeseeseesescse CeCe cere eeee eeeGeorgia High School Association Student/Parent Concussion Awareness Form DANGERS OF CONCUSSION ‘concussions at al levels of sports have recelved a great dea! of attention and a state law has buen passed to address this isue ‘Adolescent athletes ere particulary vulnerable to the effects of concussion, Once considerad ttle more than a miner “ding” to the head, tls now understood that a cancustion has the potential to result in death, or changes in brain function (either short-term or fong-tenm). A concussion is a bran Inury that results In 8 tomporary éisruption of normal brain function. A concussion occurs when the brain is violent rocked back and forth or twisted Inside the skull ss a result of a blow to the head oF body. Continued partipetion In ary sport folowing a concussion can lead! to worsening coneusson symptoms, 28 well as Increased tis for further Injury tothe brain, and even death. Player and parental educstion inthis area fs erucal ~ thot Is the reason for tis document. Refer tot regulary. This form must he signed by @ parent or guardian ofeach student who wishes to participate in GHSA athlatis. One copy needs to be returned to the school, and one retained at home. COMMON SIGHS AND SYMPTOMS OF CONCUSSION ‘+ Headache, ezziness, poor balance, moves clumsily, reduced energy level/tredness + Nausea orvoriting + Blurred vislon, sensitvty to lit and sounds + Fagsiness of memory, difleuity concentrating, slowed thought processes, confused about surroundings or game assignments + Unexplained changesin behavior and personality + toss of consclousness (UOTE: This does rot cecurin all concussion epfsodes,) BY-LAW 2.68: GHSA CONCUSSION POLICY: In accordance with Georgia law and national playing rufes published by the Netlonel Federation of Sate High School Assoclatlons, any athlete who exhlbits sls, symptoms, oF behaviors consistent with 3 concussion shall be Immediately removed fram the practice or contest and shall nat retum to play until an appropriate hesith eare professionel hus determined that no concussion has azcurred, (NOTE: An appropriate health care professional may Include licensed physician {(M0/00} or another lensed Indvidual under the superuslon of a tcensed physician, such as @ nurse practioner, physician tusistant, or certified athletic tralner who has received training in concussion evaluation and managment. 2) No athlete i allowed to return toa game or 8 practice on the seme day that a concussion (a) has been diagnosed, OR (6) cannot beruled out. ) any athlete diagnosed with a concussion shal be cleared medialy by an appropriate healthcare professional prior to resuming participation In any future practice or cantast, The formulation of a gradual return to play protocol shall be a part ofthe medical clearance, By signing thls concussion form, 1 give High School permission to transfer ths concusson form to the other sports that my child may play. lam aware of the dangers of ‘concussion and this signed coneussion form will represent myself and my child during the 2015-2016 school year. This form will be stored with the athletic physical form and other accompanying forms required by the School System, I HAVE READ THIS FORI AND I UNDERSTAND THE FACTS PRESENTED INIT. Student Name (Printed) Student Name (Signed) Bate Parent Name (Printed) Parent Name (Signed) Date (Revised: 7/15)