AUHSD Intramural Sports Packet

PARENT/ GUARDIAN INFORMATION
Father's Name*
Father's Cell*
Please enter a valid phone number.
Mother's Name*
Mother's Cell*
Please enter a valid phone number.
Family Physician*
Family Physician's Phone*

EMERGENCY INFORMATION
NOTE: Pupil may not be released from school or hospital without permission of a parent or other authorized adult. If an emergency situation requires that this pupl be dismissed from school and a parent cannot be reached, the school or hospital may contact:
Name/Relationship*
Emergency Contact Cell*
Please enter a valid phone number.
Name/Relationship (2)
Emergency Contact Cell (2)
Please enter a valid phone number.
STUDENT MEDICAL INFORMATION
NOTE: Parents must inform the school of any medication(s) a pupil takes regulary (Education Code 49430)
Medication and Dosage*
Does the student have any allergies?*
If Yes, please list:
Previous injuries/surgeries*
Does the student have asthma?*

YesNo
Date of last Tetanus booster

MonthDayYear

INSURANCE INFORMATION
NOTE: The school district does not pay physician fees or medical expenses for students who are injured at school or at off campus school sponsored activities. Student accident insurance that may defray some of these expenses is available through the school.

Families can purchase insurance through Myers Stevens Toohey if your student(s) are currently not insured. Click on the link below to enroll.

https://myers-stevens.com/enrollment/
Did you purchase insurance through the school?*

YesNo
Subscriber Name*
If no insurance, enter N/A.
Insurance Company*
If no insurance, enter N/A.
Policy #*
If no insurance, enter N/A.
Phone
Skip if no insurance.
I/we hereby grant permission to the school, referred hospital, its physicians and/or athletic trainers to render first aid or emergency treatment and all preventative and rehabilitative treatment deemed reasonably necessary to protect the health and wellbeing of this pupil. I/we additionally grant, when deemed necessary, permission for hospitalization and emergency treatment at a competent and/or accredited facility for protecting the health and well-being of this pupil. I/we further release the Anaheim Union High School District, referred hospitals, its physicians and/or athletic trainers, agents, servants, and employees from any liability for damages and/or injury to this pupil, I/we hereby accept full responsibility for any and all damages or injuries sustained as a result of participation in sports.
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Signature of Student Athlete*

Clear
Date*

MonthDayYear
Date

Opioid Fact Sheet Acknowledgement
In accordance with California Education Code section 49476, school districts that offer athletic programs must provide the Center for Disease Control's "Opioid Factsheet for Patients" to each student athlete on an annual basis. In addition, student athletes, and if they are 17 years old or younger their parents or guardians, must sign and return an acknowledgement that they received a copy of the Fact Sheet before the athlete starts practice or competition. This is an annual requirement that must be met prior to the student athlete's first official practice of the school year.

I/We acknowledge that we have received, reviewed, and understand the "Opioid Factsheet for Patients."
Student Signature*

Clear
Date*

MonthDayYear
Parent/Guardian Name*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
References: Opioid Factsheet for Patients

English: https://www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf

Spanish: https://www.cdc.gov/drugoverdose/spanish/pdf/CDC DOP HCP Patient-Opioid-Factsheet Spa

AUHSD After School Intramural Sports/Activities Program Concussion Information Sheet

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:
- Nausea or vomiting
- Neck pain
- Balance problems or dizziness
- Blurred, double, or fuzzy vision
- Sensitivity to light or noise
- Feeling sluggish or slowed down
- Feeling foggy or groggy
- Drowsiness
- Change in sleep patterns
- "Don't feel right"
- Fatigue or low energy
- Sadness
- Nervousness or anxiety
- Irritability
- More emotional
- Concentration or memory problems (forgetting game plays)
- 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
- Any change in typical behavior or personality
- Loses consciousness
Adapted from the CDC and the 3rd International Conference on Concussion in Sport
Please initial to acknowledge your reading and understanding of the information above.*

Clear

AUHSD After School Intramural Sports/Activities Program Concussion Information Sheet

What can happen if my child keeps on plaving 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 CIF Bylaw 313 now requires implementation of long and well-established return to play concussion guidelines that have been recommended for several years:

"A student-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 for the remainder of the day."

and

"A student-athlete who has been removed may not return to play until the athleteis 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 it is 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.edc.gov/ConcussionInYouthSports/
Student-Athlete Name*
Student-Athlete Signature*

Clear
Date*

MonthDayYear
Parent or Legal Guardian*
Parent or Legal Guardian Signature*

Clear
Date*

MonthDayYear
Should be Empty:

AUHSD After School Intramural Sports/Activities Program

EMERGENCY HEALTH AND MEDICAL CONSENT FORM

STUDENT INFORMATION

PARENT/ GUARDIAN INFORMATION

EMERGENCY INFORMATION

STUDENT MEDICAL INFORMATION

INSURANCE INFORMATION

Opioid Fact Sheet Acknowledgement

AUHSD After School Intramural Sports/Activities Program Concussion Information Sheet

AUHSD After School Intramural Sports/Activities Program Concussion Information Sheet