AUHSD After School Intramural Sports/Activities Program

EMERGENCY HEALTH AND MEDICAL CONSENT FORM

By its very nature, sports, including tryouts, may put students in situations in which serious catastrophic and perhaps fatal accidents may occur. Students and parents must assess the risks involved in such participation and make their choice to participate in spite of those risks.

No amount of instruction, precaution, or supervision will totally eliminate the risk of injury. Just as driving an automobile involves the risk of injury; participation in sports by students in high school athletics and junior high school intramurals involves some inherent risk. The importance of your awareness of these risks in determining whether or not to allow your child to participate cannot be overstated.. There have been accidents in this sport resulting in death, paraplegia, quadriplegia, and other very serious permanent physical impairments as a result of athletic participation.

Students will be instructed in proper techniques and in the proper utilization of all equipment or work used in practice and competition. Students must adhere to that instruction and utilization and must refrain from improper uses and techniques.
No amount of instruction, precaution, and supervision can eliminate all risk of injury, including serious, injury. Some of the injuries/illnesses which may result from participating in these activities include, but are not limited to, the following:

1. Sprains/strains
2. Fractured bones
3. Unconsciousness
4. Head and neck injuries
5. Neck and spinal injuries
6. Paralysis
7. Loss of eyesight
8. Communicable diseases
9. Internal organ injuries
10. Brain damage

By signing below, you acknowledge that you understand and accept such risk and authorize the student named previously in this form to participate in By choosing to participate in sportds, you acknowledge that such risks exist.

I authorize my son/daughter to participate in the District sponsored activity.

I have read this form in its entirety and understand its contents. I understand that it is my obligation to ask questions about anything I do not understand.
I understand and acknowledge that participation in is completely sport is voluntary and as such is not required by the District for course credit or for completion of graduation requirements.

I agree to assume financial responsibility for any medical costs and expenses incurred as a result of any injury that may be sustained by my child while participating in sport(s).

I understand, acknowledge, and agree that the District, its Board of Trustees, employees, officers, agents, or volunteers shall not be liable for any injury/illness suffered by my child which is incident to and/or association with preparing for and/or participating in this activity.

I acknowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATION FORM and that I understand and agree to the terms.

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:

NOTE: Parents must inform the school of any medication(s) a pupil takes regulary (Education Code 49430)

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/

 

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.

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."

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

Tell Your Coach and Consult Your Doctor it These Conditions are Present in Your Student-Athlete:

Potental Indicators That SCA May Occur

• Fainting, or seizure, especially during or right after exercise
• Fainting repeated yor with excitement or startle
• Excessive shortness of breath during exercise
• Racing or fluttering heart palpitations or irregular heartheat
• Repeated dizziness or lightheadedness
• Chest pains or discomfort with exercise
• Excessive unexpected fatique during or after exercise

Factors That Increase the Risk of SCA

• Family history of known heart abnormalities or sudden death before age 50
• Specific family history of Long QT Syndrome, Brugada Syndrome, Hypertrophic Cardiomyopathy, or Arrhythmogenic Right Ventricular: Dysplasia (ARVD)
• Family members with unexplained fainting, seizures, drowning or near drowning or car accidents
• Known structural heart abnormality, repaired or unrepaired
• Use of drugs, such as cocaine, inhalants, recreational drugs, excessive energy drinks or performance enhancing supplements

What is CIF doing to help protect student-athletes?
CIF amended its bylaws to include language that adds SCA training to coach certification and practice and game protocol that empowers coaches to
remove from play a student-athlete who exhibits fainting—the number one warning sign of a potential heart condition. A student-athlete who has been
removed from play after displaying signs or symptoms associated with SCA may not return to play until he or she is evaluated and cleared by a licensed
health care provider. Parents, guardians and caregivers are urged to dialogue with student-athletes about their heart health and everyone associated
with high school sports should be familiar with the cardiac chain of survival so they are prepared in the event of a cardiac emergency.

I have reviewed and understand the symptoms and warning signs of SCA and the new CIF protocol to incorporate SCA prevention strategies into my student's sports program.

For more information about Sudden Cardiac Arrest visit:

California Interscholastic Federation
http://www.cifstate.org

Eric Paredes Save A Life Foundation
http://www.epsavealife.org

National Federation of High Schools
(20-minute training video)
https://nfhslearn.com/courses/61032

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

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/