Jenks. Public Schools. of the Trojans. 205 East B Street Jenks, OK (918)

Transcription

1 Jenks Sports Medicine Jenks Public Schools 205 East B Street Jenks, OK (918) Home of the Trojans Herb Rhea, ATC

2 Athlete Participation Packet Quick Notes You, the parent, should keep and read: FRONT PAGE STUDENT ALCOHOL AND DRUG TESTING POLICY FOR PARTICIPANTS IN EXTRACURRICULAR ACTIVITIES AND/OR PARKING ON SCHOOL DISTRICT PROPERTY CONCUSSIONS and HEAD INJURIES JENKS SPORTS MEDICINE Athlete, Parent, Coach Concussion Information Sheet Oklahoma State Law requires more education to be given concerning concussions. Please refer to the Jenks Sports Medicine Concussion Fact Sheet. You, the parent, should fill out, have athlete sign, date and return: Starting with the OSSAA Physical / Vision and History Form, the remaining pages should be returned to the Jenks High School Athletic Trainer. If you choose to use your personal physician for the physical, the OSSAA Form MUST BE USED. Make a copy after the exam for your records and return the original to the Jenks HS Athletic Trainer. After completing all forms, please make sure the athlete and parent have signed every signature line. If not signed, the page will be returned for a signature. If an injury were to occur to your son or daughter, please contact Herb Rhea, Jenks HS Athletic Trainer, at the RL Sharp Center 2nd Floor. Treatments are available Monday - Friday from 7:00-7:45 AM. His phone number is ext 2338 or herb.rhea@jenksps.org. If we can be of any further assistance, please contact us. Sincerely, Herb Rhea ATC Nancy Grable ATHLETE PARTICIPATION PACKET CHECK LIST (Some items to double check) ONLY USE BLACK or BLUE INK. Thank you! OSSAA Physical / Vision - Fill out top part of page before exam. OSSAA History - Fill out before visiting doctor. BOTH athlete and parent/guardian must sign and date. Emergency Information - If your child were hurt, who would we contact? Circle DO or DO NOT for consent to treat your child. Student Insurance - Please check the appropriate space and BOTH athlete and parent/guardian sign. Consent For Transportation - List athlete s name and BOTH athlete and parent/guardian fill out. Concussion and Head Injury Acknowledgement - Read, BOTH athlete and parent/guardian sign, and date. Extracurricular Activities Participant Alcohol and Illegal or Performance Enhancing Drugs Contract - Read, BOTH student and parent/guardian sign, and date.

3 Jenks School District Student Alcohol and Drug Testing Policy for Participants in Extracurricular Activities STUDENT ALCOHOL AND DRUG TESTING POLICY FOR PARTICIPANTS IN EXTRACURRICULAR ACTIVITIES AND/OR PARKING ON SCHOOL DISTRICT PROPERTY (See also Student Behavior Policy; Extracurricular Activities Contract; Student use of Alcohol, Illegal Drugs; Testing Students Alcohol, Illegal Substances) The Board of Education of the Jenks School District (the School District ), in order to protect the health and safety of students and to educate and direct students away from drug and alcohol use and abuse, adopts the following Policy for testing students for the use of illegal drugs, alcohol and performance enhancing drugs. This policy shall apply to students participating in extracurricular activities and/or students who apply for and are granted a parking permit to park on School District property. a. Statement of Purpose and Intent 1) It is the desire of the Board of Education, administration and staff that every student in the School District refrains from using or possessing alcohol and illegal or performance enhancing drugs. Therefore, except as provided below, the sanctions of this Policy shall relate solely to limiting the opportunity of any student determined to be in violation of this Policy to participate in extracurricular activities and/or park on School District property. This Policy is intended to supplement and complement all other policies, rules and regulations of the School District regarding possession or use of alcohol and illegal or performance enhancing drugs. 2) Participation in school-sponsored extracurricular activities is a privilege, not a right. Students who participate in these activities are respected by the student body and are expected to conduct themselves as good examples of behavior, sportsmanship and training. Accordingly, students who participate in extracurricular activities carry a responsibility to themselves, their fellow students, their parents and their school to set the highest possible example of conduct, which includes avoiding the use or possession of alcohol and illegal or performance enhancing drugs. 3) The purpose of this Policy is to prevent alcohol and illegal or performance enhancing drug use, to educate students as to the serious physical, mental and emotional harm caused by alcohol and illegal or performance enhancing drug use, to alert students who have possible substance abuse problems to the potential harms of use, to prevent injury, illness and harm as a result of alcohol and illegal or performance enhancing drug use, and to strive within the School District for an environment free of alcohol and illegal or performance enhancing drug possession or use. This policy is not intended to be disciplinary or punitive in nature. The sanctions of this policy relate solely to limiting the opportunity of students to participate in extracurricular activities or to park on campus when they are found to be in violation of this policy. There will be no academic sanction solely for a violation of this policy. Notwithstanding the foregoing, a student may be disciplined, including suspended out of school, if a violation of this policy also results in a violation of the School District s Student Behavior Policy b. Definitions 1) Extracurricular means any School District sponsored team, club, organization or activity in which student participation is voluntary and in which students represent the School District in competitions. 2) Student extracurricular activities participant means any student participating in any competitive extracurricular activity. 3) Student Athlete means a 7th-12th grade member of any School District sponsored interscholastic sports team, including athletes, cheerleaders, and pom participants. 4) Coach/Sponsor means any person employed by the School District to coach athletic teams of the School District, to act as a sponsor or coach of a cheerleader team of the School District, or to serve as sponsor for any other extracurricular activity. 5) Athletics and athletic activity means participation by a student athlete on any athletic team, cheerleader team or pom team sponsored by the School District. 6) In-season means anytime during the day, night, weekends or holidays, including all time in and away from school during the entire school year for all student extracurricular activities participants. 7) Permit Holder means a student who currently holds a permit to park on School District property. 8) Alcohol means ethyl alcohol or ethanol and any alcoholic beverage and includes low-point beer as defined by Oklahoma law. 9) Illegal drugs means any substance which an individual may not sell, possess, use, distribute or purchase under either federal or Oklahoma law. Illegal drugs includes, but is not limited to, all scheduled drugs as defined by the Oklahoma Uniform Controlled Dangerous Substance Act, all prescription drugs obtained without authorization and all prescribed and over-the-counter drugs being used for an abusive purpose, and paraphernalia to use such drugs. 10) Performance enhancing drugs include anabolic steroids and any other natural or synthetic substance used to increase muscle mass, strength, endurance, speed or other athletic ability. The term performance enhancing drugs does not include dietary or nutritional supplements such as vitamins, minerals and proteins that can be lawfully purchased in over-the-counter transactions. 11) Drug or alcohol use test means a chemical test administered for the purpose of determining the presence or absence of alcohol or illegal or performance enhancing chemical substances or their metabolites in a student s blood, bodily tissue, fluids, products, urine, breath or hair. 12) Random selection basis means a mechanism for selecting student extracurricular activities participants for drug and/or alcohol use testing that: a. results in an equal probability that any student extracurricular activity participant from a group of student extracurricular activity participants subject to the selection mechanism will be selected, and b. does not give the School District discretion to waive the selection of any student extracurricular activity participant selected under the mechanism. 13) Positive when referring to an alcohol or drug use test administered under this Policy means a toxicological test result which is considered to demonstrate the presence of alcohol or an illegal or a performance enhancing drug or the metabolites thereof using the standards customarily established by the testing laboratory administering the drug or alcohol use test. 14) Reasonable suspicion means a suspicion based on specific personal observations concerning the appearance, speech or behavior of a student extracurricular activity participants and reasonable inferences drawn from those observations in the light of experience. Information provided by a reliable source, if based on personal knowledge, shall constitute reasonable suspicion. In the context of performance enhancing drugs, reasonable suspicion specifically includes unusual increases in size, strength, weight or other athletic abilities. 15) Games/competitions mean regular season, tournament and playoff games/competitions and do not include practice games and scrimmages. 16) School Day(s) means a day when school is in session and students are required to report to school. By way of example only and not as a limitation, school days does not include snow days, holidays, or parent-teacher conference days. 17) School District Property means any property owned by or under the control of the School District. c. Participation Extracurricular Activities 1) Alcohol and illegal or performance enhancing drug possession or use is incompatible with participation in extracurricular activities on behalf of the School District. For the safety, health and well being of the student extracurricular activity participants of the School District, the School District has adopted this Policy for use by all participating students at the 7th-12th grade level. Any student found to be in possession of, or having used alcohol or illegal or performance enhancing drugs, either by observation or drug or alcohol use test, will be considered to have violated this Policy. 2) Each student extracurricular activity participant shall be provided with a copy of this Policy via the Student/Parent Handbook and the Student Extracurricular Activity Participant Alcohol and Illegal or Performance Enhancing Drugs Contract (the Extracurricular Activities Contract ), which shall be read, signed and dated by the student, parent or custodial guardian and a coach/ sponsor before such student shall be eligible to practice or participate in any extracurricular activity. No student shall be allowed to practice or participate in any extracurricular activity unless the student has returned the properly signed Extracurricular Activities Contract. 3) The principal and sponsor, or, in the case of student athletes only, the athletic director or designee and applicable coach, shall be responsible for determining whether a violation of this Policy has occurred when an observation of possession or use of alcohol or illegal drug by a student extracurricular activity participant has been reported. If a violation of the Policy is determined to have occurred by a student extracurricular activities participant other than a student athlete, a principal will contact the student, the sponsor, and the parent or custodial guardian of the student and schedule a conference. If a violation of the Policy is determined to have occurred by a student athlete, the athletic director or designee will contact the student, the sponsor or head coach, the applicable principal, and the parent or custodial guardian of the student and schedule a conference. At the conference, the violation of the Policy will be described and the restrictions explained. 4) The Extracurricular Activities Contract for alcohol and illegal or performance enhancing drug and/or alcohol use testing shall be to provide a urine sample for student athletes, as part of the annual physical examination. The School District will set a fee charge to be collected from each student when the Extracurricular Activities Contract is signed and returned to the coach. Student athletes who have physical examinations performed by their personal physicians must nonetheless sign the Extracurricular Activities Contract and comply with all Policy requirements. For all student extracurricular activity participants, tests will be done as chosen by the random selection basis; or at any time a student extracurricular activities participant is requested by the principal, athletic director, athletic trainer or by the sponsor or coach, based on reasonable suspicion (See Policy for Testing Students with regard to the use of Alcohol and Illegal Chemical Substances), to be tested for alcohol and illegal or performance enhancing drugs. 5) Drug and/or alcohol use testing for student extracurricular activities participants will be chosen on a random selection basis weekly from all student participants. The School District will determine a weekly number of student names to be drawn at random to provide a urine sample for drug and/or alcohol use testing for alcohol and/or illegal or performance enhancing drugs. 6) In addition to the drug and alcohol use tests required above, any student extracurricular activities participant may be required to submit to a drug and/or alcohol use test for alcohol or illegal or performance enhancing drugs or the metabolites thereof at any time upon reasonable suspicion.

4 d. Testing Procedures 1) Any alcohol or drug use test required by the School District under the terms of this Policy will be administered by or at the direction of a professional laboratory chosen by the School District using scientifically validated toxicological methods. The professional laboratory shall be required to have detailed written specifications to assure chain of custody of the specimens, proper laboratory control and scientific testing. 2) All aspects of the alcohol or drug use testing program, including the taking of specimens, will be conducted so as to safeguard the personal and privacy rights of the student to the maximum degree possible. The test specimen shall be obtained in a manner designed to minimize intrusiveness of the procedure. In particular, the specimen must be collected in a restroom or other private facility behind a closed stall. The principal, athletic director, or athletic trainer shall designate a sponsor or coach or other adult person of the same sex as the student to accompany the student to a restroom or other private facility behind a closed stall. The monitor shall not observe the student while the specimen is being produced, but the monitor shall be present outside the stall to listen for the normal sounds of urination in order to guard against tampered specimens and to insure an accurate chain of custody. The monitor shall verify the normal warmth and appearance of the specimen. If at any time during the testing procedure the monitor has reason to believe or suspect that a student is tampering with the specimen, the monitor may stop the procedure and inform the principal, athletic director, or athletic trainer who will then determine if a new sample should be obtained. If a student is determined to have tampered with any specimen or otherwise engaged in any conduct that disrupts the testing process of any student, then the student will be deemed to have committed a second offense under this Policy and the sanctions for a second offense will be imposed. The monitor shall give each student a form on which the student may list any medications he/she has taken or any other legitimate reasons for having been in contact with illegal drugs or performance enhancing drugs in the preceding thirty (30) days. The medication list may be submitted to the lab in a sealed and confidential envelope. 3) If an initial drug use test is positive, the initial test result will be subject to confirmation by a second and different test of the same specimen. The second test will use the gas chromatography/mass spectrometry technique. A specimen shall not be reported positive unless the second test utilizing the gas chromatography/mass spectrometry procedure is positive for the presence of an illegal drug or performance enhancing drug or the metabolites thereof. If an initial alcohol use test is positive for the presence of alcohol, the initial test result will be subject to confirmation by a second test using any scientifically accepted method. The unused portion, if any, of a specimen that tested positive for alcohol or illegal or performance enhancing drugs shall be preserved by the laboratory for a period of six (6) months. 4) If the alcohol or drug use test for any student has a positive result, the laboratory will contact the principal or the athletic director with the results. In the case of student extracurricular activities participants who are not athletes, a principal will contact the student, the sponsor, and the parent or custodial guardian of the student and schedule a conference. In the case of student athletes, the athletic director or athletic trainer will contact the student, the sponsor or head coach, the applicable principal, and the parent or custodial guardian of the student and schedule a conference. In the case of Permit Holders, a principal will contact the student and the parent or custodial guardian of the student and schedule a conference. 5) At the conference, a principal or the athletic director or designee will solicit any explanation for the positive result and ask for doctor prescriptions of any drugs that the student was taking that might have affected the outcome of the alcohol or drug use test. If the student and his/her parent or custodial guardian desires another test of the remaining portion, if any, of the specimen, the principal, athletic director, or athletic trainer will arrange for another test at the same laboratory or at another laboratory agreeable to the principal or athletic director or designee. Any such re-test shall be at the expense of the student and his/her parent or custodial guardian. 6) If the student asserts that the positive test results are caused by other than consumption of alcohol or an illegal or performance enhancing drug by the student, then the student will be given an opportunity to present evidence of such to the principal or to the athletic director. The School District will rely on the opinion of the original laboratory that performed the test in determining whether the positive test result was produced by other than consumption of alcohol or an illegal or performance enhancing drug. 7) A student who has been determined by the appropriate school administrator to be in violation of this Policy shall have the right to appeal the decision to the superintendent or the superintendent s designee(s). Such appeal must be lodged within five (5) business days of notice of the initial report of the offense, during which time the student will remain ineligible to participate in any extracurricular activities and/or park on School District property. The superintendent or designee(s) shall then determine whether the original finding was justified. There is no further appeal right from the superintendent s decision and such decision shall be conclusive in all respects. Any necessary interpretation or application of this Policy shall be the sole and exclusive judgment and discretion of the superintendent, which shall be final and non-appealable. 8) Before a student who has tested positive in an alcohol or drug use test may rejoin his/her extracurricular activity and/or park on School District property after a first or second offense, such student may be required to undergo one or more additional alcohol or drug use tests to determine whether the student is no longer using alcohol or illegal or performance enhancing drugs. The School District will rely on the opinion of the laboratory that performed or analyzed the additional alcohol or drug use test in determining whether a positive result in the additional alcohol or drug use test was produced by alcohol or illegal or performance enhancing drugs used by the student before the offense or by more recent use. 9) All documents created pursuant to this Policy with regard to any student will be kept in a confidential folder and will never be made a part of the student s cumulative folder nor be considered a disciplinary record. e. Violations 1) Any student who is determined by observation or by alcohol or drug use tests to have violated this Policy shall be subject to the loss of the privilege to participate in extracurricular activities and/or loss of the privilege to park on School District property. Such student shall be offered educational and support assistance to stop using alcohol or illegal or performance enhancing drugs. 2) First Offense: Athletes: Suspension from participation in all scheduled extracurricular activities (including all meetings, practices, performances and games/ competitions) and suspension of the parking permit for 30 school days, which may be reduced by 15 school days (five school days reduced for professional drug/ alcohol evaluation/assessment and ten school days reduced for participating in and successfully completing at least four (4) hours of substance abuse education/ counseling provided by the School District or an outside agency). A student athlete participant must miss a minimum of 40% of the allowable number of regular season contests allowed by the Oklahoma Secondary Schools Activities Association (OSSAA) which may be reduced to 20% upon completion of the assessment and substance abuse education counseling. If the student is not competing in an athletic activity during any suspension period due to injury, academic ineligibility or the games or competitions for that sport are finished or have not begun for that school year and, therefore, does not miss a minimum of 40% of the games/competitions during the suspension period, then the student will be required to miss a minimum of 40% of the games/ competitions after he or she returns from the injury, becomes eligible or the games or competitions resume in the following school year or begin later in the same school year. These restrictions and requirements shall begin immediately following the determination of an observed violation or the reporting of the results of a positive alcohol or drug use test. Such suspension will extend into a succeeding competition season if necessary to fulfill the suspension. All other extracurricular participants will face participation restrictions as determined by the administrator, related to the event/contest schedule of that particular activity and/or suspension of the parking permit for 30 school days. 3) Second Offense: Complete suspension from participation in all extracurricular activities including all meetings, practices, performances and competition and/ or suspension of the parking permit for eighteen (18) continuous and successive school weeks from the date of the determination of a violation or the reporting of the results of a positive alcohol or drug use test under this Policy. Such suspension will extend into a succeeding school year if necessary to fulfill the suspension. Offenses occurring during the seventh and eighth (7-8) grades shall be cumulative for the duration of the student s middle school career. Offenses occurring in grades nine through twelve (9-12) shall be cumulative throughout the student s high school career. Athletes will be required to miss a minimum of 40% of regular season contests, whenever scheduled. 4) Self-Reporting: As an option to the consequences for a first offense only, a student may self-report to the principal, athletic director, athletic trainer or to a coach or sponsor before being notified of a Policy violation or prior to being asked or required to submit to an alcohol or drug use test. A student who self-refers will be allowed to remain active in all extracurricular activities and retain his or her parking permit after the following conditions have been fulfilled: a conference has been held with the student, the principal, athletic director, athletic trainer, the sponsor or coach, and the parent or custodial guardian of the student to discuss the Policy violation; an alcohol or drug use test is provided by the student that is not positive, and a participation commitment by the student and parent for four (4) hours of substance abuse education/counseling provided by the school or an outside agency. Documentation of successful completion of this commitment must be provided to the principal, athletic director or athletic trainer by the student or parent. A student who self-refers will, however, be considered to have committed his/her first offense under this Policy. A self-referral may be used only once in a student s time in the School District. f. Refusal to submit to alcohol or drug use test If a student refuses to submit to an alcohol or drug use test authorized under this Policy, such student shall not be eligible to participate in any extracurricular activities including all meetings, practice, performances and competition, or park on campus for eighteen (18) continuous and successive school weeks. Athletes will be required to miss a minimum of 40% of regular season contests, whenever scheduled. Such suspension will extend into a succeeding school year if necessary to fulfill the suspension. Please read this Policy in its entirety before signing the Student Alcohol and Drug Testing Policy for Participants in Extracurricular Activities.

5 Concussions and Head Injuries The Jenks Board of Education recognizes concussions and head injuries may result from contact sports and can have serious consequences if not properly evaluated and treated. Therefore, consistent with state law, the District will inform and educate student-athletes and their parents/legal guardians of the nature and risk of concussions or head injuries, including dangers associated with continuing to play after a concussion or head injury through this policy and the distribution of associated informational sheets and forms. After suffering a concussion, a student-athlete s physical and cognitive activities should be carefully managed and monitored by the licensed healthcare professional. Pursuant to Oklahoma Statute Section of Title 70, any student-athlete removed from participation shall not be allowed to participate in practices or competition until he/she is evaluated by a licensed healthcare provider and received the provider s written release to return to participation, a copy of which shall be provided to the District. The Jenks Board of Education has defined a licensed healthcare provider as follows: M.D. medical doctor; D.O. doctor of osteopathy. On an annual basis and prior to a student athlete s participation in any athletic practices or competitions, a concussion and head injury information sheet will be distributed to the student-athlete and their parent/legal guardian. Attached to the information sheet shall be an acknowledgement form which the student-athlete and their parent/legal guardian must sign to verify they have read the information sheets and understand the content and warnings. Completed acknowledgement forms shall be returned to the Jenks Coordinator of Sports Medicine prior to the student-athlete s participation in practice or competition during the school year. The student-athlete may not practice or compete until the form has been returned. If the District s coaching personnel suspect that a student-athlete has sustained a concussion or head injury during practice or competition, the coach shall immediately remove that student-athlete from participation and direct the student-athlete to obtain a physical and mental status examination by a licensed health care provider selected by the student-athlete s parent/legal guardian. The licensed healthcare provider must be trained in the evaluation and management of concussions. The District shall not be financially responsible for any healthcare bills associated with the examination For more information, see the next page.

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7 Student fill out top two lines. OKLAHOMA SECONDARY SCHOOLS ACTIVITIES ASSOCIATION (OSSAA) PREPARTICIPATION PHYSICAL EVALUATION Student Name Last First Middle Initial Student ID # Date of Birth Circle Incoming Grade Do NOT write below this line = Physician or Nurse Use Only Date of Exam Height Weight Pulse BP / ( / ) ( / ) Initial BP Post Exercise 5 min. Post Ex. Vision: R20/ L 20/ Corrected Y N Glasses Contacts Pupils: Equal Unequal MEDICAL Normal Abnormal Findings Appearance Eyes/Ears/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (male only) Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot CLEARANCE ( ) Cleared ( ) Cleared after completing evaluation/rehabilitation for: ( ) Not cleared for: Reason: Recommendations: Name & Title of Examiner (Print/Type) Date Address Phone Signature of Examiner

8 OKLAHOMA SECONDARY SCHOOLS ACTIVITIES ASSOCIATION (OSSAA) PHYSICAL EXAMINATION AND PARENTAL CONSENT FORM PLEASE PRINT IN BLACK or BLUE INK Date Name ID# Sex Age Date of Birth Last First Middle Initial Circle Grade JPS Team(s) participating on: Address City Phone Personal Physician Phone In case of emergency, contact: Name Relationship Phone -Home Work Explain Yes answers below, Circle questions you don t know the answers to. YES NO Cell The information below is correct to the best of my knowledge. I hereby give my informed consent for the above-mentioned student to participate in activities. I understand the risk of injury in athletic participation. If my son/daughter becomes ill or is injured, necessary medical care can be instituted by Physicians, Athletic Trainer, Coaches or other personnel properly trained. Signature of athlete Date Signature of parent/guardian Date 1 Have you had a medical illness or injury since your last check up or sports physical? Do you have an ongoing or chronic illness? 2 Have you ever been hospitalized overnight? Have you ever had surgery? 3 Are you currently taking any prescription or nonprescription (overthe-counter) medications or pills or using an inhaler? Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance 4 Do you have any allergies (i.e. pollen, medicine, food or stinging insects)? Have you ever had a rash or hives develop during or after exercise? 5 Have you ever passed out during or after exercise? Have you ever been dizzy during or after exercise? Have you ever had chest pain during or after exercise? Do you get tired more quickly than your friends do during exercise? Have you ever had racing of your heart or skipped heartbeats? Have you had high blood pressure or high cholesterol? Have you ever been told you have a heart murmur? Has any family member or relative died of heart problems or of sudden death before age 50? Have you had a severe viral infection (i.e. mononucleosis or myocarditis) within the last month? Has a physician ever denied or restricted your participation in sports for any heart problems? 6 Do you have any current skin problems (i.e. itching, rashes, acne, warts, fungus or blisters)? 7 Have you ever had a head injury or concussion? Have you ever been knocked out, become unconscious or lost your memory? Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in your arms, hands, legs or feet 8 Have you ever become ill from exercising in the heat? 9 Do you cough, wheeze or have trouble breathing during or after activity? Do you have asthma? Do you have seasonal allergies that require medical treatment? 10 Do you use any special protective or corrective equipment or devices that aren t usually used for your sport or position (i.e. knee brace, special neck roll, foot orthotics, retainer on your teeth or hearing aid)? 11 Have you had any problems with your eyes or vision? Do you wear glasses, contacts or protective eyewear? 12 Have you ever had a sprain, strain or swelling after injury? Have you broken or fractured any bones or dislocated any joints? Have you had any other problems with pain or swelling in muscles, tendons, bones or joints? YES NO If yes, check appropriate box and explain below. Head Elbow Hip Neck Forearm Thigh Back Wrist Knee Chest Hand Shin-calf Shoulder Finger Ankle Upper arm Foot 13 Do you want to weight more or less than you do now? Do you lose weight regularly to meet weight requirements for your sport? 14 Do you feel stressed out? 15 Record the dates of your most recent immunizations (shots) for Tetanus Measles Hepatitis Chickenpox Explain Yes answers here:

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11 Jenks Public Schools Concussion and Head Injury Acknowledgement In compliance with Oklahoma Statute Section of Title 70, the purpose of this form is to confirm you have read and understand the CONCUSSION FACT SHEET provided to you by Jenks Public Schools. The CONCUSSION FACT SHEET is designed to educate parents/legal guardians and student-athletes about potential concussions and head injuries occurring during participation in athletics. I,, have read the CONCUSSION FACT SHEET and understand (Print name of student-athlete) the content, as well as the warnings about potential concussions and head injuries. I,, have read the CONCUSSION FACT SHEET and understand (Print name of parent/legal guardian) the content, as well as the warnings about potential concussions and head injuries. Signature of Student-Athlete Date Grade Student ID# Signature of Parent/Legal Guardian Date This form should be completed annually prior to the student- athlete s first practice and/or competition and be maintained for one year beyond the date of signature in the Athletic Department.

12 Jenks School District Student Extracurricular Activities Participant Alcohol and Illegal or Performance Enhancing Drugs Contract School Year STATEMENT OF PURPOSE AND INTENT: Participation in school sponsored extracurricular activities at the Jenks School District is a privilege and not a right. Such privilege is governed by the Jenks School District Policy on Alcohol and Drug Testing of Students Participating in Extracurricular Activities and/or Parking on School District Property (the Policy ). This policy is found in the Jenks Policies and Procedures Handbook and the Student/Parent Handbook. Alcohol and illegal or performance enhancing drug use of any kind is incompatible with participation in extracurricular activities on behalf of the Jenks School District. Students who participate in activities are respected by the student body and are expected to hold themselves as good examples of conduct, sportsmanship and training. Accordingly, student extracurricular activities participants carry a responsibility to themselves, their fellow students, their parents and their school to set the highest possible examples of conduct, which includes avoiding the use or possession of alcohol or illegal or performance enhancing drugs. PARTICIPATION IN EXTRACURRICULAR ACTIVITIES: For the safety, health and well-being of the students of the Jenks School District, the Jenks School District has adopted the Policy and this Student Extracurricular Activities Participant Alcohol and Illegal or Performance Enhancing Drugs Contract (the Extracurricular Activities Contract ) which shall be read, signed and dated by the student, parent or custodial guardian and sponsor or coach before such student shall be eligible to practice or participate in any extracurricular activity. No student shall be allowed to practice or participate in any extracurricular activity unless the student has returned the properly signed Extracurricular Activities Contract. STUDENT: I understand after having read the Policy and this Extracurricular Activities Contract that, out of care for my safety and health, the Jenks School District enforces the rules applying to the consumption or possession of alcohol and illegal or performance enhancing drugs. As a student extracurricular activities participant, I realize that the personal decision that I make daily in regard to the consumption or possession of alcohol and illegal or performance enhancing drugs may affect my health and well-being as well as the possible endangerment of those around me and reflect upon any organization with which I am associated. If I choose to violate the Policy regarding the use or possession of alcohol and illegal or performance enhancing drugs any time during the school year, I understand upon determination of that violation I will be subject to the restrictions of my participation as outlined in the Policy. Please Print using BLACK or BLUE INK. Thank You! PRINT STUDENT Last Name First Name Middle Student Signature Date Student ID # Circle Grade Date of Birth PARENT(s): We have read and understand the Policy and this Extracurricular Activities Contract. We desire that the student named above participate in the extracurricular activities of the Jenks School District and we hereby agree to abide by all provisions of the Jenks School District s Policy. We accept and consent to the method of obtaining urine samples, testing and analyses of such specimens, and all other aspects of the program. We agree to cooperate in furnishing urine specimens that may be required from time to time. We further agree and consent to the disclosure of the sampling, testing and results as provided for in this program. This consent is given pursuant to all State and Federal Privacy Statutes and is a waiver of rights to non-disclosure of such test records and results only to the extent of the disclosures authorized in the program. Please Print using BLACK or BLUE INK. Thank You! PRINT Parent / Custodian Guardian Name Parent / Custodian Guardian Signature Date (If the STUDENT ATHLETE is 18 years or older, he/she must also sign at this line in addition to the line above.) BELOW PLEASE OBTAIN THE SIGNATURE OF ANY SPONSOR OR COACH OF AN EXTRACURRICULAR ACTIVITY IN WHICH YOU ARE INVOLVED: Signature of Sponsor / Coach Team / Extracurricular Activity