We are looking forward to you participating in the athletic program at Mitchell Community Schools.

Dear Athlete and Parent/Guardian, We are looking forward to you participating in the athletic program at Mitchell Community Schools. Before an athlete is eligible to participate in ANY conditioning, open gym, try-out or practices you will need to read this packet thoroughly and sign and return all of the appropriate pages. T he IHSAA physical and insurance information will need to be turned into the office, athletic trainer, or your athlete s coach. Reminder that an athlete must have health insurance to participate in athletics at Mitchell Community Schools. Please include the name and policy number the student is covered under on the appropriate IHSAA form. It is an Indiana High School Athletic Association (IHSSA) guideline that all athletes receive a pre-participation examination. The goal of this preparticipation exam is to provide a screening test to ensure our athletes are not at an increased risk for injury or illness while participating in athletic practices or competitions. However, these examinations are not designed to replace the athlete s annual full physical examination. We strongly encourage you to continue annual health maintenance examinations with your pediatrician or family physician, as well as any follow up for any problem that might have been found on the screening exam. Physicals must be dated after April 1, 2018 to participate in any sports related event after the end of the 2017-18 school year. Physicals may be signed by a physician (holding an unlimited license to practice medicine), a nurse practitioner, or a physician assistant. This packet also includes information about the Indiana State Laws (IC 20-34-7 and IC 20-34-8) requiring athletes and parents acknowledge in writing that they have received information related to concussion and sudden cardiac arrest. Lastly, there is a consent for healthcare procedures and consent to receive and release protected information so that athletes can receive treatment deemed necessary by the athletic trainer and to facilitate proper communication between athletic trainer, other healthcare providers, and coaches. We appreciate your cooperation in helping to ensure the health and safety of our student-athletes. We look forward to another great year of athletics at Mitchell Community Schools. Sincerely, Danny Reynolds Athletic Director Mitchell High School reynoldsda@mitchell.k12.in.us Kelsey Lepore Athletic Trainer Mitchell Community Schools leporek@mitchell.k12.in.us

https://www.cdc.gov/headsup/pdfs/highschoolsports/athletes_fact_sheet-a.pdf https://www.cdc.gov/headsup/pdfs/highschoolsports/parents_fact_sheet-a.pdf http://www.doe.in.gov/sites/default/files/health/sudden-cardiac-arrest-fact-sheet-student-athletes. pdf http://www.doe.in.gov/sites/default/files/health/sudden-cardiac-arrest-fact-sheet-parents.pdf https://drive.google.com/open?id=1bcry9uir1j63w-fnncv61mnazbywzankwrijbsx-u2c https://drive.google.com/open?id=1us3jganuxfwo0qhuboze2brsq4skujhaibsyqcvykrq

A Fact Sheet for HIGH SCHOOL ATHLETES WHAT IS A CONCUSSION? A concussion is a brain injury that affects how your brain works. It can happen when your brain gets bounced around in your skull after a fall or hit to the head. This sheet has information to help you protect yourself from concussion or other serious brain injury and know what to do if a concussion occurs. WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? GET CHECKED OUT. If you think you have a concussion, do not return to play on the day of the injury. Only a health care provider can tell if you have a concussion and when it is OK to return to school and play. The sooner you get checked out, the sooner you may be able to safely return to play. REPORT IT. Tell your coach, parent, and athletic trainer if you think you or one of your teammates may have a concussion. It s up to you to report your symptoms. Your coach and team are relying on you. Plus, you won t play your best if you are not feeling well. GIVE YOUR BRAIN TIME TO HEAL. A concussion can make everyday activities, such as going to school, harder. You may need extra help getting back to your normal activities. Be sure to update your parents and doctor about how you are feeling. WHY SHOULD I TELL MY COACH AND PARENT ABOUT MY SYMPTOMS? Playing or practicing with a concussion is dangerous and can lead to a longer recovery. While your brain is still healing, you are much more likely to have another concussion. This can put you at risk for a more serious injury to your brain and can even be fatal. GOOD TEAMMATES KNOW: IT S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON.

HOW CAN I TELL IF I HAVE A CONCUSSION? You may have a concussion if you have any of these symptoms after a bump, blow, or jolt to the head or body: HOW CAN I HELP MY TEAM? Get a headache Feel dizzy, sluggish or foggy Be bothered by light or noise Have double or blurry vision Vomit or feel sick to your stomach PROTECT YOUR BRAIN. Avoid hits to the head and follow the rules for safe and fair play to lower your chances of getting a concussion. Ask your coaches for more tips. Have trouble focusing or problems remembering Feel more emotional or down Feel confused Have problems with sleep BE A TEAM PLAYER. You play an important role as part of a team. Encourage your teammates to report their symptoms and help them feel comfortable taking the time they need to get better. Concussion symptoms usually show up right away, but you might not notice that something isn t right for hours or days. A concussion feels different to each person, so it is important to tell your parents and doctor how you are feeling. The information provided in this document or through linkages to other sites is not a substitute for medical or professional care. Questions about diagnosis and treatment for concussion should be directed to a physician or other health care provider. To learn more, go to www.cdc.gov/headsup

A Fact Sheet for HIGH SCHOOL PARENTS This sheet has information to help protect your teens from concussion or other serious brain injury. What Is a Concussion? A concussion is a type of traumatic brain injury or TBI caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move quickly back and forth. This fast movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging the brain cells. How Can I Help Keep My Teens Safe? Sports are a great way for teens to stay healthy and can help them do well in school. To help lower your teens chances of getting a concussion or other serious brain injury, you should: Help create a culture of safety for the team. Work with their coach to teach ways to lower the chances of getting a concussion. Emphasize the importance of reporting concussions and taking time to recover from one. Ensure that they follow their coach s rules for safety and the rules of the sport. Tell your teens that you expect them to practice good sportsmanship at all times. When appropriate for the sport or activity, teach your teens that they must wear a helmet to lower the chances of the most serious types of brain or head injury. There is no concussion-proof helmet. Even with a helmet, it is important for teens to avoid hits to the head. How Can I Spot a Possible Concussion? Teens who show or report one or more of the signs and symptoms listed below or simply say they just don t feel right after a bump, blow, or jolt to the head or body may have a concussion or other serious brain injury. Signs Observed by Parents Appears dazed or stunned. Forgets an instruction, is confused about an assignment or position, or is unsure of the game, score, or opponent. Moves clumsily. Answers questions slowly. Loses consciousness (even briefly). Shows mood, behavior, or personality changes. Can t recall events prior to or after a hit or fall. Symptoms Reported by Teens Headache or pressure in head. Nausea or vomiting. Balance problems or dizziness, or double or blurry vision. Bothered by light or noise. Feeling sluggish, hazy, foggy, or groggy. Confusion, or concentration or memory problems. Just not feeling right, or feeling down. Talk with your teens about concussion. Tell them to report their concussion symptoms to you and their coach right away. Some teens think concussions aren t serious or worry that if they report a concussion they will lose their position on the team or look weak. Remind them that it s better to miss one game than the whole season. GOOD TEAMMATES KNOW: IT S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON.

Concussions affect each teen differently. While most teens with a concussion feel better within a couple of weeks, some will have symptoms for months or longer. Talk with your teens health care provider if their concussion symptoms do not go away or if they get worse after they return to their regular activities. Plan ahead. What do you want your teen to know about concussion? What Are Some More Serious Danger Signs to Look Out For? In rare cases, a dangerous collection of blood (hematoma) may form on the brain after a bump, blow, or jolt to the head or body and can squeeze the brain against the skull. Call 9-1-1 or take your teen to the emergency department right away if, after a bump, blow, or jolt to the head or body, he or she has one or more of these danger signs: One pupil larger than the other. Drowsiness or inability to wake up. A headache that gets worse and does not go away. Slurred speech, weakness, numbness, or decreased coordination. Repeated vomiting or nausea, convulsions or seizures (shaking or twitching). Unusual behavior, increased confusion, restlessness, or agitation. Loss of consciousness (passed out/knocked out). Even a brief loss of consciousness should be taken seriously. You can also download the CDC HEADS UP app to get concussion information at your fingertips. Just scan the QR code pictured at left with your smartphone. What Should I Do If My Teen Has a Possible Concussion? As a parent, if you think your teen may have a concussion, you should: 1. Remove your teen from play. 2. Keep your teen out of play the day of the injury. Your teen should be seen by a health care provider and only return to play with permission from a health care provider who is experienced in evaluating for concussion. 3. Ask your teen s health care provider for written instructions on helping your teen return to school. You can give the instructions to your teen s school nurse and teacher(s) and return-to-play instructions to the coach and/or athletic trainer. Do not try to judge the severity of the injury yourself. Only a health care provider should assess a teen for a possible concussion. You may not know how serious the concussion is at first, and some symptoms may not show up for hours or days. A teen s return to school and sports should be a gradual process that is carefully managed and monitored by a health care provider. Teens who continue to play while having concussion symptoms or who return to play too soon while the brain is still healing have a greater chance of getting another concussion. A repeat concussion that occurs while the brain is still healing from the first injury can be very serious and can affect a teen for a lifetime. It can even be fatal. Revised 12/2015 To learn more, go to www.cdc.gov/headsup

SUDDEN CARDIAC ARREST A Fact Sheet for Parents FACTS Sudden cardiac arrest is a rare, but tragic event that claims the lives of approximately 500 athletes each year in the United States. Sudden cardiac arrest can affect all levels of athletes, in all sports, and in all age levels. The majority of cardiac arrests are due to congenital (inherited) heart defects. However, sudden cardiac arrest can also occur after a person experiences an illness which has caused an inflammation to the heart or after a direct blow to the chest. WARNING SIGNS There may not be any noticeable symptoms before a person experiences loss of consciousness and a full cardiac arrest (no pulse and no breathing). Warning signs can include a complaint of: Chest Discomfort Unusual Shortness of Breath Racing or Irregular Heartbeat Fainting or Passing Out EMERGENCY SIGNS Call EMS (911) If a person experiences any of the following signs, call EMS (911) immediately: If an athlete collapses suddenly during competition If a blow to the chest from a ball, puck or another player precedes an athlete s complaints of any of the warning signs of sudden cardiac arrest If an athlete does not look or feel right and you are just not sure How can I help my child prevent a sudden cardiac arrest? Daily physical activity, proper nutrition, and adequate sleep are all important aspects of lifelong health. Additionally, parents can assist student athletes prevent a sudden cardiac arrest by: Ensuring your child knows about any family history of sudden cardiac arrest (onset of heart disease in a family member before the age of 50 or a sudden, unexplained death at an early age) Ensuring your child has a thorough preseason screening exam prior to participation in an organized athletic activity Asking if your school and the site of competition has an automatic defibrillator (AED) that is close by and properly maintained Learning CPR yourself Ensuring your child is not using any non-prescribed stimulants or performance enhancing drugs Being aware that the inappropriate use of prescription medications or energy drinks can increase risk Encouraging your child to be honest and report symptoms of chest discomfort, unusual shortness of breath, racing or irregular heartbeat, or feeling faint What should I do if I think my child has warning signs that may lead to sudden cardiac arrest? 1. Tell your child s coach about any previous events or family history 2. Keep your child out of play 3. Seek medical attention right away Developed and Reviewed by the Indiana Department of Education s Sudden Cardiac Arrest Advisory Board (1-7-15)

SUDDEN CARDIAC ARREST A Fact Sheet for Student Athletes FACTS Sudden cardiac arrest can occur even in athletes who are in peak shape. Approximately 500 deaths are attributed to sudden cardiac arrest in athletes each year in the United States. Sudden cardiac arrest can affect all levels of athletes, in all sports, and in all age levels. The majority of cardiac arrests are due to congenital (inherited) heart defects. However, sudden cardiac arrest can also occur after a person experiences an illness which has caused an inflammation to the heart or after a direct blow to the chest. Once a cardiac arrest occurs, there is very little time to save the athlete, so identifying those at risk before the arrest occurs is a key factor in prevention. WARNING SIGNS There may not be any noticeable symptoms before a person experiences loss of consciousness and a full cardiac arrest (no pulse and no breathing). Warning signs can include a complaint of: Chest Discomfort Unusual Shortness of Breath Racing or Irregular Heartbeat Fainting or Passing Out EMERGENCY SIGNS Call EMS (911) If a person experiences any of the following signs, call EMS (911) immediately: If an athlete collapses suddenly during competition If a blow to the chest from a ball, puck or another player precedes an athlete s complaints of any of the warning signs of sudden cardiac arrest If an athlete does not look or feel right and you are just not sure How can I help prevent a sudden cardiac arrest? Daily physical activity, proper nutrition, and adequate sleep are all important aspects of lifelong health. Additionally, you can assist by: Knowing if you have a family history of sudden cardiac arrest (onset of heart disease in a family member before the age of 50 or a sudden, unexplained death at an early age) Telling your health care provider during your pre-season physical about any unusual symptoms of chest discomfort, shortness of breath, racing or irregular heartbeat, or feeling faint, especially if you feel these symptoms with physical activity Taking only prescription drugs that are prescribed to you by your health care provider Being aware that the inappropriate use of prescription medications or energy drinks can increase your risk Being honest and reporting symptoms of chest discomfort, unusual shortness of breath, racing or irregular heartbeat, or feeling faint What should I do if I think I am developing warning signs that may lead to sudden cardiac arrest? 1. Tell an adult your parent or guardian, your coach, your athletic trainer or your school nurse 2. Get checked out by your health care provider 3. Take care of your heart 4. Remember that the most dangerous thing you can do is to do nothing Developed and Reviewed by the Indiana Department of Education s Sudden Cardiac Arrest Advisory Board (1-7-15)

Mitchell Community Schools Emergency Medical Information This document must be signed and returned to the athletic trainer or coach before a student athlete is allowed to participate in any athletic event at Mitchell Community Schools. Student s name DOB Age Male/Female Student s Current Physical Address: Street City State Zip Parent/Guardian *first call in case of emergency Parent/Guardian *second call in case of an emergency Name Relation to student Name Relation to student Phone # 1(cell/work/home) Phone #2 (cell/work/home) Phone # 1 (cell/work/home) Phone #2 (cell/work/home) Address *if different than athlete Address *if different than athlete City, State, Zip City, State, Zip Primary Medical Insurance Policy Number Student s Allergies Student s Medication Health Condition(s) the emergency medical staff should be aware of Preferred Hospital

Consent to Receive and Release Protected Information 2018-19 School Year I understand that the athletic trainer(s) and/or team physician(s) providing healthcare coverage on behalf of MCS may request protected information regarding the athlete s health status from another healthcare provider, and I hereby give my permission for the receipt and release of this protected information as it pertains to my child s ability to safely participate in school sponsored athletics and where their health and safety are a concern. The protected information may pertain to past and present health. Permission for a healthcare provider to release medical information and/or records to another healthcare provider is given to allow for timely treatment of my child should it be necessary. I also give my permission to release this information to coaches and other school officials in order to protect the health and safety of the athlete and to optimize the delivery of care. This information cannot and will not be released to an other parties without first being approved by the parent or guardian of the athlete. I understand that I have the right to revoke this consent at any time by informing the MHS athletic director, in writing, of my intent to do so and that in doing so the student-athlete may be declared ineligible to participate in athletics at MCS. In the event I revoke consent, it will not have any effect on actions taken by MCS or it s agents prior to the revocation. Consent for Healthcare Procedures 2018-19 School Year I hereby give consent for my child to receive healthcare treatment including but not limited to first aid, diagnostic procedures, injury assessment, rehabilitation, and other medical treatment that is deemed appropriate and necessary to the health and wellbeing of my child and provided by the athletic trainer(s), team physician(s) and/or emergency medical technicians providing coverage for MCS or the opposing team s school. I understand this does not prevent me from receiving healthcare from another provider of my choice. Additionally, I give permission for my child to be transported to the nearest and/or most appropriate emergency department based on local emergency medical services (EMS) protocols and to receive any and all treatments deemed necessary by the healthcare providers. I understand that with participation in athletics there comes an inherent risk of injury and that injury may range from minor sprains and strains to total paralysis and even death. Additionally, I understand that it is the responsibility of the athlete to report any and all health related conditions and any and all injuries and illnesses to the athletic trainer and the coach. I also understand that it is the responsibility of the athlete to report any problems or potential problems with protective equipment to the coach and athletic trainer(s) providing coverage for their sport at MCS. Fulfilling these responsibilities will help ensure the health and safety of the athlete as well as the health and safety of those they compete with and against. I further understand that it is important for the athlete to be an active participant in his/her own healthcare and to seek out information and ask questions about health issues they may experience or have questions/concerns about. I understand that I have the right to revoke the consent regarding the provision of healthcare procedure at any time by informing the MHS athletic director, in writing, of my intent to do so and that in doing so the student-athlete may be declared ineligible to participate in athletics at MCS. In the event I revoke consent, it will not have any effect on actions taken by MCS or its agents prior to the revocation. Consent page 1

Concussion Policy Summary After reading the Head s Up information sheet you can now better recognize the signs and symptoms of concussions. You have also read the state law pertaining to concussions. All MHS athletes participating in contact sports will be required to take a baseline concussion test called the ImPACT their 9th and 11th grade school years. It is highly recommended that athletes follow up with physicians who have been trained to administer and read the results of this test if/when an athlete has sustained a concussion. Athlete s that suspect a teammate has a concussion or exhibits concussion like symptoms, he/she should report it to a coach, athletic trainer(s), and/or team physician(s) providing coverage for MCS immediately. If an athlete has been removed from practice or competition after sustaining a concussion, the athlete must meet the following criteria prior to unrestricted activity and sports participation: rest and exertional symptoms have returned to baseline level, successfully complete a graduated re-integration of physical exertion program, and receive written clearance from a licensed healthcare provider preferably trained in the evaluation and management of concussions and head injuries. Sudden Cardiac Arrest Summary You have read and understand the SCA fact sheet and are now familiar with signs and symptoms of SCA. Sudden cardiac arrest is rare but does take life life of athletes at all levels each year. In most cases, SCA occurs due to an inherited heart defect but can also occur after a direct blow to the chest, or after illness causing inflammation of the heart. An athlete who exhibits SCA related symptoms during a practice or game will be removed immediately and will not return to a practice and/or game on the same day. The parent/guardian of the athlete will be notified of the athlete s symptoms. In addition to verbal and written permission to return to practice/competition the athletic trainer may request the athlete receive further testing and clearance from a physician. I have thoroughly read and understand the information and consent to all provisions set forth in these documents. I give my consent for and agree to abide by all the processes, stipulations, and guidelines set forth by Mitchell Community Schools, including all policies, procedures, information forms, consent forms. I have had the opportunity to ask questions. The consent for the receipt and release of protected health information expires at the conclusion of athletic events during the 2018-19 school year. Student Signature/ Print Name/Date Parent Signature/Print Name/Date Consent page 2