Athletic Registration Form



 
SPORTS INFORMATION
 
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STUDENT INFORMATION:
 
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PARENT/GUARDIAN INFORMATION
 
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AUTHORIZED PERSON TO CONTACT IN CASE OF AN EMERGENCY
(if Parent/Guardian cannot be reached)
 
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PRIMARY CARE and HEALTH INFORMATION 
 
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If yes to either of the previous two questions please explain in pre-exisiting conditions.
 
 
 
 
 
 
 

 
STUDENT/ATHLETE HEAD INJURY HISTORY
 
  Have you every exhibited signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) during a sporting competition at any level? 
     
     
 
  Have you ever been diagnosed with a concussion? 
     
     
 
 
 
  Do you currently have or have you ever had athletic participation restrictions in relation to being diagnosed with a concussion? 
     
     
 

 
RETURN TO ACTIVITY/COMPETITION PERMISSION
 
This form is to be used after a student/athlete is removed from and not returned to activity/competition after exhibiting concussion symptoms.  The student/athlete should not be returned to activity until written authorization is obtained from an appropriate health care professional and the parent/guardians.  This form should be kept on file at the school.

Download the form here.
 

 
CONSENT FOR MEDICAL TREATMENT
 
This is the form that the South Dakota High School Activities Association recommends to those member schools that feel it is important to get consent from parents and/or legal guardians for medical treatment when away from home on road trips for various activities. This form should be kept on file at the school and another copy should travel with each team on which the athlete competes.

I, the Parent/Legal Guardian whose electronic signature appears below hereby consent my child who participates in co-curricular activities for High School to any medical services that may be required while said child is under the supervision of an employee of the School District while on a school-sponsored activity and hereby appoint said employee to act on behalf in securing necessary medical services from any duly licensed medical provider. 
 
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CONSENT OF CHILD

I, the student whose electronic signature appears below have read the above Consent form signed by my Parent/Legal Guardian and join with my Parent/Legal Guardian in the consent.
 
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 CONSENT FOR RELEASE OF MEDICAL INFORMATION FORM (HIPAA)

1. I authorize the use or disclosure of the above named individual’s health information including the Initial and Interim Pre-Participation History and Physical Exam information pertaining to a student’s ability to participate in South Dakota High School Activities Association sponsored activities.  Such disclosure may be made by any Health Care Provider generating or maintaining such information. 

2. The information identified above may be used by or disclosed to the school nurse, athletic 
trainer, coaches, medical providers and other school personnel involved in the care of this student.   

3. This information for which I am authorizing disclosure will be used for the purpose of  determining the student’s eligibility to participate in extracurricular activities, any  limitations on such participation and any treatment needs of the student. 

4. I understand that I have a right to revoke this authorization at any time.  I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school administration.  I understand that the revocation will not apply to information that has already been released in response to this authorization.  I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.   

5. This authorization will expire on July 1, 2018. 

6. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
 
7. I understand authorizing the use or disclosure of the information identified above is voluntary.  However, a student’s eligibility to participate in extracurricular activities depends on such authorization.  I need not sign this form to ensure healthcare treatment.
 
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CONCUSSION FACT SHEET FOR ATHLETES
 
What is a concussion?
A concussion is a brain injury that:
  • Is caused by a bump, blow, or jolt to the head or body
  • Can change the way your brain normally works
  • Can occur during practices or games in any sport or recreational activity
  • Can happen even if you haven’t been knocked out
  • Can be serious even if you’ve just been “dinged” or “had your bell rung”
All concussions are serious.  A concussion can affect your ability to do schoolwork and other activities (such as playing video games, working on a computer, studying, driving, or exercising).  Most people with a concussion get better, but it is important to give your brain time to heal.
 
What are the symptoms of a concussion?
You can’t see a concussion, but you might notice one or more of the symptoms listed below or that you “don’t feel right” soon after, a few days after, or even weeks after the injury.

 
  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Bothered by light or noise
  • Feeling sluggish, hazy, foggy, or groggy
  • Difficulty paying attention
  • Memory problems
  • Confusion
What should I do if I think I have a concussion?
  • Tell your coaches and your parents.  Never ignore a bump or blow to the head even if you feel fine.  Also, tell your coach right away if you think you have a concussion or if one of your teammates might have a concussion.
  • Get a medical check-up.  A doctor or other health care professional can tell if you have a concussion and when it is OK to return to play.
  • Give yourself time to get better.  If you have a concussion, your brain needs time to heal.  While your brain is still healing, you are much more likely to have another concussion.  Repeat concussions can increase the time it takes for you to recover and may cause more damage to your brain.  It is important to rest and not return to play until you get the OK from your health care professional that you are symptom-free.
How can I prevent a concussion?
Every sport is different, but there are steps you can take to protect yourself.
  • Use the proper sports equipment, including personal protective equipment.  In order for equipment to
  • protect you, it must be:
    • The right equipment for the game, position, or activity
    • Worn correctly and the correct size and fit
    • Used every time you play or practice
  • Follow you coach’s rules for safety and the rules of the sport
  • Practice good sportsmanship at all times
It’s better to miss one game than the whole season.
 
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CONCUSSION FACT SHEET FOR PARENTS
 
What is a concussion?
A concussion is a brain injury. Concussions are caused by a bump, blow, or jolt to the head or body. Even or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms?
You can’t see a concussion, Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days after the injury. If your teen reports, one or more symptoms of concussion listed below, or if you notice the symptoms yourself, keep your teen out of play and seek medical attention right away.
 
Signs Observed By Parents or Guardians Symptoms Reported by Athlete
  • Appears dazed or stunned
  • Headache or “pressure” in head
  • Is confused about assignment or position
  • Nausea or vomiting
  • Forgets an instruction
  • Balance problems or dizziness
  • Is unsure of game, score, or opponent
  • Double or blurry vision
  • Moves clumsily
  • Sensitivity to light or noise
  • Answers questions slowly
  • Feeling sluggish, hazy, foggy, or groggy
  • Loses consciousness (even briefly)
  • Concentration or memory problems
  • Shows mood, behavior, or personality changes
  • Confusion
  • Can’t recall events prior to hit or fall
  • Just not “feeling right"
  • Can’t recall events after hit or fall
 

How can you help your teen prevent a concussion?
Every sport is different, but there are steps your teens can take to protect themselves from concussion and other injuries.
  •  Make sure they wear the right protective equipment for their activity. It should fit properly, be well maintained, and be worn consistently and correctly.
  •  Ensure that they follow their coaches’ rules for safety and the rules of the sport
  •  Encourage them to practice good sportsmanship at all times.
What should you do if you think your teen has a concussion?

1. Keep your teen out of play. If your teen has a concussion, her/his brain needs time to heal. Don’t let your teen return to play the day of the injury and until a health care professional, experienced in evaluating for concussion, says your teen is symptom-free and it’s OK to return to play. A repeat concussion that occurs before the brain recovers from the first – usually within a short period of time (hours, days, or weeks) – can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death.

2. Seek medical attention right away. A health care professional experienced in evaluating for concussion will be able to decide how serious the concussion is and when it is safe for your teen to return to sports.

3. Teach your teen that it’s not smart to play with a concussion. Rest is key after a concussion.  Sometimes athletes wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don’t let your teen convince you that s/he’s “just fine”.

4. Tell all of your teen’s coaches and the student’s school nurse about ANY concussion. Coaches, school nurses, and other school staff should know if your teen has ever had a concussion. Your teen may need to limit activities while s/he is recovering from a concussion. Things such as studying, driving, working on a computer, playing video games, or exercising may cause concussion symptoms to reappear or get
worse. Talk to your health care professional, as well as your teen’s coaches, school nurse, and teachers.
If needed, they can help adjust your teen’s school activities during her/his recovery.
 
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ImPACT CONCUSSION INFORMATION
 
ImPACT Testing:  All 7th, 9th, and 11th grade students, along with any student NEW to Tri-Valley athletics, are required to take the ImPACT Test before the start of practice. The baseline test is valid for 2 years. For more information on ImPACT please click HERE.
 

ImPACT CONSENT FORM

For use of the Immediate Post-Concussion Asssesment and Cognitive Testing (ImPACT).

I have read the above information. I understand its contents. I have been given an opportunity to ask questions and all questions have been answered to my satisfaction. I agree to participate in the ImPACT Concussion Management Program.
 
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Travel Release/Bus Policy

The Tri-Valley School District encourages all students to ride home on the school provided transportation after each activity.  Students who choose to ride home with an adult family member must receive permission from the coach/advisor of the activity they are participating in. Prior to riding home with an adult family member, the student and family member must sign the travel release provided by the coach/advisor.  After a school activity, students may sign out and ride with non-family members in EMERGENCY SITUATIONS ONLY(MUST BE PRE-APPROVED WITH THE ACTIVITIES DIRECTOR).

By signing my name below, I authorize my child to sign out and ride home with an adult family member or non-family member (Emergencies Only) after school activities.
 
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STUDENT-ATHLETE:
 
As an athlete/activities participant of the Tri-Valley High School, I have been informed and agree to obey all guidelines outlined in the Athletic Packet 2017-18 and South Dakota High School Activities Association rules, including and not limited to, the specified rules listed below.


By signing my name below, I authorize and acknowledge that I have read and understood the items listed below:

I have read the Tri-Valley Academic & Training Rules Eligibility
I have read the SDHSAA Directory/Participation/Safety Consent
 
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PARENT/GUARDIAN

I have read and understand the:

SDHSAA Directory/Participation/Consent Information
Tri-Valley Parent/Coach Communication and Code of Conduct

 
 
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After submitting please make certain to complete Step Three: Physical Form submission if needed. Click here.

Physical examination taken April 1 and thereafter is valid for the following school year; physical examination before April 1 is valid only for the remainder of that school year.
 




  Send a copy of the completed form to this email address : 





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