ATHLETIC ELIGIBILITY PACKET - Flowing Wells High School · 2018. 6. 26. · 2018 / 2019 FLOWING WELLS HIGH SCHOOL - DEPARTMENT OF ATHLETICS ATHLETIC ELIGIBILITY PACKET You must complete

2018 / 2019

FLOWING WELLS HIGH SCHOOL - DEPARTMENT OF ATHLETICS

ATHLETIC ELIGIBILITY PACKET

You must complete the entire packet and return it to the Athletic Office BEFORE your first practice/tryout. ALL STUDENTS WILL NEED A NEW PHYSICAL EXAMINATION, EVERY YEAR, DATED AFTER MARCH 1st, BEFORE THEY MAY TRY OUT FOR A SPORT. Parents need to complete and sign evaluation form and physicians complete examination form and sign. ATHLETIC RESPONSIBILITY AND ELIGIBILITY REQUIREMENTS FORM:

a. ATHLETIC PRACTICE PERMIT: The Athletic Department shall issue an Athletic Practice Permit to the student when ALL ELIGIBILITY requirements have been verified and recorded. Until the Athletic Practice Permit is completed, signed by the secretary, presented to the equipment manager, and the coach, NO EQUIPMENT OF ANY KIND SHALL BE ISSUED TO THE STUDENT NOR SHALL HE/SHE BE PERMITTED TO PRACTICE OR PARTICIPATE IN INTERSCHOLASTIC ATHLETICS.

b. ACADEMIC ELIGIBILITY: A student must be passing ALL subjects at grade check time in order to be

academically eligible to compete in athletic contests. Grades will be checked on a weekly basis.

c. I will not use or be in possession of alcohol, tobacco or any illegal substances.

d. I will be a good citizen and conduct myself in an exemplary manner at all times so as not to bring discredit or embarrassment to me personally, to my parents, my team, and my school.

e. COMPETITION ON SCHOOL TEAM: A student who is member of a school team can not practice or compete

for or with any other group, club, organization, association, etc. in that same sport during the interscholastic season of competition of that sport as defined in the A.I.A. Handbook. Any student violating the above rule shall forfeit his/her eligibility for a minimum of the balance of the season. Contact the Athletic Director for exceptions to this rule.

ATHLETIC FEE:

A $10.00 athletic fee, per sport needs to be paid in the BOOKSTORE.

Baseball – Basketball – Cheer – Chess – Cross Country – Football – Golf – JROTC – Soccer –Softball – Swim – Tennis – Track – Volleyball – Wrestling

Student Signature _________________________________________________Date________________

Parent Signature___________________________________________________Date________________

***RETURN THIS PACKET TO THE ATHLETIC OFFICE ONLY***

FLOWING WELLS HIGH SCHOOL ATHLETIC PARTICIPATION FORM

2018 / 2019 STUDENT'S _______________________________________________BIRTHDATE___/__/___ GRADE____ Last First Middle Initial ADDRESS __________________________________________________________________________________

Number and Street Apt # Zip Code HOME PHONE __________________PARENT'S WORK PHONE: Mother ____________Father ______________

EMERGENCY CONTACT____________________________________________PHONE ___________________ (Person who can answer in your behalf for your son/daughter in case of an emergency)

PARENT OR GUARDIAN PERMISSION: I/We give our permission for the above named student to participate in organized high school athletics, realizing that such activity involves the potential for injury and/or transmittable diseases which is inherent in all sports. I/We acknowledge that even with qualified coaching, use of approved equipment and strict observance of rules, injuries and/or transmittable diseases are still a possibility. On rare occasions these injuries and/or transmittable diseases can be so severe as to result in total disability, paralysis or even death.

CONSENT FOR EMERGENCY CARE: BE IT KNOWN that I, the undersigned parent or guardian of the above named student, do hereby give and grant unto any medical doctor or hospital my consent and authorization to render such aid, treatment or care to said student as, in the judgement of said doctor or hospital, may be rendered, on an emergency basis, in the event said student should be injured or stricken ill while participating in an Interscholastic activity sponsored or sanctioned by Arizona Interscholastic Association, Inc., of which the above named high school is a member.

IT IS HEREBY understood that the consent and authorization hereby given and granted are continuing and are intended by me to extend throughout the current school year.

IT IS FURTHER understood that any expenses incurred will be paid for by insurance or the parent of the student. Payment of any medical expense is not a school responsibility. STATEMENT OF INSURANCE COVERAGE: (CHECK EITHER OPTION # 1 OR OPTION #2)

_____ OPTION #1: I/We affirm that I/we are the parent or the legal guardian of the above named student. I/we certify that the above named student is currently covered and will be covered during the present school year by an accident insurance policy which includes coverage in the event of injury in a school supervised game or activity. Insurance Carrier: ___________________________________________ Policy/Group Number _________ ______OPTION # 2: I/We desire to PURCHASE student activity insurance through the school.

FORMS ARE AVAILABLE IN THE ATHLETIC OFFICE.

RESPONSIBILITY FOR EQUIPMENT RETURN: I/We agree to be responsible for the safe return of all athletic and/or activity equipment issued by the school to the above named student. I/WE HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE STATEMENTS AND THEIR CONDITIONS.

___________________________________________________________________ ___________________ Student’s Signature Date

___________________________________________________________________ ___________________ Parent/Guardian’s Signature Date

NOTE: ATHLETIC FEE OF $10.00 PER SPORT TO BE PAID IN THE BOOKSTORE (including Cheer, Chess & JROTC)

ARIZONA INTERSCHOLASTIC ASSOCIATION7007 North 18th Stree t, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

2018-2019 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION(The Parent or Guardian should fill out this form with assistance from the student athlete.)

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Relationship:

Relationship:

Phone (Home):

Phone (Home):

(Work):

(Work):

(Cell):

(Cell):

Y N

Sex: Age: Date of Birth:

Grade:School:Sport(s):

Home Address:

Phone:

Personal Physician: Hospital Preference:

In case of emergency, contact:

Exam Date:

Explain "Yes" answers on following page. Circle questions you don’t know the answers to.

1) Has a doctor ever denied or restricted your participation in sports for any reason?

2) Do you have an ongoing medical condition (like diabetes or asthma)?

3) Are you currently taking any prescription or nonprescription (over-the-counter) medicines or supplements?(Please specify):

4) Do you have allergies to medicines, pollens, foods, or stinging insects?(Please specify):

5) Does your heart race or skip beats during exercise?

6) Has a doctor ever told you that you have (check all that apply):

High Blood Pressure A Heart Murmur High Cholesterol A Heart Infection

7) Have you ever spent the night in the hospital?

8) Have you ever had surgery?

* 9) Have you ever had an injury (sprain, muscle/ligament tear, tendinitis, etc.) that caused you to miss a practice orgame? (If yes, circle affected area in the box below):

*10) Have you had any broken/fractured bones or dislocated joints? (If yes, circle affected area in the box below):

* 11) Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physicaltherapy, a brace, a cast, or crutches? (If yes, circle affected area in the box below):

Neck Shoulder Upper Arm Elbow Forearm

Hand/Fingers Chest Upper Back Low Back Hip Thigh

Knee Calf/Shin Ankle Foot/Toes

The Preferred Urgent Care of the Arizona Interscholastic Association

1NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

Y N12) Have you ever had a stress fracture?13) Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?14) Do you regularly use a brace or assistive device?15) Has a doctor told you that you have asthma or allergies?16) Do you cough, wheeze, or have difficulty breathing during or after exercise?17) Is there anyone in your family who has asthma?18) Have you ever used an inhaler or taken asthma medicine?19) Were you born without, are you missing, or do you have a nonfunctioning kidney,eye, testicle or any other organ?20) Have you had infectious mononucleosis (mono) within the last month?21) Do you have any rashes, pressure sores, or other skin problems?22) Have you had a herpes skin infection?23) Have you ever had an injury to your face, head, skull or brain (including a concussion, confusion, memory lossor headache from a hit to your head, having your “bell rung” or getting “dinged”)?

24) Have you ever had a seizure?

25) Do you have headaches with exercise?26) Have you ever had numbness, tingling, or weakness in your arms or legs after being hit, falling, stingers or burners?27) When exercising in the heat, do you have severe muscle cramps or become ill?28) Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?29) Have you ever been tested for sickle cell trait?

30) Have you had any problems with your eyes or vision?31) Do you wear glasses or contact lenses?32) Do you wear protective eyewear, such as goggles or a face shield?33) Are you happy with your weight?34) Are you trying to gain or lose weight?35) Has anyone recommended you change your weight or eating habits?36) Do you limit or carefully control what you eat?37) Do you have any concerns that you would like to discuss with a doctor?

Females Only Explain “Yes” Answers Here

38) Have you ever had a menstrual period?

39) How old were you when you had your firstmenstrual period?

40) How many periods have you had in thelast year?

Y N

ARIZONA INTERSCHOLASTIC ASSOCIATION7007 North 18th Street, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

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2018-2019 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION (The Physician should fill out this form with assistance from the Parent or Guardian.)

Student Name: Date of Birth:

Patient History Questions: Please tell me about your child...

Family History Questions: Please tell me about any of the following in your family...

1) Has your child fainted or passed out DURING or AFTER exercise, emotion or startle?

3) Has your child had extreme fatigue associated with exercise (different from other children)?

2) Has your child ever had extreme shortness of breath during exercise?

4) Has your child ever had discomfort, pain or pressure in his/her chest during exercise?

5) Has a doctor ever ordered a test for your child's heart?

6) Has your child ever been diagnosed with an unexplained seizure disorder?

7) Has your child ever been diagnosed with exercise-induced asthma not well controlled with medication?

8) Are there any family members who had sudden, unexpected, unexplained death before age 50? (including SIDS, car accidents, drowning, ornear drowning)

9) Are there any family members who died suddenly of "heart problems" before age 50?

10) Are there any family members who have unexplained fainting or seizures?

11) Are there any relatives with certain conditions, such as:

Enlarged Heart

Hypertrophic Cardiomyopathy (HCM)

Dilated Cardiomyopathy (DCM)

Heart Rhythm problems:

Long QT Syndrome (LQTS)

Short QT Syndrome

Brugada Syndrome

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

Marfan Syndrome (Aortic Rupture)

Heart Attack, age 50 or younger

Pacemaker or Implanted Defibrillator

Deaf at Birth (Congenital Deafness)

Explain “Yes” Answers Here

I hereby state that, to the best of my knowledge, my answers to all of the above questions are complete and correct. Furthermore, I acknowledge and understand that my eligibility may be revoked if I have not given truthful and accurate information in response to the above questions.

Signature of athlete Signature of parent/guardian Date

Signature of MD/DO/ND/NMD/NP/PA-C/CCSP Date:

FORM 15.7-A 02/14

Y N

ARIZONA INTERSCHOLASTIC ASSOCIATION7007 North 18th Stree t, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

The Preferred Urgent Care of the Arizona Interscholastic Association

3 NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

1-888-364-7502NextCareAZ.com

Apache Junction • 851202080 West Southern Ave., Suite #A1

Broadway Road

Mer

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Ironw

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Driv

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Southern Avenue

60

Walgreens

Avondale • 8539213075 W. McDowell Rd., Suite #D106

W. McDowell Rd.

W. Van Buren St.

W. Indian School Rd.

N. D

ysart Rd.

N. Litchfield Rd.

Fry’s

Casa Grande • 851221683 E. Florence Blvd., Suite #7

10

E. Florence Blvd.

E. Cottonwood Ln.

N. Arizola Rd.

County Rd.

N. Verbena H

enness Rd.

99¢ Store

Bank ofAmerica

Walmart Chandler • 85224600 S. Dobson Road, Suite #C-26

Pecos Road Dob

son

Roa

dFrye Road

Chandler Blvd.

Glendale • 853065410 W. Thunderbird Road, Suite #101

W. Greenway Rd

N. 5

9th

Ave

N. 5

1st A

ve

N. 4

3rd

Ave

W. Thunderbird RdASU West Campus

Thunderbird Paseo Park

N. 3

5th

Ave

17N. 5

5th

Ave

H

Glendale • 8530210240 N. 43rd Ave., Suite #310240 North 43rd Avenue, Ste #3 Glendale, AZ 85302

W. Cactus Rd.

Peoria Ave.

N. 5

1st A

ve.

N. 4

3rd

Ave.

W. Dunlap Ave.

17

17

Glendale • 853059494 W. Northern Ave., Suite #101Peoria/Glendale9494 W. Northern Ave.

W. Olive Ave.

W. Northern Ave.N. 9

9th

Ave.

N. 9

1st A

ve.

W. Glendale Ave.

101

101

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Mesa • 852051066 N. Power Road, Suite #101

E. Brown Rd

Red MountainHigh School

N. P

ower

Rd

202

N. R

ecke

r Rd

E. McKellips Rd

Mesa • 852043130 E. Baseline Road, Suite #105

60

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N. V

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Mesa • 85203535 E. McKellips Road, Suite #101

McKellips Dr.

N. M

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N. H

orne

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Walmart

Cottonwood • 86326450 S. Willard Street, Suite #120

89AS. Calv

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Willa

rd St

.

W. Cottonwood St.

Airpark Rd.

89A

Glendale • 8530818589 N. 59th Ave., Suite #101

N. 59th Ave

W. Union Hills Dr

Honeywell

101

N. 51st Ave

N. 67th Ave

Starbucks

Chino Valley • 86323474 State Highway 89

Safeway

89

89

W. Rd 1 N E. Rd 1 N

W. Rd 2 N

N. R

d 1

E

Walgreens

Center St.

Chino ValleyHigh School

Flagstaff • 860011000 N. Humphreys St., Suite #104

180

180

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N. H

umph

reys

St

reet

W. Columbus Avenue

W. Desilva Avenue

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Flagstaff MedicalCenter

Lake Havasu City • 864031810 Mesquite Ave., Suite B

Kmart95 Mesqu

ite A

ve.

N. McC

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Blvd.

Rivi

era

Blv

d

Capri Blvd.Library Ln

Civic Center Ln

95

Swanso

n Ave.

WheelerPark

Havasu RegionalMedical Center

Mesa • 852154401 E. McKellips Road, Suite #102

LOOP202

McKellipsVal V

ista

Gre

enfie

ld

McDowell

Walmart

Peoria • 8538220470 N. Lake Pleasant Rd., Suite #102

Rose Garden Ln.

Beardsley Rd.

Lake

Ple

asan

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d(9

9th

Ave.

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(91s

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101

20470 N. Lake Pleasant Rd.Suite 102Peoria, AZ 85382

Lake Pleasant Pkwy

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Walgreens

Phoenix • 850161701 E. Thomas Road, Suite #A104

51

E. Oak St.

E. Thomas Rd.

E. Osborn Rd.

N. 16th St.

N. 21st St.

N. 20 th St.

PhoenixChildren’sHospital

Phoenix • 850184730 E. Indian School Rd., Suite #211

N. A

rcad

ia Dr.

Indian School

N. 4

4th

St.

48th

St.

Arcadia H.S.

Safeway

Phoenix • 850218101 N. 19th Ave., Suite #A

8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021

W. Northern Ave.

W. Orangewood Ave.N. 1

9th

Ave.

N. 7

th A

ve.

17

Albertson’s

The Preferred Health Care Partner of the Arizona Interscholastic Association

Phoenix • 8505020950 N. Tatum Blvd., Suite #190

E. Deer Valley Rd.

N. T

atum

Blv

d.

E. Rose Garden Ln.DESERT RIDGEMARKET PLACE

101101

Scottsdale • 852607425 E. Shea Blvd., Suite #108

N. S

cotts

dale

Rd

E. Shea Blvd

Harkins Theaters

N. Hayden Rd

E. Mountain View Rd

N. 7

0th

St

N. 7

4th

St

Sun City • 853519745 W. Bell Road, Suite #105

W. Union Hills Dr.

W Bell Rd.N. 9

9th

Ave

N. 9

8th

Ave

.

N. 9

1st

Ave.

W. Thunderbird Rd.

101

101

Tempe • 85281914 N. Scottsdale Rd., Suite #104

Curry Road

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Jack inthe Box

Rura

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Tucson • 857126238 E. Pima Street

Pima

SpeedwayWilmot10

Circle K

Tucson • 857489525 E. Old Spanish Trail, Suite #101

E. Old Spanish Trail

E 22nd St

S Ha

rriso

n Rd

Target

Starbucks

Tucson • 857054280 North Oracle Rd., Suite #100

W. Wetmore Rd.

W. Prince Rd.

W. Miracle Mile

N. O

racl

e Rd

.

N. F

low

ing

Wel

ls Rd

.

10

4280 N. Oracle Rd. Ste. 100

77

Walgreens

W. Limberlast Dr.

Tucson • 857065369 S. Calle Santa Cruz, Suite #145

W. Ajo Way

W. Valencia Rd.

W. Drexel Rd.

W. Irvington Rd.

S. M

idva

le P

ark

Rd.

S. C

alle

San

ta C

ruz R

d.

10

86 86

Harkins

19

Tucson • 85719501 North Park Ave., Suite #110

E. 6th St.

Speedway Blvd.

University Blvd.

N. E

uclid

Ave

.

10

N. P

ark

Ave.

MetroWildcat

Sedona • 863362530 W. SR 89A, Suite #A

89A

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Anda

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Prescott • 863012062 Willow Creek Road

Green Ln.

Miller Valley Rd.

Willow

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Prescott Valley • 863143051 N. Windsong Drive

N. W

inds

ong

Dr.

N. R

ober

t Rd.

69

E. Florentine Dr.

E. Lakeshore Dr.

Phoenix • 850323229 E. Greenway Rd., Suite #102

51

Greenway Rd.

E. Bell Rd.

N. 32nd St.

N. 40th St.

Food City

Phoenix • 850355920 W. McDowell Road

W. McDowell Rd.

W. Coronado Rd.

N. 59th Ave.

7-11

Walgreens

Surprise • 8537414800 W. Mtn. View Blvd., Suite #100

60

N. Reem

s Road

W. Mountain View Boulevard

Hampton Inn & Suites

Albertson’sMarket

W. Grand Ave

Colon n ade Way

1-888-364-7502NextCareAZ.com

The Preferred Health Care Partner of the Arizona Interscholastic Association

ARIZONA INTERSCHOLASTICASSOCIATION7007 North 18th Street, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

The Preferred Health Care Partner of the Arizona Interscholastic Association

Name:

Sex: Age: Date of Birth:

Height: Weight:

% Body fat (optional):

Pupils:

Pulse:

BP:____ /____ (____ /____,____ /____)

Corrected: Y___ N___Vision: R20/_____ L20/_____

Normal Abnormal Findings Initials*

Medical

Musculoskeletal

Appearance

Lymph Nodes

Back

Pulses

Wrist/Hand/Fingers

Eyes/Ears/Throat/Nose

Heart

Shoulder/Arm

Lungs

Hip/Thigh

Genitourinary †

Leg/Ankle

Hearing

Neck

Murmurs

Elbow/Forearm

Abdomen

Knee

Skin

Foot/Toes* Multi-examiner set-up only.† Having a third party present is recommended for the genitourinary examination.

NOTES:

Recommendations:

Name of Physician(Print/Type):

Address:

Signature of Physician:

FORM 15.7-B 03/12

Exam Date:

Phone:

, MD/DO/NP/PA-C

Cleared Without RestrictionNot Cleared For: All Sports Certain Sports Reason:

Equal_____ Unequal____

2018-2019 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION

1-888-364-7502NextCareAZ.com

Apache Junction • 851202080 West Southern Ave., Suite #A1

Broadway Road

Mer

idia

n Ro

ad

Ironw

ood

Driv

e

Southern Avenue

60

Walgreens

Avondale • 8539213075 W. McDowell Rd., Suite #D106

W. McDowell Rd.

W. Van Buren St.

W. Indian School Rd.

N. D

ysart Rd.

N. Litchfield Rd.

Fry’s

Casa Grande • 851221683 E. Florence Blvd., Suite #7

10

E. Florence Blvd.

E. Cottonwood Ln.

N. Arizola Rd.

County Rd.

N. Verbena H

enness Rd.

99¢ Store

Bank ofAmerica

Walmart Chandler • 85224600 S. Dobson Road, Suite #C-26

Pecos Road Dob

son

Roa

dFrye Road

Chandler Blvd.

Glendale • 853065410 W. Thunderbird Road, Suite #101

W. Greenway Rd

N. 5

9th

Ave

N. 5

1st A

ve

N. 4

3rd

Ave

W. Thunderbird RdASU West Campus

Thunderbird Paseo Park

N. 3

5th

Ave

17N. 5

5th

Ave

H

Glendale • 8530210240 N. 43rd Ave., Suite #310240 North 43rd Avenue, Ste #3 Glendale, AZ 85302

W. Cactus Rd.

Peoria Ave.

N. 5

1st A

ve.

N. 4

3rd

Ave.

W. Dunlap Ave.

17

17

Glendale • 853059494 W. Northern Ave., Suite #101Peoria/Glendale9494 W. Northern Ave.

W. Olive Ave.

W. Northern Ave.N. 9

9th

Ave.

N. 9

1st A

ve.

W. Glendale Ave.

101

101

Target

Mesa • 852051066 N. Power Road, Suite #101

E. Brown Rd

Red MountainHigh School

N. P

ower

Rd

202

N. R

ecke

r Rd

E. McKellips Rd

Mesa • 852043130 E. Baseline Road, Suite #105

60

Baseline Road

N. L

inds

ay R

d.

N. V

al V

ista

Dr.

S. 3

2nd

St.

Dan

a Pa

rk

Mesa • 85203535 E. McKellips Road, Suite #101

McKellips Dr.

N. M

esa

Dr.

N. H

orne

LOOP202

Walmart

Cottonwood • 86326450 S. Willard Street, Suite #120

89AS. Calv

ary W

ayS.

Willa

rd St

.

W. Cottonwood St.

Airpark Rd.

89A

Glendale • 8530818589 N. 59th Ave., Suite #101

N. 59th Ave

W. Union Hills Dr

Honeywell

101

N. 51st Ave

N. 67th Ave

Starbucks

Chino Valley • 86323474 State Highway 89

Safeway

89

89

W. Rd 1 N E. Rd 1 N

W. Rd 2 N

N. R

d 1

E

Walgreens

Center St.

Chino ValleyHigh School

Flagstaff • 860011000 N. Humphreys St., Suite #104

180

180

N. F ort Valley Road

N. H

umph

reys

St

reet

W. Columbus Avenue

W. Desilva Avenue

Basha’sN.

Bea

ver S

treet

Flagstaff MedicalCenter

Lake Havasu City • 864031810 Mesquite Ave., Suite B

Kmart95 Mesqu

ite A

ve.

N. McC

ulloch

Blvd.

Rivi

era

Blv

d

Capri Blvd.Library Ln

Civic Center Ln

95

Swanso

n Ave.

WheelerPark

Havasu RegionalMedical Center

Mesa • 852154401 E. McKellips Road, Suite #102

LOOP202

McKellipsVal V

ista

Gre

enfie

ld

McDowell

Walmart

Peoria • 8538220470 N. Lake Pleasant Rd., Suite #102

Rose Garden Ln.

Beardsley Rd.

Lake

Ple

asan

t Roa

d(9

9th

Ave.

)

(91s

t Av

e.)

101

20470 N. Lake Pleasant Rd.Suite 102Peoria, AZ 85382

LakePleasant Pkwy

Bashas

Walgreens

Phoenix • 850161701 E. Thomas Road, Suite #A104

51

E. Oak St.

E. Thomas Rd.

E. Osborn Rd.

N. 16th St.

N. 21st St.

N. 20 th St.

PhoenixChildren’sHospital

Phoenix • 850184730 E. Indian School Rd., Suite #211

N. A

rcad

ia Dr.

Indian School

N. 4

4th

St.

48th

St.

Arcadia H.S.

Safeway

Phoenix • 850218101 N. 19th Ave., Suite #A

8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021

W. Northern Ave.

W. Orangewood Ave.N. 1

9th

Ave.

N. 7

th A

ve.

17

Albertson’s

The Preferred Health Care Partner of the Arizona Interscholastic Association

Phoenix • 8505020950 N. Tatum Blvd., Suite #190

E. Deer Valley Rd.

N. T

atum

Blv

d.

E. Rose Garden Ln.DESERT RIDGEMARKET PLACE

101101

Scottsdale • 852607425 E. Shea Blvd., Suite #108

N. S

cotts

dale

Rd

E. Shea Blvd

Harkins Theaters

N. Hayden Rd

E. Mountain View Rd

N. 7

0th

St

N. 7

4th

St

Sun City • 853519745 W. Bell Road, Suite #105

W. Union Hills Dr.

W Bell Rd.N. 9

9th

Ave

N. 9

8th

Ave

.

N. 9

1st

Ave.

W. Thunderbird Rd.

101

101

Tempe • 85281914 N. Scottsdale Rd., Suite #104

Curry Road

Scot

tsda

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oad

LOOP202

Jack inthe Box

Rura

l

Tucson • 857126238 E. Pima Street

Pima

SpeedwayWilmot10

Circle K

Tucson • 857489525 E. Old Spanish Trail, Suite #101

E. Old Spanish Trail

E 22nd St

S Ha

rriso

n Rd

Target

Starbucks

Tucson • 857054280 North Oracle Rd., Suite #100

W. Wetmore Rd.

W. Prince Rd.

W. Miracle Mile

N. O

racl

e Rd

.

N. F

low

ing

Wel

ls Rd

.

10

4280 N. Oracle Rd. Ste. 100

77

Walgreens

W. Limberlast Dr.

Tucson • 857065369 S. Calle Santa Cruz, Suite #145

W. Ajo Way

W. Valencia Rd.

W. Drexel Rd.

W. Irvington Rd.

S. M

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Rd.

S. C

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San

ta C

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10

86 86

Harkins

19

Tucson • 85719501 North Park Ave., Suite #110

E. 6th St.

Speedway Blvd.

University Blvd.

N. E

uclid

Ave

.

10

N.P

ark

Ave.

MetroWildcat

Sedona • 863362530 W. SR 89A, Suite #A

89A

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Prescott • 863012062 Willow Creek Road

Green Ln.

Miller Valley Rd.

Willow

Creek R

d.

Prescott Valley • 863143051 N. Windsong Drive

N. W

inds

ong

Dr.

N. R

ober

t Rd.

69

E. Florentine Dr.

E. Lakeshore Dr.

Phoenix • 850323229 E. Greenway Rd., Suite #102

51

Greenway Rd.

E. Bell Rd.

N. 32nd St.

N. 40th St.

Food City

Phoenix • 850355920 W. McDowell Road

W. McDowell Rd.

W. Coronado Rd.

N. 59th Ave.

7-11

Walgreens

Surprise • 8537414800 W. Mtn. View Blvd., Suite #100

60

N. Reem

s Road

W. Mountain View Boulevard

Hampton Inn & Suites

Albertson’sMarket

W. Grand Ave

Colon n ade Way

1-888-364-7502NextCareAZ.com

The Preferred Health Care Partner of the Arizona Interscholastic Association

 Arizona Interscholastic Association, Inc. 

Mild Traumatic Brain Injury (MTBI) / Concussion 

Annual Statement and Acknowledgement Form 

I, _________________________ (student), acknowledge that I have to be an active participant in my own health 

and have the direct responsibility for reporting all of my injuries and illnesses to the school staff (e.g., coaches, 

team physicians, athletic training staff).  I further recognize that my physical condition is dependent upon 

providing an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or 

disabilities experienced before, during or after athletic activities.    

By signing below, I acknowledge:  

My institution has provided me with specific educational materials including the CDC Concussion fact 

sheet (http://www.cdc.gov/concussion/HeadsUp/youth.html) on what a concussion is and has given me 

an opportunity to ask questions.    

I have fully disclosed to the staff any prior medical conditions and will also disclose any future conditions.  

There is a possibility that participation in my sport may result in a head injury and/or concussion. In rare 

cases, these concussions can cause permanent brain damage, and even death.  

A concussion is a brain injury, which I am responsible for reporting to the team physician or athletic 

trainer.  

A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance, 

sleep, and classroom performance.    

Some of the symptoms of concussion may be noticed right away while other symptoms can show up 

hours or days after the injury.    

If I suspect a teammate has a concussion, I am responsible for reporting the injury to the school staff.    

I will not return to play in a game or practice if I have received a blow to the head or body that results in 

concussion related symptoms.   

I will not return to play in a game or practice until my symptoms have resolved AND I have written 

clearance to do so by a qualified health care professional.   

Following concussion the brain needs time to heal and you are much more likely to have a repeat 

concussion or further damage if you return to play before your symptoms resolve.    

Based on the incidence of concussion as published by the CDC the following sports have been identified as high risk 

for concussion; baseball, basketball, diving, football, pole vaulting, soccer, softball, spiritline and wrestling.      

I represent and certify that I and my parent/guardian have read the entirety of this document and fully understand 

the contents, consequences and implications of signing this document and that I agree to be bound by this 

document.    

Student Athlete:  

Print Name: _________________________ Signature: __________________________  

Date: ___________  

Parent or legal guardian must print and sign name below and indicate date signed. 

Print Name: _________________________ Signature: __________________________ 

 Date: ___________ 

FORM 15.7‐C   06/15

SPECTATOR CODE OF CONDUCT

To the Student-Athlete and Parents/Guardians: Attending an athletic event should be a fun and significant part of a sound educational program that embodies high standards of ethics and sportsmanship. Flowing Wells has a code of conduct for spectators attending athletic events on our campus. Attending an athletic event should be a positive experience for everyone associated with the event. We request that you and your family be familiar with this code. We also request that you and those who attend the events with you abide by the code.

ATHLETIC CODE OF CONDUCT FOR SPECTATORS AND FANS

As a spectator attending a Flowing Wells High School athletic event, I recognize

That the goal of this event is to provide young people with the opportunity for healthy competition in the spirit of sportsmanship and camaraderie.

That I have a role to project a positive and supportive attitude toward the

participants, officials, school authorities, and fellow spectators of the event.

That my words and behavior have a powerful impact on those around me and that I have a role to conduct myself in a mature and dignified fashion.

That for the orderly management of this event, I have a role to adhere to

directions stated by school authorities.

That if my conduct is not conducive to a positive environment, I may be asked to leave the event.

That at no time will I enter the area of competition.

I have read and understand this Code of Conduct and recognize that I may not be allowed to attend games if I violate any of its statements. Student Signature____________________________ Date __________________ Parent Signature_____________________________ Date __________________

APPLICATION FOR ELIGIBILITY

INTERSCHOLASTIC SPORTS

This form is to be completed by all student athletes who are competing in sports at FWHS.

Student Name ____________________________________________ Grade _______

Current Home Address _____________________________________ Zip Code ______

Do you reside with your parents? Yes ______ No ______

Did you transfer to FWHS from another high school? Yes ______ No ______

If yes, name and address of high school ________________________________________

________________________________________________________________________

If yes, list sports you participate in at previous high school _________________________

NOTE: You will need to sign either a 520 or 530 form with Athletics if you have

transferred from another school.

Date of enrollment at FWHS _______________

**************************************************************************

STATEMENT OF RESIDENCY

We, the undersigned parent / guardian and student affirm:

____ That our primary residence is within the boundaries of the Flowing Wells School District.

OR ____ That we have received permission from the Flowing Wells School District for our

child to attend FWHS as a non-resident student. Student Signature ____________________________________________Date _______ Parent Signature ____________________________________________ Date _______

EXPECTATIONS AND PHILOSOPHY LETTER Dear Parent/Guardian and Student-Athlete:

We would like to take a moment to partially explain how the athletic program is conducted at the high school as well as some of our expectations and philosophy.

1. In each program, coaches are hired by the school district to be responsible for team selection.

The head coach establishes conditions for selection, possibly with input from other coaches. This may be a highly subjective process and any one of us might select different athletes for the team. We believe it is the coaches’ responsibility and right to select the team with whom they will work for the entire season. If you have questions regarding the procedure used to determine a team, please feel free to talk with the head coach. Please call the coach to make an appointment outside of class time, practice time, or game time.

2. A main goal of a competitive athletic team is to play the best combination of athletes available, in

the judgment of the coaches, in order to win the contest. Starting positions and playing time are not guaranteed to any team member. Each member of the team is very valuable to the team’s overall progress. Some members may play a great deal of time in a contest while others may not see what a parent would consider “significant” playing time. We believe it is the coaches’ responsibility and right to determine the playing time each team member receives in a game or during a season. Each student should have personal improvement as one of his or her goals.

3. Every team and every coach wants to win. In the attempt to win, coaches will use different game

strategies at appropriate times. These strategies may differ with the decisions you might have made if you were the coach. The coaches do the best that they can to make the proper decisions so that our teams play well and hopefully win the game. We believe it is the coaches’ responsibility and right to determine the strategies used during a game.

4. There may be times when you have concerns about your child’s participation in our teams.

When these concerns arise, we ask that you follow the described chain of command to deal with the concern. First, have the athlete talk with the coach. If the concern has not been resolved, then the parent or guardian may request a meeting with the coach. The athlete should be present at this meeting. If these first two steps have not solved the concern, then the parent should request a meeting with the athletic director. The coach and athlete should be included in this meeting. If these meetings have not addressed your concerns to your satisfaction, the parent and student-athlete may request a meeting with the principal. We believe that by using this approach, most of the concerns can be resolved to the benefit of all. By being a sports spectator or member of a team, regardless of time spent in actual competition, a person can learn many valuable lessons. These lessons include sportsmanship, appreciating good play by an opponent and respect for others, winning and losing with dignity, self-control, and being responsible for one’s own actions. We sincerely hope this helps you to understand some of the goals and philosophies of the competitive athletic program at Flowing Wells High School.

I have read and understand the Expectation and Philosophy letter. Student Signature _____________________________________ Date ___________________ Parent Signature______________________________________ Date ___________________

FLOWING WELLS HIGH SCHOOL ATHLETIC

AUTHORIZATION TO RELEASE STUDENT

TRANSCRIPTS FORM

___________________________________________ ________________ NAME I.D NUMBER

______________________________________________________________________ ADDRESS

_________________________________ ______________________ CITY ZIP CODE

_________________________________ PHONE I AUTHORIZE Flowing Wells High School to release my transcripts, including ACT and SAT scores, to educational institutions in order to determine my academic and athletic eligibility.

I FURTHER AUTHORIZE Flowing Wells High School coaching and administrative personnel to release information or records to educational institutions in order to determine my academic and athletic eligibility. _______________________________________________________ ___________ Signature of Student Date _______________________________________________________ ___________ Signature of parent or guardian (required if student is under 18 years of age) Date

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Please leave blank if you give permission

for your childs picture to be posted

FLOWING WELLS HIGH SCHOOL PARENT PERMISSON SLIP

POSTING ATHLETIC PICTURES ON THE FWHS WEBSITE

I hereby DO NOT give my consent for _________________________________________ (STUDENT) to have his/her picture placed on the Flowing Wells High School website for the purpose of recognizing his/her athletic accomplishments while participating in an athletic event . Your child’s picture will include a caption describing his/her accomplishments and his/her name. My signature indicates I am not in support for posting this information. _________________________ ________________________________________ (DATE) (PARENT’S SIGNATURE)

AWARDS, LOCKER AND FUND RAISING POLICIES

To Student-Athletes and Parents/Guardians:

1. Student-athletes who quit a team or are removed from a team before the end of the season are not entitled to any of the team awards and/or rewards available to remain with a team throughout the season. The minimum requirement to receive team awards and/or rewards is satisfactory completion of team membership through the conclusion of the season.

2. Student-athletes are issued lockers for use during their season of competition.

Student-athletes who quit a team or are removed from a team before the end of the season must clear their assigned locker of all athletic equipment and/or uniforms as well as any personal items within 72 hours after quitting a team or being removed from a team. All school issued athletic equipment and/or uniforms are to be returned to the high school equipment manager within 72 hours after quitting a team or being removed from a team.

After the 72-hour deadline has passed, the high school equipment manager and athletic director are authorized to clear the assigned locker without the presence or permission of the student-athlete. The athletic director will record all items removed from the locker. Athletic equipment and/or uniforms issued by the school will be checked against the items issued to the student-athlete and returned to the athletic storage area. Items not issued by the high school equipment manager will be turned over to the high school lost and found.

3. The money raised by student-athletes, as a member of a team, will be deposited

into that team’s club account. The money raised through fund raising efforts belongs to the team and not to the student-athlete who raised the money. The team or club is not obligated to return or refund any money to student-athletes who quit the team or are removed from the team.

Fund raising efforts performed by student-athletes while the student-athlete is a member of a team does not obligate the team or club account to purchase or give awards, rewards, or items because the student-athlete participated in the fund raising efforts of the team.

Student Signature __________________________________ Date ________________ Parent Signature____________________________________ Date _______________

CONSENT TO TREAT FORM

Parental consent for minor athletes is generally required for sports medicine services, defined as services including, but not limited to, evaluation, diagnosis, first aid and emergency care, stabilization, treatment, rehabilitation and referral of injuries and illnesses, along with decisions on return to play after injury or illness. Occasionally, those minor athletes require sports medicine services before, during and after their participation in sport-related activities, and under circumstances in which a parent or legal guardian is not immediately available to provide consent pertaining to the specific condition affecting the athlete. In such instances it may be imperative to the health and safety of those athletes that sports medicine services necessary to prevent harm be provided immediately, and not be withheld or delayed because of problems obtaining consent of a parent/guardian. Accordingly, as a member of the Arizona Interscholastic Association (AIA), ____________________________ (name of school or district) requires as a pre-condition of participation in interscholastic activities, that a parent/guardian provide written consent to the rendering of necessary sports medicine services to their minor athlete by a qualified medical provider (QMP) employed or otherwise designated by the school/district/AIA, to the extent the QMP deems necessary to prevent harm to the student/athlete. It is understood that a QMP may be an athletic trainer, physician, physician assistant or nurse practitioner licensed by the state of Arizona (or the state in which the student/athlete is located at the time the injury/illness occurs), and who is acting in accordance with the scope of practice under their designated state license and any other requirement imposed by Arizona law. In emergency situations, the QMP may also be a certified paramedic or emergency medical technician, but only for the purpose of providing emergency care and transport as designated by state regulation and standing protocols, and not for the purpose of making decisions about return to play.

PLEASE PRINT LEGIBLY

“I, ________________________________, the undersigned, am the parent/legal guardian of,

_________________________________, a minor and student/athlete at ______________________________ who

intends to participate in interscholastic sports and/or activities.

I understand that the school/district/AIA employs or designates QMP’s (as defined above) to provide sports medicine services (as also defined above) to the school’s interscholastic athletes before, during or after sport-related activities, and that on certain occasions there are sport-related activities conducted away from the school/district facilities during which other QMP’s are responsible for providing such sports medicine services. I hereby give consent to any such QMP to provide any such sports medicine services to the above-named minor. The QMP may make decisions on return to play in accordance with the defined scope of practice under the designated state license, except as otherwise limited by Arizona law. I also understand that documentation pertaining to any sports medicine services provided to the above-named minor, may be maintained by the QMP. I hereby authorize the QMP who provides such services to the above-named minor to disclose such information about the athlete’s injury/illness, assessment, condition, treatment, rehabilitation and return to play status to those who, in the professional judgment of the QMP, are required to have such information in order to assure optimum treatment for and recovery from the injury/illness, and to protect the health and safety of the minor. I understand such disclosures may be made to above-named minor’s coaches, athletic director, school nurse, any classroom teacher required to provide academic accommodation to assure the student/athlete’s recovery and safe return to activity, and any treating QMP. If the parent believes that the minor is in need of further treatment or rehabilitation services for the injury/illness, the minor may be treated by the physician or provider of his/her choice. I understand, however, that all decisions regarding same day return to activity following injury/illness shall be made by the QMP employed/designated by the school/district/AIA. Date: ______________________ Signature ____________________________________________________________

This last page is for Freshmen or New Athletes only, all

returning athletes DO NOT need to do the 2 steps listed

below if you have already done them.

1. Please attach your BIRTH CERTIFICATE HERE

2. BrainBook Concussion on-line Course

Please follow the steps below to take and complete the course. The course must be completed with a grade

of 80%. Then the certification must be printed and attached to your athletic packet.

Steps to take the on-line course from Brain Book

1. Login with your FW Login info (if doing this OFF campus, at home, etc, you can skip this step and start with 2.)

2. Open up a browser and type http://aiaacademy.org/users/login/brainbook

3. Click on REGISTER AS A STUDENT

4. Fill in the registration Information

5. Take the survey and complete the course

6. PRINT THE CERTIFICATE AND ATTACH IT TO THE ATHLETIC PACKET

Attach the Concussion Training

Certification to the Athletic packet

ATTENTION TRANSFER STUDENTS: Please go

to Athletic Office to fill out 520 form.