They must be completed and turned in every year, …...Dear Parents, I am extremely excited about how well our sports programs performed this year and the 2017-2018 school year will

Dear Parents,

I am extremely excited about how well our sports programs performed this year and the 2017-2018 school year will be here before you know it. Please click on the following links for the important forms that need to be completed in order for your son or daughter to participate in athletics next year.

The Health Examination Form needs to be completed by your doctor. This can be done during a student’s physical.

The Informed Consent Form needs to be completed by a parent and the student.

Concussion Information Form needs to be signed by a parent and student.

Parent Driver Form needs to be signed by a parent.

ALL forms must be completed and returned to me by August 15, 2017. Doctors forms must be emailed to [email protected] or printed and brought to the front desk between 10:00 am and 4:00 pm M-F.

They must be completed and turned in every year, regardless if they were done in previous years, in order to be cleared to participate in a practice or game.

I strongly urge you to consider completing all forms, even if you believe your child will not be participating in sports this next school year. Many students change their minds and decide to try a new sport last minute. If I have a completed medical form signed by a doctor’s office and the parent consent completed by the parent, and the concussion information sheet signed the student-athlete will be able to play immediately. This will save time, energy, and stress in the long run if all forms are completed before the school year begins.

Our Fall Sports offerings are as follows: Girls Volleyball, Soccer, and Cross Country.

The following link will take you to the athletics calendar, where you can download team calendar feeds and find information regarding practice times and game schedules: https://kehillah.org/athletics/teams-and-schedules/

Please make a note on your calendar that the fall sports meeting will be held on Thursday, August 17th at 4:00pm at Kehillah.

We will discuss participant expectations as well as coach expectations, practice times, game schedules, and all details regarding the Fall Sports program. I am looking forwarding to working with you and all of the students this upcoming school year.

Go Rams!

Howard Kaplan Athletic Director

A Sudden Cardiac Arrest Information Sheet for Athletes and Parents/Guardians

What is sudden cardiac arrest? Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly.When this happens blood stops flowing to the brain and other vital organs. SCA is NOT aheart attack. A heart attack is caused by a blockage that stops the flow of blood to theheart. SCA is a malfunction in the heart’s electrical system, causing the victim to collapse.The malfunction is caused by a congenital or genetic defect in the heart’s structure.How common is sudden cardiac arrest in the United States? As the leading cause of death in the U.S., there are more than 300,000 cardiac arrestsoutside hospitals each year, with nine out of 10 resulting in death. Thousands ofsudden cardiac arrests occur among youth, as it is the #2 cause of death under 25and the #1 killer of student athletes during exercise.

Who is at risk for sudden cardiac arrest?SCA is more likely to occur during exercise or physicalactivity, so student-athletes are at greater risk. Whilea heart condition may have no warning signs, studiesshow that many young people do have symptoms butneglect to tell an adult. This may be because they areembarrassed, they do not want to jeopardize their play-ing time, they mistakenly think they’re out of shape and need to train harder, orthey simply ignore the symptoms, assuming they will “just go away.” Additionally,some health history factors increase the risk of SCA.

What should you do if your student-athlete is experiencing any of thesesymptoms? We need to let student-athletes know that if they experience any SCA-relatedsymptoms it is crucial to alert an adult and get follow-up care as soon as possiblewith a primary care physician. If the athlete has any of the SCA risk factors, theseshould also be discussed with a doctor to determine if further testing is needed.Wait for your doctor’s feedback before returning to play, and alert your coach,trainer and school nurse about any diagnosed conditions.

The Cardiac Chain of SurvivalOn average it takes EMS teams up to 12 minutes to arrive

to a cardiac emergency. Every minute delay in attending

to a sudden cardiac arrest victim decreases the chance

of survival by 10%. Everyone should be prepared to take

action in the first minutes of collapse.

Early Recognition of Sudden Cardiac ArrestCollapsed and unresponsive.Gasping, gurgling, snorting, moaning or labored breathing noises.Seizure-like activity.

Early Access to 9-1-1Confirm unresponsiveness.Call 9-1-1 and follow emergency dispatcher's instructions.Call any on-site Emergency Responders.

Early CPRBegin cardiopulmonary resuscitation(CPR) immediately. Hands-only CPR involves fastand continual two-inch chest compressions—about 100 per minute.

Early DefibrillationImmediately retrieve and use an automated external defibrillator (AED) as soon as possible to restore the heart to its normal rhythm. MobileAED units have step-by-step instructions for a by-stander to use in an emergency situation.

Early Advanced CareEmergency Medical Services (EMS) Responders begin advanced life support including additional resuscitative measures andtransfer to a hospital.

Cardiac Chain of Survival Courtesy of Parent Heart Watch

What is an AED? An automated external defibrillator (AED) is the only way to save a suddencardiac arrest victim. An AED is a portable, user-friendly device that automat-

ically diagnoses potentially life-threatening heartrhythms and delivers an electric shock to restore nor-mal rhythm. Anyone can operate an AED, regardless oftraining. Simple audio direction instructs the rescuerwhen to press a button to deliver the shock, whileother AEDs provide an automatic shock if a fatal heartrhythm is detected. A rescuer cannot accidently hurt a

victim with an AED—quick action can only help. AEDs are designed to onlyshock victims whose hearts need to be restored to a healthy rhythm. Checkwith your school for locations of on-campus AEDs.

A E D

FAINTINGis the

#1SYMPTOMOF A HEART CONDITION

Keep Their Heart in the Game

Recognize the Warning Signs & Risk Factorsof Sudden Cardiac Arrest (SCA)

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

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

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

STUDENT-ATHLETE SIGNATURE PRINT STUDENT-ATHLETE’S NAME DATE

PARENT/GUARDIAN SIGNATURE PRINT PARENT/GUARDIAN’S NAME DATE

For more information about Sudden Cardiac Arrest visit

California Interscholastic Federation Eric Paredes Save A Life Foundation National Federation of High Schoolshttp.www.cifstate.org http:www.epsavealife.org (20-minute training video)

https://nfhslearn.com/courses/61032

Potential Indicators That SCA May Occur� Fainting or seizure, especially during or

right after exercise

� Fainting repeatedly or with excitement orstartle

� Excessive shortness of breath during exercise

� Racing or fluttering heart palpitations or irregular heartbeat

� Repeated dizziness or lightheadedness

� Chest pain or discomfort with exercise

� Excessive, unexpected fatigue during orafter exercise

Factors That Increase the Risk of SCA� Family history of known heart abnormalities or

sudden death before age 50

� Specific family history of Long QT Syndrome, Brugada Syndrome, Hypertrophic Cardiomyopathy, orArrhythmogenic Right Ventricular Dysplasia (ARVD)

� Family members with unexplained fainting, seizures,drowning or near drowning or car accidents

� Known structural heart abnormality, repaired or unrepaired

� Use of drugs, such as cocaine, inhalants, “recreational” drugs, excessive energy drinks or performance-enhancing supplements

Keep Their Heart in the Game

Student-athlete Name Printed Student-athlete Signature Date

Parent/Guardian Printed Parent/Guardian Signature Date

SUDDEN CARDIAC ARREST AND CONCUSSION INFORMATION SHEET

I have read and understood the contents of the Kehillah Jewish High School Sudden Cardiac Arrest and Concussion Information Sheet. I understand

that the lack of knowledge of a rule or procedure is not an excuse. I understand that I will not be able to practice or play without having signed

and submitted this form.

Please return all forms by August 12, 2016

ATHLETIC DEPARTMENT DRIVER’S LIABILITY INSURANCE STATEMENT

Thank you for your interest in transporting Kehillah students on a school sponsored athletic contests. This statement is required when a person who is not a direct employee drives a vehicle carrying students on a school-sponsored athletic contest.

Please include a copy of your driver’s license, vehicle registration, and car insurance with this form.

Name of driver: _______________________________

Owner of vehicle: _____________________________

Make of vehicle: _____________________ License plate number: _____________

(There must be an operable seat belt for the driver and each passenger)

Insurance carrier: __________________ Policy Number: ______________

CA Driver’s License Number: _________________ Expiration Date: ______

I have not been convicted of a misdemeanor or felony driving under the influence charge. I do not have a driving under the influence pending. I have no had more than one moving violation within the past two years. I do not have more than one DMV point charged against my driving record.

I understand that my own automobile liability coverage is the prime coverage in case of an accident. It is my responsibility to inform the school immediately of any change in the above information.

The above statements are true to the best of my knowledge.

Parent Signature: _______________________________________

Date: ____________

Please return all forms by August 12, 2016

KEHILLAH JEWISH HIGH SCHOOL ATHLETIC PROGRAM Informed Consent and Permission for Interscholastic Sports

Student’s Name: ______________________________________________________________________________ Last First Middle Intl.

Grade: _________________ Date of Birth: _____________________ Student’s Cell: _____________________

Address: ___________________________________________________________________________________

__________________________________________________________________________________________

Legal Guardian Contact No. 1 Legal Guardian Contact No. 2

Name: __________________________________________ (please print)

Name: __________________________________________ (please print)

Day Phone: _______________________________________ Day Phone: _______________________________________

Evening Phone: ___________________________________ Evening Phone: ____________________________________

↓ Legal Guardians Initial items 1–8 and sign. Student Athletes Initial items 5-8 and sign.

______1. Permission to participate. By initialing and signing this form, I hereby grant permission for my student to participate in all interscholastic sports and to go with a representative of the school on any trips related to school activity. I am fully aware of what these athletic activities involve and I agree that Kehillah Jewish High School or its employees shall not be responsible for injuries incurred in practice, games, in traveling to or from practice or games. These extracurricular activities are not required of the student.

______2. Affirmation of Athletic Insurance. By initialing and signing this form, I confirm that my student athlete has medical and dental insurance coverage. Proof of this insurance must be provided to the Kehillah Registrar by August 1st.

______3. Transportation. It will usually be necessary to use private transportation for tournaments, games and field trips. If this is necessary, I give permission for my student to travel in a private vehicle, driven by a licensed, fully insured adult approved by Kehillah Jewish High School. By initialing and signing this form, I hereby give my consent for my student to go with a representative of the school on any trips.

______4. Medical & Dental Care Authorization. By initialing and signing this form, I agree that in the case of injury or illness requiring medical or dental treatment, every attempt will be made to contact the parent, but if necessary, a Kehillah Jewish High School representative is authorized to have my student transported and/or treated. Also see KJHS Medical and Dental Care Authorization form.

______5. Performance Enhancing Drugs. By initialing and signing this form, we acknowledge that it is illegal to use and abuse anabolic steroids. We further understand that Kehillah Jewish High School does not support the use of performance enhancing supplements and prohibits coaches from promoting such substances.

_____ Student Athlete initials ______6. By initialing and signing this form, we agree that the student shall not conspire to engage in hazing, participating in hazing, or commit any act that causes or is likely to cause bodily damage, physical harm, or personal degradation or disgrace resulting in physical or mental harm to any fellow student or person attending the institution. We understand that the student’s violation of this policy regarding hazing may result in discipline against him/her, including, but not limited to, restriction from athletics, suspension, or expulsion.

_____ Student Athlete initials ______7. Transcript Release. By initialing and signing this form, we hereby grant permission for the school to issue a student transcript to college recruiters.

_____ Student Athlete initials ______8. Informed Consent. By initialing and signing this form, we agree that the student athlete is a willing participant and we assume such risks as described below.We understand that there is a certain amount of risk associated with athletic participation. While competing in the Kehillah Jewish High School Athletic Program / Interscholastic Sports, my student athlete may suffer a fracture, sprain, contusion, laceration, abrasion, or other injuries. My student athlete may even suffer severe injuries such as brain injuries, paralysis or death. We are aware of and understand the risk of participating in the Kehillah Jewish High School Athletic Program / Interscholastic Sports.

_____ Student Athlete initials

If this form is signed by only one parent or guardian, I hereby certify that I have sole legal custody of the above-named minor.

Signature of Legal Guardian No. 1 Signature of Legal Guardian No. 2 Signature of Student Athlete

Date Date Date

Athlete Parent

KEHILLAH JEWISH HIGH SCHOOL ATHLETIC PROGRAM HEALTH EXAMINATION FORM

(Give this to the doctor to complete during student athlete’s physical exam, no earlier than 5/31/17)

Please return all forms by August 11, 2017

Student's Name Last First AGE BIRTHDATE

Address City Zip Phone #

Parent/Guardian Name (please print) Parent/Guardian Signature Date

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

ALL INFO BELOW & ON 2nd PAGE MUST BE COMPLETED BY PHYSICIAN

IMMUNIZATION RECORD

This record must be filled out by physician. It must include both month and year to be complete. It is a requirement of the State of California that all health forms be up-to-date. ______________________________________________________________________________________ VACCINE 1st 2nd 3rd 4th 5th Booster ______________________________________________________________________________________ Polio (OPV or IPV) / / / / / / / / / / / / ______________________________________________________________________________________ DTP/DTaP/DT/Td (Diphtheria, tetanus and (acellular) pertussis OR tetanus and diphtheria only) / / / / / / / / / / / / ______________________________________________________________________________________ MMR (Measles, mumps, and rubella) / / / / ______________________________________________________________________________________ Hepatitis B / / / / / / ______________________________________________________________________________________ Varicella (Chickenpox) / / / / ______________________________________________________________________________________

Last tetanus shot given _____________ Date of Physical Examination ____________________________

Have any tests or immunizations listed above caused severe illness? _____ Yes _____ No

TB SKIN TEST Type* Date given Date read mm indur Impression __ PPD-Mantoux __________ __ Pos __ Other / / / / __________ __ Neg *Must be Mantoux unless exception granted by local health department.

Chest X-Ray (Necessary if skin is positive.) Film date: / / Impression: __ Normal __ Abnormal

MEDICAL HISTORY IF STUDENT HAS HAD ISSUES WITH ANY OF THE FOLLOWING, CHECK YES AND EXPLAIN UNDER COMMENTS. IF NOT, CHECK NO. COMMENTS Seizures? _____ Yes _____ No ________________________________________ Speech, Hearing or Visual Difficulty?_____ Yes _____ No ________________________________________ Diabetes? _____ Yes _____ No ________________________________________ If yes, specify medication and if student brings his/her medication supplies to school. Heart or Pulmonary? _____ Yes _____ No ________________________________________ Orthopedic? _____ Yes _____ No ________________________________________ Allergy? _____ Yes _____ No ________________________________________ Does student carry a kit? _____ Yes _____ No ________________________________________ Is student on medication? _____ Yes _____ No ________________________________________

HAS THE STUDENT HAD ANY PREVIOUS DISEASES, OPERATIONS OR INJURIES THAT LIMIT HIM/HER FROM PARTICIPATION IN THE FOLLOWING ACTIVITIES? Classroom Activities _____ Yes _____ No ________________________________________ Physical Education _____ Yes _____ No ________________________________________ Competitive Athletics _____ Yes _____ No ________________________________________ Is there an emotional or physical condition for which this student should remain under periodic medical observation? _____ Yes _____ No ________________________________________ Is this student subject to fainting spells? _____ Yes _____ No ________________________________________ Does this student have any learning disability problems? _____ Yes _____ No ________________________________________ Height: ____________ Weight: ___________ Check ( ) if negative; otherwise please comment. COMMENTS AND RECOMMENDATIONS Skin ( ) Muscalature ( ) Reflexes ( ) Posture and Body Alignment ( ) Gait and extremities ( ) Ears ( ) Hearing Loss? ( ) Eyes ( ) Vision: 20/_____ 20/_____ Throat (tonsils, etc.) ( ) Lungs ( ) Heart ( ) Blood Pressure _________ Pulse Rate at Rest _________ Abdomen ( ) Hernia ( ) External Genitalia ( ) Teeth ( ) DISEASES: (check if student has had history of disease or condition) Chicken Pox ( ) Heart Disease ( ) Allergies, such as German measles ( ) Asthma ( ) to Penicillin ( ) Mumps ( ) Rheumatic Fever ( ) to Bee Stings ( ) Whooping Cough ( ) Epilepsy ( ) to Poison Oak ( ) Diabetes ( )

THIS STUDENT/ATHLETE IS MEDICALLY FREE TO PARTICIPATE IN INTERSCHOLASTIC ATHLETICS: Yes _____ No _____ RESTRICTIONS: (IF ANY) ______________________________________________________________________________________ Physician Name & Address (print or stamp) Physician Signature ___________________________________ Date _________________