East Ridge Middle School
2022-2023
Student-Athlete
Eligibility Packet
Student name_______________________________Grade_______
Dear Future Spartan Athletes and Parents,
Welcome to East Ridge Middle School sports! If your child has received this packet they have expressed an interest in trying out for one of our extracurricular sports. This packet contains all the information we will need to allow your student to attend intramurals and tryouts.
Please look over this packet and fill it out completely. If there is any missing information the form will be returned to you and your student will not be allowed to attend practice. Each athlete will need a current athletic physical (different from a normal physical). If the physical is dated before June of 2022, they will need to get a new physical to ensure that they will be eligible for the entire season. POP WARNER physicals and the health department SCHOOL ENTRY physicals are NOT ACCEPTED. Be sure to include your health insurance information where indicated. Each athlete is required to have health insurance; if you do not have insurance you may purchase school insurance. Please see the front office for more information about school insurance or visit www.schoolinsuranceofflorida.com. A copy of your health insurance card MUST be attached to your packet.
Each sport will have a specific deadline for turning in paperwork. If your student athlete misses that deadline, or if their paperwork is not complete by the deadline, they will not be allowed to participate in that specific sport. This, however, does not exclude them from participating in a future sport that same school year.
All sports will consist of a few weeks of intramurals, followed by tryouts and the interscholastic season. Every eligible student is allowed to participate in intramurals and the coach for each sport will choose the interscholastic team after tryouts. Attendance throughout intramurals is a necessity if your student would like to play on the interscholastic team. Please be sure you are there to pick up your student on time. Two late pickups will result in removal from the team. Check the athletic calendar on the school website for practice times. Practice times are subject to change though, so please have your student listen to their coaches and to the announcements for schedule changes and check the calendar on a regular basis.
The coaching staff here at East Ridge Middle School and I look forward to working with you and your student athletes. Please do not hesitate to contact me if you have any questions or concerns.
Thank you and GO SPARTANS!
ERMS Athletic Director Scott St. Clair
Parent Signature__________________________ Student Signature____________________
LAKE COUNTY SCHOOLS
SPORTS SCREENING PHYSICAL EXAMINATION
NOTICE TO PARENT/LEGAL GUARDIAN
Lake County Schools recommends that your child have a yearly comprehensive physical examination by your personal physician. The screening sport physical, given by volunteer doctors, are not intended to replace your child’s regular health maintenance. It is the responsibility of the parent/guardian to make the choice for medical care regarding your child. It is your clear understanding that participation in athletic activities creates a risk normally associated with such activities and that the risk increases as the sport becomes more vigorous and/or involves bodily contact.
PARENTAL/LEGAL GUARDIAN & CHILD/WARD NOTICE OF RESPONSIBILITY & CONSENT FOR PARTICIPATION
As a parent/legal guardian of a student who will be participating in any Lake County School Board (LCSB) athletic activity, your authorization to permit your child/ward to participate requires you understand and agree to certain rules, responsibilities and regulations.
1. Athletics is a sports activity that will require your child/ward to maintain satisfactory grades and behavior in accordance with the LCSB Code of Conduct and school/team rules. Once a child is approved for sports activities you hereby give consent for participation.
2. You understand if a parent, guardian or student falsifies any signature or information on the sports screening physical examination form, the child/ward will be declared ineligible to participate in any Lake County interscholastic activity for one full calendar year from disclosure date.
3. You understand that your child/ward must have a physical evaluation each year and be certified as being physically fit to participate in interscholastic athletic programs. A physical evaluation shall be valid for a period not to exceed one calendar year from the date of practitioner’s signature. The student cannot be allowed to participate in any activity related to interscholastic athletic programs until the fully executed physical evaluation form is on file in the school.
4. You further give permission for appropriate school staff and their designees to render medical treatment or authorize medical treatment by a hospital and/or doctor and agree to hold LCSB and its employees harmless in the administration of such assistance.
5. You understand that if the child/ward consults a medical physician concerning any injury received in a LCSB sponsored athletic practice or interscholastic sports contest, written medical approval must be obtained from a physician prior to the child/ward’s further participation in activity. You understand that a written doctor’s note on the doctor’s stationary or prescription pad must be given to the athletic trainer or athletic director before that student will be allowed to resume activity.
6. You also consent for your child to be transported in connection with participation in athletic activities. You fully understand that this consent is given knowing that your child/ward’s participation in approved activities may, from time to time, require travel out of state as well as out of and within Lake County. You realize, and agree, that the travel may be by private or publicly owned vehicles, bus, passenger car, on foot or various other means, as deemed appropriate and approved by the school principal.
7. Athletics require that your child/ward and you commit to timely arrival and departure from the activity in accordance with the directive issued by the school principal or coach designated by the school principal to direct said activities. Your failure to timely pick up your child/ward may result in your child/ward’s exclusion from the athletic activity.
8. You do authorize and give permission to the school principal, coaches, and school representatives to release your child at the conclusion of the athletic activity. You do authorize and give permission to your child to individually determine his/her method and means of returning to your home upon conclusion of any daily athletic activity including but not limited to his/her walking, riding with a friend, or any other means of transportation he/she chooses. If you have elected to give your child/ward
permission herein, you hereby release the LCSB, its employees, agents, and assigns, from any and all liability or claim that may arise from or after your child/ward leaves the athletic activity.
9. You do grant permission to the school principal, coaches, school representatives the right to photograph and/or videotape your child/ward and further to use name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, and promotional materials without reservation or limitation.
10. You do grant permission to LCSB to release any and all athletic injury information relating to the named athlete to the Sports Medicine Program Injury Registry.
11. In addition to the routine sports screening evaluation required by FHSAA Bylaws, you understand and acknowledge that you are hereby advised that your child/ward should undergo a cardiovascular assessment, which may include such diagnostic tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test provided by your personal physician.
12. You further hereby authorize the use or disclosure of your child’s/ward’s individually identifiable health information should treatment for illness or injury become necessary. You understand that this authorization is voluntary and that you may revoke it at any time by submitting the revocation in writing to your child/ward’s school principal.
13. Hazing is defined as any method that causes, or is likely to cause, bodily danger or physical harm, or serious mental or emotional harm to any student. You understand activities that expose individuals to embarrassment, abuse, ridicule, or humiliation will not be tolerated and are subject to enforcement under the LCSB Code of Conduct, depending upon the seriousness of the violation.
14. You and child/ward have read and discussed the LCSB Code of Conduct and acknowledge that she/he may be disciplined or removed from a team if any of the provisions are violated.
I hereby acknowledge and certify that I have read the sports screening document.
I understand and agree to be bound by its terms.
__________________________________ _________________________________________________ __________
Signature of Parent/Legal Guardian Print Name of Parent/Legal Guardian Date
___________________________________ _______________________________________________ _____________
Signature of Student Print Legal Name of Student Date
FAMILY / STUDENT HEALTH HISTORY
Student Name_____________________________________________________ DOB ________________________ Sex ____
Street Address
_____________________________________________________________________________________________________
City______________________________State_____________________________ Zip Code ____________________________
Home Phone _____________________________________________ Other Phone(s) _________________________________
Identify the answer for each of the following questions as well as circle any questions you are unable to answer. Explain “yes” answers on the next page.
YES NO Have you had a medical illness or injury since your last medical check or sports physical? YES NO Do you have an ongoing chronic illness?
YES NO Have you ever been hospitalized overnight?
YES NO Are you currently taking any prescription or nonprescription medications or pills or using an inhaler? YES NO Have you taken any supplements or vitamins to help you gain or lose weight to improve performance? YES NO Do you have any allergies? (For example pollen, medicine, latex, food, or stinging insects) YES NO Have you ever had a rash or hives develop during or after exercise?
YES NO Have you ever passed out during or after exercise?
YES NO Have you ever been dizzy during or after exercise?
YES NO Do you get tired more quickly than your friends do during exercise?
YES NO Have you had a severe viral infection? (For example: myocarditis or mononucleosis)
YES NO Do you have any current skin problems? (For example: itching, rashes, acne, warts, fungus, blisters or pressure sores) YES NO Have you ever become ill from exercising in the heat?
YES NO Do you cough, wheeze, or have trouble breathing during or after activity?
YES NO Do you have asthma?
YES NO Do you have seasonal allergies that require medical treatment?
YES NO Have you had any problems with your eyes or vision?
YES NO Do you wear glasses, contacts, or protective eyewear?
YES NO Have you ever had a sprain, strain or swelling after injury?
YES NO Have you broken or fractured any bones or dislocated any joints?
YES NO Do you want to weigh more or less than you do now?
YES NO Has your weight fluctuated up or down over the past year?
YES NO If you are female, do you experience any problems with your period?
YES NO Do you use any special protective or corrective equipment or medical devices that aren’t usually for your sport or position?
(knee brace, special neck roll, foot orthotics, shunt, retainer on your teeth or hearing aid)
YES NO Have you ever been hospitalized? (Include date(s) in explanation)
YES NO Have you ever had surgery? (Include date(s) in explanation)
YES NO Have you ever had a seizure?
YES NO Do you have frequent or severe headaches?
YES NO Have you ever had a head injury or concussion? (Include how many and how long ago) YES NO Have you ever been rendered unconscious, or lost your memory?
YES NO Have you ever had a stinger, burner or pinched nerve?
YES NO Have you ever had numbness or tingling in your arms, hands, legs or feet?
YES NO Have you ever had chest pain during or after exercise?
YES NO Have you ever had racing of your heart or skipped heartbeats?
YES NO Have you had high blood pressure or high cholesterol?
YES NO Have you ever been told you had a heart murmur?
YES NO Have you ever been diagnosed with sickle cell anemia?
YES NO Have you ever been diagnosed with the sickle cell trait?
YES NO Has a physician ever denied or restricted your participation in sports for any heart problems?
YES NO Has any family member or relative died of heart problems or sudden death before age 50?
YES NO Have you had any injuries to, or experienced pain or swelling in muscles, tendons, bones, or joints? If YES, check appropriate area and explain below:
___head ___elbow ___neck ___ankle ___thigh ___back ___wrist ___toe ___hand ___shin/calf ___shoulder ___finger ___upper arm ___foot ___forearm ___chest ___hip ___knee
Record the dates of your most recent immunizations (shots) for
Tetanus _______________ Measles ________________
Hepatitis B _______________ Chickenpox _______________
EXPLAIN YES ANSWERS BELOW (If more space is needed; attach page.)
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
VERIFICATION OF MEDICAL INSURANCE
Know that I/we do hereby waive, relinquish, remise, and release the LCSB from any claim or cause of action which may arise as a result of my/our said minor child participating in the athletic program of the public school system of Lake County, insofar as I/we have elected to assume said risk, I/we have insured myself/ourselves against said risk. I/We further relieve and release said LCSB from any liability in its failure to provide insurance upon my/our said child/ward while he/she shall be engaged in
the program of said public school system. I/We am providing information for medical insurance coverage for my child/ward. If I/we falsify any insurance information I/we understand that my child/ward will forfeit athletic eligibility from date of disclosure. The information below is required for participation.
A copy of your valid insurance card must be attached; if you do not have family insurance you must purchase and sign below that you have football and/or school insurance for your child/ward.
Name of insurance company
________________________________________________________________________________
Insurance policy number
___________________________________________________________________________________
Name of insurance contact
__________________________________________________________________________________
Insurance company phone number
___________________________________________________________
___________________________________ ______________________________________________ ________________________ Signature of Parent/Legal Guardian Print Name of Parent/Legal Guardian Date
Copy of Insurance Card (Front) | Copy of Insurance Card (Back) |
PHYSICAL EXAMINATION (to be completed by licensed physician, licensed chiropractic physician, licensed osteopathic physician, licensed physician assistant or certified advanced nurse practitioner).
Student Name (please print)
_____________________________________________________________________________________________________ List all sport(s) in which child/ward will participate.
______________________________________________________________________________________________________ _
Height __________ Weight ___________ % Body Fat (optional) ____________
Resting Pulse __________ Blood Pressure ___________ Temperature _______________
Hearing – Right P __________ F __________ Left P __________ F ________
Visual Acuity - Right: 20/____________ Left: 20/ ____________ Corrected YES NO
Pupils Equal________ Unequal _________
MEDICAL FINDINGS NORMAL ABNORMAL FINDINGS
General Appearance _________ __________________________________________ Eyes/Ears/Nose/Throat _________ __________________________________________ Lymph Nodes _________ __________________________________________ Heart _________ __________________________________________ Pulses _________ __________________________________________ Lungs _________ __________________________________________ Abdomen _________ __________________________________________ Genitalia (males only) _________ __________________________________________ Skin _________ ___________________________________________ Musculoskeletal
Neck _________ ___________________________________________ Back _________ ___________________________________________ Shoulder, Arm _________ ___________________________________________ Elbow, Forearm _________ ___________________________________________ Wrist, Hand _________ ___________________________________________ Hip, Thigh _________ ___________________________________________ Knee _________ ___________________________________________ Leg, Ankle _________ ___________________________________________ Foot _________ ___________________________________________ ASSESSMENT OF EXAMINING PHYSICIAN ASSESSMENT
______ Cleared without limitation
______ Disability ___________________________________________Diagnosis _____________________________________
______________________________________________________________________________________________________ __
______________________________________________________________________________________________________ _
Precautions
______________________________________________________________________________________________________ _
______________________________________________________________________________________________________ __
______________________________________________________________________________________________________ __
Disability __________________________________________ Diagnosis______________________________________
______________________________________________________________________________________________________ __
______________________________________________________________________________________________________ __
______ Not cleared for _____________________________________ Reason
________________________________________
Recommendations
_____________________________________________________________________________________________________
______________________________________________________________________________________________________ __
______________________________________________________________________________________________________ __
Physician Signature ______________________________________________________________ Date __________________ Physician office stamp must be on this page.
LAKE COUNTY SCHOOLS
EMERGENCY TREATMENT AUTHORIZATION CARD – FILL THIS PAGE OUT ENTIRELY
(Please Print)
Student Legal Name ____________________________________________________ School ____________________________________ Grade__________ Student DOB _______________________________ Date of last tetanus shot______________________ My child/ward has the following allergies
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Child/ward is allergic to the following medications
__________________________________________________________________________________________________________________ Please identify any serious injuries or disease your child/ward has had ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
Name alternate contact in case of emergency
________________________________________________________________________________
Telephone Number
_____________________________________________________________________________________________________
Primary Care Doctor Name
______________________________________________________________________________________________
Telephone Number
_____________________________________________________________________________________________________
I/We the parent/guardian understand that the medical insurance coverage for our/my child/ward is my/our responsibility; whether it is family insurance or purchased school insurance. I/we relieve and release LCSB from any liability in its failure to carry insurance upon our/my child/ward. I/We are providing information for medical insurance coverage for my/our child/ward. I/We further understand that if I/We falsify any insurance information that my/our child/ward will forfeit athletic eligibility from date of disclosure. The information below is required for participation, if you do not have family insurance you must purchase and identify below that you have football/school insurance for your child/ward.
Name of Insurance Company
_____________________________________________________________________________________________
Insurance Policy Number
________________________________________________________________________________________________
Name of Insurance Contact
______________________________________________________________________________________________
Telephone Number
_____________________________________________________________________________________________________
I/We further give permission for appropriate school staff and their designees to render medical treatment or authorize medical treatment by a hospital and/or doctor and agree to hold the Lake County School Board and its employees harmless in the administration of such assistance. I/We hereby acknowledge and certify that I/We have read the emergency medical document and I/We understand and agree with its terms. According to Florida Statues (92.525) "Under penalties of perjury, I/we declare that I/we have read the foregoing and that the facts stated in it are true." I/We agree to be bound by its terms and I/we have reviewed and explained the notice with my/our child/ward.
____________________________________________ ___________________________________________________ ____
Signature of Parent/Legal Guardian Print Name of Parent Legal Guardian Date
Telephone (H) ________________________________ Telephone (W)
___________________________Other__________________________
Street Address
___________________________________________________________________________________________________________________ City _________________________________________________________ State _________________________ Zip ____________________
LAKE COUNTY SCHOOLS
NOTIFICATION OF RISK AGREEMENT for MIDDLE SCHOOL ONLY
All athletic forms for eligibility must be completed and returned to the school athletic office before your child/ward will be permitted to try out, practice or participate in any athletic event. I/We have marked, for the current school year, and I/we hereby give permission for our child/ward to participate in the following activities.
____________ALL SPORTS ______________SOCCER __________CROSS COUNTRY ____________BASKETBALL ______________VOLLEYBALL ___________FLAG FOOTBALL
I/We am/are aware that playing or practicing any sport can be dangerous in nature involving many risks of injury, including but not limited to death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, serious injury to virtually all internal organs, and serious injury or impairment to other aspects of the body, general health and well being. I/We understand that the dangers and risks of playing or practicing in any of the above sports may result not only in serious injury, but in serious impairment of my child’s/ward’s future abilities to earn a living, to engage social and recreational activities, and generally to enjoy life. Because of the dangers of participating in any sport, I/We recognize the importance of following coaches’ instructions regarding playing techniques and training, Lake County School Board (LCSB) Code of Conduct, school policies and other team rules and my/our child/ward agrees to obey such instructions.
As consideration for the LCSB allowing my child/ward to participate, practice or try out for any LCSB sponsored athletic activity, I/We understand that there is a risk of injury associated with all athletic activity including, but not limited to injury caused by contact, physical conditioning, exertion, medical conditions known or unknown, equipment defects, equipment failures, equipment misuse or equipment maintenance, playing field conditions, playing field maintenance, facility conditions, facility maintenance, intentional acts of third-persons, supervision and student disregard of conduct codes and safety instructions, to which my child/ward may be exposed. I/We agree to assume the risk set out above and, on my/our own behalf and on behalf of my/our child/ward, heirs, executors and administrators, release and forever discharge the released parties defined below, of and from all liabilities claims, actions, damages, or costs or expense of any nature arising of my/our child/ward playing, practicing or trying out for any athletic activity. I/We further agree to indemnify and hold each of the released parties harmless against any and all such liabilities, claims, actions, damages, costs or expenses including, but not limited to, attorney’s fees and disbursements. The released parties are the LCSB, its employees, agents, representatives and any of its insurers. I/We understand that this Notification of Risk Agreement includes any claims based on the negligent actions or inactions of any of the above-released parties and covers bodily injury and property damage whether suffered by me/us, my/our child/ward before, during or after such participation. I/We further authorize medical treatment for said child or ward at my/our cost if the need arises.
I/We hereby authorize the use or disclosure of my individually identifiable health information should treatment for illness or injury become necessary. I/We hereby grant to FHSAA the right to review all records relevant to my/our child’s/ward’s athletic eligibility including, but not limited to, his/her records relating to enrollment and attendance, academic standing, age, discipline, finances, residence and physical fitness. I/We hereby grant the released parties the right to photograph and/or videotape my/our child/ward and further to use his/her name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein. I/We understand that the authorizations and rights granted herein are voluntary and that I/we may revoke any or all of them at any time by submitting said revocation in writing to my/our child’s/ward’s school; in doing so, however, /I/we understand that I/we will no longer be eligible for participation in interscholastic athletics.
By signing this Agreement below, I/we affirm that I/we have read the afforded mentioned Notification of Risk. Agreement and voluntarily and knowingly agree to be legally bound by its provisions.
__________________________________ ___________________________________________ __________
Signature of Parent/Legal Guardian Print Name of Parent/Legal Guardian Date
__________________________________ __________________________________________ __________
Signature of Student Print Legal Name of Student Date
Lake County Schools
Voluntary Extracurricular Activities
Authorization Form and Liability Waiver and Release
I, ___________________________. The parent/legal guardian of (hereafter "child/ward) give permission for my child/ward to participate in voluntary extracurricular activities sponsored by Lake County Schools.
Beginning in the summer of 2022 and continuing into the 2022-2023 school year, certain voluntary extracurricular activities will be available to your child/ward. Due to COVID-19 and general health and safety concerns, these activities, hereinafter known as "Activity" will be conducted with safety protocols appropriate under the circumstances at the time. For the safety of all people involved, participants in the Activity will be required to adhere to all safety protocols and are subject to immediate removal from the Activity if they do not comply. Extracurricular activities are voluntary and a privilege, not a right, of public school students.
In an effort to ensure the safety and wellness of our school community, I understand the importance of students being healthy and safe when they participate in the Activity. By signing below I agree that I will:
• Keep my child/ward home if they show any signs of illness.
• Promptly pick up my child/ward or arrange for pickup if signs or symptoms of illness are present.
• Follow all Health Department, CDC, State, Local, District and School guidelines relating to COVID 19 safety protocols, quarantine and/or isolation guidelines and any other applicable regulations, rules or recommendations.
By signing this document below, I acknowledge and affirm all of the statements above. I also voluntarily assume all risks of injury as well as the potential exposure and/or infection of COVID-19 as a result of the participation in the Activity. I agree that such injury, exposure or infection may result in personal injury, illness, sickness and/or death. I understand that the risk of exposure or infection may result from the actions, omissions, or negligence of myself, my child/ward, LCS staff, volunteers, or agents, other Activity participants, or others not listed, and I acknowledge that all such risks are known to me.
In consideration of being permitted to participate in the Activity and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, it is hereby agreed as follows:
I HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT SO SUE, the School Board of Lake County, Florida, and its insurers, members, employees, representatives, contractors, sponsors, agents, successors and assignors (collectively referred to as "Released Parties") from all liability to my child/ward, me, my personal representatives, assigns, heirs and next of kin for any and all loss or damage, and any claim or demands therefore on account of illness or injury of my child/ward and or myself to the person or property or resulting in death, whether caused by the negligence of the releases collectively, of third parties, or otherwise while my child/ward and/or I are observing, attending or in any way participating in the Activity.
I HEREBY AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Released Parties and each of them from any loss, liability, damage, or cost they may incur due to my child/ward's or my presence in or upon the area or in any way observing, attending, or in any way participating in the Activity, whether caused by the negligence of the Released Parties or otherwise.
I EXPRESSLY ACKNOWLEDGE AND AGREE THAT ATTENDING, OBSERVING, AND/OR PARTICIPATING IN THE ACTIVITY COULD BE DANGEROUS AND INVOLVE RISK OR SERIOUS INJURY AND/OR DEATH TO ME AND/OR MY CHILD/WARD AND/OR PROPERTY DAMAGE.
I HEREBY ASSUME FULL RESPONSIBILITY FOR COVID-19 EXPOSURE, ILLNESS AND RISK OF BODILY INJURY, DEATH OF MY CHILD/WARD AND OR ME OR PROPERTY DAMAGE due to the Negligence of Released Parties or otherwise while in or upon the area and/or while observing, attending, or in any way participating in the Activity.
I further expressly agree that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by law of the State of Florida and that if any portion thereof is heldinvalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Further, I agree that if any of the Released Parties seek to enforce this Release due to any claims made by me or by any third party, I will indemnity them for all costs associated with enforcement of this Release, including, but not limited to
attorney's fees.
I acknowledge that I have read this Release carefully, in its entirety and fully understand its terms. I acknowledge I have given up substantial rights by signing this form and have signed it freely and voluntarily, intending to be legally bound.
Parent/Guardian Printed Name: ____________________________Date: ____________________
Parent/Guardian Signature: ________________________