2017 Spring Athletic Participation Form
This form provides the athletic department, coaches and trainer with all the information needed for the SPRING sports season. It must be completed prior to the first day of practice.

**All athletes must have a WIAA Physical Form on file in the athletic office showing a physician's signature for an examination after April 1, 2015.

Athlete Last Name
Your answer
Athlete First Name
Your answer
Student's School Email
Please include the full email with "@stu.waukesha.k12.wi.us"
Your answer
Sport
Graduation Year
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian Information:
Student lives with:
PRIMARY CONTACT Name
Your answer
Relationship to student:
Your answer
Email Address
Your answer
Current Address
Your answer
City
Your answer
Zip Code
Your answer
Most accessible phone number
Your answer
Employer
Your answer
Work Phone
Your answer
Work Hours
Your answer
SECONDARY Contact Name
Your answer
Relationship to student:
Your answer
Email Address
Your answer
Current Address
Your answer
City
Your answer
Zip Code
Your answer
Most accessible phone number
Your answer
Employer
Your answer
Work Phone
Your answer
Work Hours
Your answer
Emergency Contacts
If my child becomes ill or injured at school and I cannot be reached, we have made arrangements with the following local friends or relatives:
Contact #1 Name:
Additional contact person, not included above
Your answer
Contact #1 Phone:
Your answer
Contact #1 Relationship to Student:
Your answer
Contact #2 Name:
Your answer
Contact #2 Phone:
Your answer
Contact #2 Relationship to Student:
Your answer
Contact #3 Name:
Your answer
Contact #3 Phone:
Your answer
Contact #3 Relationship to Student:
Your answer
Health Information for Coaches and Trainers
Please enter the up-to-date contact and medical information for Waukesha North Coaches and Trainers
Physician name and phone number
Your answer
Dentist name and phone number
Your answer
Date of Last Physical Exam
A WIAA physical card with this date of physical and the physician's signature must be on file in the athletic office. This date must be after April 1, 2015 to be valid for the 2016-17 school year.
MM
/
DD
/
YYYY
Does the athlete have significant health concerns?
Required
Please use this space to explain health concerns listed above:
If none, please enter "none."
Your answer
If Inhaler is required for asthma, please enter "yes." Also, enter location where Inhaler will be kept during practice and competition.
If none, please enter "none."
Your answer
Does the athlete have allergies?
Please list FOOD allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please list MEDICATION allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please list LATEX allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please list OTHER allergies, reactions and date of last reaction
If none, please enter "none."
Your answer
Please add any other health information you feel would be important for your athlete's coaches and trainer
If none, please enter "none."
Your answer
Medication
Does your athlete take any daily medications?
Required
Medication
Does your athlete take medications at school? If yes, obtain Medication Authorization from office
Required
Please list all medications (If none, please enter "none."):
Name, Form, Time taken and Reason
Your answer
Consent for Emergency Treatment:If a situation occurs in which my son/daughter needs immediate medical attention and I am unavailable to give consent, this signed statement will serve as an authorization for a school representative to obtain any medical care for my son/daughter that is in his/her best interest, until I can be contacted. I understand that every effort will be made to contact me prior to initiating care. I also understand that any expenses incurred for emergency transportation and/or care are my responsibility.
Parent / Guardian FIRST and LAST Name serves as Electronic Signature
Your answer
Insurance Company my child is adequately covered by
Your answer
Insurance Carrier Telephone
Your answer
Insurance Primary Subscriber Member Name
Your answer
SDW Spectator Code of Conduct
The audience is an important part of our athletic programs. Support from the audience can be a source of significant encouragement for the athletes. It is critical that our fans exhibit high standards of sportsmanship and citizenship. Negative behaviors, which are disrespectful to referees, coaches, athletes, fans, students, parents, or school staff, are inappropriate. Those who engage in such behaviors or who are in violation of school policies or local ordinances will be subject to removal from the athletic event, possible future athletic events, and subject to referral to appropriate authorities.

The Waukesha School District believes that good sportsmanship is essential to a successful extra-curricular program. The elements of fairness, courteous behavior, and gracious acceptance of winning and losing, in both individual performance and team contests, must be incorporated into our programs.

With these objectives in mind, the Waukesha School District strongly supports the following fundamentals of sportsmanship:

1. Respect is to be shown to opponents at all times. The opponent should be treated as a guest who is greeted cordially on arriving, given the best accommodations, and accorded the tolerance, honesty and generosity that all human beings deserve.
2. Officials are to be accorded respect at all times. Officials should be recognized as impartial decision makers who are trained to do their job and who can be expected to do it to the best of their ability. Good sportsmanship implies the willingness to accept and abide by the decisions of the officials.
3. Coaches are to be accorded respect at all times. Spectators shall respect all decisions made by coaches.
4. Spectator language should be such that it will reflect favorably on the school and the students.
5. The rules of the contest are to be known, understood, and appreciated.
6. Self-control must always be maintained. A proper perspective must be maintained if the potential educational values of athletic competition are to be realized.
7. All spectators shall behave in a manner that respects others, regardless of gender, race, ethnicity, and place of origin, nationality, physical or mental disability.
8. All spectators are to refrain from using tobacco/alcohol on school property.

I understand all of the rules and regulations of the Waukesha School District Spectator Code. I furthermore agree to cooperate with the schools in enforcing the code for the betterment of all concerned.
Parent / Guardian FIRST and LAST Name serves as Electronic Signature
Your answer
I understand all of the rules and regulations of the Waukesha School District Spectator Code. I furthermore agree to cooperate with the schools in enforcing the code for the betterment of all concerned.
Athlete FIRST and LAST Name serves as Electronic Signature
Your answer
Concussion Information Acknowledgment
Concussion Information - When in Doubt, Sit Them Out!
1. Before a student may participate in practice or competition: At the beginning of a season for a youth athletic activity, the person operating the youth athletic activity shall distribute a concussion and head injury information sheet to each person who will be coaching that youth athletic activity and to each person who wishes to participate in that youth athletic activity. No person may participate in a youth athletic activity unless the person returns the information sheet signed by the person and, if he or she is under the age of 19, by his or her parent or guardian.
2. An athletic coach, or official involved in a youth athletic activity, or health care provider shall remove a person from the youth athletic activity if the coach, official, or health care provider determines that the person exhibits signs, symptoms, or behavior consistent with a concussion or head injury or the coach, official, or health care provider suspects the person has sustained a concussion or head injury.
3. A person who has been removed from a youth athletic activity may not participate in a youth athletic activity until he or she is evaluated by a healthcare provider and receives a written clearance to participate in the activity from the health care provider.

These are some SIGNS concussion (what others can see in an injured athlete):
Dazed or stunned appearance
Change in the level of consciousness or awareness
Confused about assignment
Forgets plays
Unsure of score, game, opponent
Clumsy
Answers more slowly than usual
Shows behavior changes
Loss of consciousness
Asks repetitive questions or memory concerns

These are some of the more common SYMPTOMS of concussion (what an injured athlete feels):
Headache
Nausea
Dizzy or unsteady
Sensitive to light or noise
Feeling mentally foggy
Problems with concentration and memory
Confused
Slow

Injured athletes can exhibit many or just a few of the signs and/or symptoms of concussion. However, if a player exhibits any signs or symptoms of concussion, the responsibility is simple: remove them from participation. “When in doubt sit them out.”

It is important to notify a parent or guardian when an athlete is thought to have a concussion. Any athlete with a concussion must be seen by an appropriate health care provider before returning to practice (including weight lifting) or competition.

RETURN TO PLAY

Current recommendations are for a stepwise return to play program. In order to resume activity, the athlete must be symptom free and off any pain control or headache medications. The athlete should be carrying a full academic load without any significant accommodations. Finally, the athlete must have clearance from an appropriate health care provider.

The program described below is a guideline for returning concussed athletes when they are symptom free. Athletes with multiple concussions and athletes with prolonged symptoms often require a very different return to activity program and should be managed by a physician that has experience in treating concussion.

The following program allows for one step per 24 hours. The program allows for a gradual increase in heart rate/physical exertion, coordination, and then allows contact. If symptoms return, the athlete should stop activity and notify their healthcare provider before progressing to the next level.

STEP ONE: About 15 minutes of light exercise: stationary biking or jogging

STEP TWO: More strenuous running and sprinting in the gym or field without equipment

STEP THREE: Begin non-contact drills in full uniform. May also resume weight lifting

STEP FOUR: Full practice with contact

STEP FIVE: Full game clearance

118.293 Concussion and head injury.

(1) In this section:
(a) "Credential" means a license or certificate of certification issued by this state.
(b) "Health care provider" means a person to whom all of the following apply:
1. He or she holds a credential that authorizes the person to provide health care.
2. He or she is trained and has experience in evaluating and managing pediatric concussions and head injuries.
3. He or she is practicing within the scope of his or her credential.
(c) "Youth athletic activity" means an organized athletic activity in which the participants, a majority of whom are under 19 years of age, are engaged in an athletic game or competition against another team, club, or entity, or in practice or preparation for an organized athletic game or competition against another team, club, or entity. "Youth athletic activity" does not include a college or university activity or an activity that is incidental to a nonathletic program.
(2) In consultation with the Wisconsin Interscholastic Athletic Association, the department shall develop guidelines and other information for the purpose of educating athletic coaches and pupil athletes and their parents or guardians about the nature and risk of concussion and head injury in youth athletic activities.
(3) At the beginning of a season for a youth athletic activity, the person operating the youth athletic activity shall distribute a concussion and head injury information sheet to each person who will be coaching that youth athletic activity and to each person who wishes to participate in that youth athletic activity. No person may participate in a youth athletic activity unless the person returns the information sheet signed by the person and, if he or she is under the age of 19, by his or her parent or guardian.
(4) (a) An athletic coach, or official involved in a youth athletic activity, or health care provider shall remove a person from the youth athletic activity if the coach, official, or health care provider determines that the person exhibits signs, symptoms, or behavior consistent with a concussion or head injury or the coach, official, or health care provider suspects the person has sustained a concussion or head injury.
(b) A person who has been removed from a youth athletic activity under par. (a) may not participate in a youth athletic activity until he or she is evaluated by a health care provider and receives a written clearance to participate in the activity from the health care provider.
(5) (a) Any athletic coach, official involved in an athletic activity, or volunteer who fails to remove a person from a youth athletic activity under sub. (4) (a) is immune from civil liability for any injury resulting from that omission unless it constitutes gross negligence or willful or wanton misconduct.
(b) Any volunteer who authorizes a person to participate in a youth athletic activity under sub. (4) (b) is immune from civil liability for any injury resulting from that act unless the act constitutes gross negligence or willful or wanton misconduct.
(6) This section does not create any liability for, or a cause of action against, any person.

As a Parent and as an Athlete it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form you are stating that you understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury and certify that you have read, understand, and agree to abide by all of the information contained in this sheet. You further certify that if you have not understood any information contained in this document, you have sought and received an explanation of the information prior to signing this statement.
I have read the Parent Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a concussion is suspected. I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me. I understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach. I understand the possible consequences of my child returning to practice/play too soon.
Parent / Guardian FIRST and LAST Name serves as Electronic Signature
Your answer
I have read the Athlete Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I understand the importance of reporting a suspected concussion to my coaches and my parents/guardian. I understand that I must be removed from practice/play if a concussion is suspected. I understand that I must provide written clearance from an appropriate health care provider to my coach before returning to practice/play. I understand the possible consequence of returning to practice/play too soon and that my brain needs time to heal.
Student-Athlete FIRST and LAST Name serves as Electronic Signature
Your answer
WIAA Athletic Permision
1. I hereby give my permission for the above named student to practice and compete and represent the school in WIAA approved sports.
2. I also attest to the fact that the above named student has had no injury or illness serious enough to warrant a medical evaluation prior to participating this school year.
3. Pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (collectively known as “HIPAA”), I authorize health care providers of the student named above, including emergency medical personnel and other similarly trained professionals that may be attending an interscholastic eventor practice, to disclose/exchange essential medical information regarding the injury and treatment of this student to appropriate school district personnel such as but not limited to:Principal,Athletic Director,Athletic Trainer, Team Physician, Team Coach,AdministrativeAssistant to theAthletic Director and/or other professional health care providers, for purposesof treatment, emergency care and injury record-keeping.
4. It is recommended that information regarding your child’s allergies and prescribed medication be made available.PARENT: If there is any question that this student may not be qualified for athletic competition without, at least, a partial re-evaluation, contact your medical advisor before signing below.
Your Signature represents that you have read the statements presented above and give permission for your child to participate in athletics
Parent / Guardian FIRST and LAST Name serves as Electronic Signature
Your answer
WIAA Athletic Eligibility Bulletin Acceptance
I certify that I have read, understand and agree to abide by all of the information contained in the WIAA Athletic Eligibility Bulletin. I further certify that if I have not understood any information contained in that document, I have sought and received an explanation of the information prior to signing this statement.
This information is available at:
http://www.wiaawi.org/Portals/0/PDF/Eligibility/eligibilityinfoform.pdf
Your Signature represents that you have read and agree to abide by the WIAA Athletic Eligibility Bulletin.
Parent / Guardian FIRST and LAST Name serves as Electronic Signature
Your answer
Your Signature represents that you have read and agree to the Athletic Code of Conduct set forth by the School District of Waukesha
Student-Athlete FIRST and LAST Name serves as Electronic Signature
Your answer
School District of Waukesha Athletic Code of Conduct AcceptanceUntitled Title
Waukesha Public Schools Athletic Code of Conduct: I understand all of the rules and regulations of the Waukesha Public Schools Athletic Code of Conduct. I further agree to cooperate with the school in enforcing the code for the betterment of all concerned.
1. I agree to be responsible for all the equipment issued and pay for any items not returned or damaged due to negligence.
2. I understand the dangers unique to the sport(s) in which [My child/I] will be participating.
3. Parent/Guardian and Athlete understand attendance is required for new and first time athletes at a Parent/Athlete Meeting Prior to participation. For years where meeting attendance is not required, athlete must attend the meeting held by the team.
The complete school board policy of "co-curricular activity and athletic rights and responsibilities" can be seen at:
https://goo.gl/gcZtCu
Your Signature represents that you have read and agree to the Athletic Code of Conduct set forth by the School District of Waukesha
Parent / Guardian FIRST and LAST Name serves as Electronic Signature
Your answer
Your Signature represents that you have read and agree to the Athletic Code of Conduct set forth by the School District of Waukesha
Student-Athlete FIRST and LAST Name serves as Electronic Signature
Your answer
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