FORMS AND RELEASES Before a student may participate in athletics, tryouts, practices or games, s/he must provide the following information and/or forms to the athletic director or main office. Please do not give forms to coaches. All athletes must be academically eligible. There must be an updated physical on file or a note from a physician showing the date the student passed a physical exam and approving participation in athletic activities. A physical exam is good for thirteen months and can expire midseason

Form # 1: Georgetown School District Registration, Health and Emergency Form - 2016-2017 must be filled out and returned (Fall only)

FORM # 2: User Fee Guideline Form must be filled out and accompanied by a check made out to the Town of Georgetown.

Form # 3: Athletic Waiver Form must be filled out and returned. One per year. Form # 4: Head Injury and Concussion Form must be filled out and returned. One per year.

Form # 4A: Opiod Misuse Prevention and Sports Form #5: Authorization for Sports Medicine Services and Consent for Treatment must be filled out and returned every season Form #6: Consent for Impact Testing must be filled out and returned. One per year.

Form #7: Travel Permission Form (Optional)

Athletes will not be cleared for participation until the following are received: • Up to date physical • User Fee Payment (full or 1st installment) • Forms 1-6 Athletes must be signed up at least 2 business days before the first tryout. Failure to do so may result in missing tryouts

FORM # 1

GEORGETOWN SCHOOL DISTRICT

Registration, Health and Emergency Information Form 2016/2017 This form must be completely filled out, signed, and returned by the first day of school Student’s Name______________________________________________________________________________Grade:__________Year of Graduation:___________________ (Last) (First) (Full Middle Name) Male:________Female:________ Place of Birth__________________________ Date of Birth________________________Home Phone:______________________________ Address____________________________________________________________________________________________________ (Street) (Town) (Zip)

Check if new address: _________

Name and location of school last attended:_________________________________________________Grade:________________ Primary Language:_____________________ Optional - Ethnicity: Please check Hispanic or Non-Hispanic then choose appropriate selection on second line: ____American Indian or Native American

_______Hispanic

____Asian or Pacific Islander

____Black

________Non-Hispanic ____White

LANGUAGE SPOKEN IN HOME:________________________

Student residing with: _______

Mother/Father________ Mother only________ Father only________ Guardian_______

Check if new phone numbers:

Mother/Guardian__________________________________________________Address (if different)___________________________________Phone:____________________ E-Mail Address:__________________________________________________________Cell Phone: _________________________Work # _____________________________ Father/Guardian____________________________________________________Address (if different)__________________________________Phone:____________________ E-Mail Address:__________________________________________________________Cell Phone:__________________________Work #_____________________________

EMERGENCY INFORMATION Name of friends/relatives who will assume responsibility/transportation of your child if you cannot be reached: Name_______________________________________________Relationship________________________Daytime Phone ____________________________________ Name_______________________________________________Relationship________________________Daytime Phone ____________________________________ The following information is requested for use in emergency situations only if parent/guardian cannot be located: Physician Name_________________________________________________________________________ Phone ______________________________________ Dentist Name___________________________________________________________________________ Phone______________________________________

SIGNATURE OF PARENTS Mother/Guardian:___________________________________________ OR GUARDIAN: Father/Guardian:____________________________________________ Please list all medications that your child takes ______________________________________________________________________________________________________________________________________________ Please check all that apply to your child: Heart Condition Diabetes Asthma Seizure Disorder ADD/ADHD Migraines Depression Other(Specify)_______________________________________________________________________________________________________________ Allergies (food, insects, medications, environment) (Specify)____________________________________________________________________________________________________________________________________ Hearing Problems (Specify) ______________________________________________________________ Left ear_____ Right ear________ Hearing Aide________ Vision Problems(Specify)________________________________________________________________ Wears Eyeglasses___________

Contact Lenses________

Does your child have health insurance? Yes_____No_____ Does your child have Dental Insurance? Yes_____ No _____ Health Insurance Co.____________________________________ Policy No.___________________________ Policyholder:_______________________________________ Dental Insurance Co.____________________________________ Policy No.____________________________ Policyholder:________________________________________ I give permission to the school nurse to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my child’s health and safety needs. I give permission to exchange information with my child’s primary care physician for purpose of referral, diagnosis and treatment. I give permission for the school nurse to administer the age/weight appropriate dose of :

____Tylenol to my child.

Signature____________________________________________________ Date:______________________________ If you have no health insurance, Massachusetts has health insurance plans that will provide uninsured children with affordable health care (restrictions may apply). Please contact the school nurse (978-352-5790 ext. 520) for more information about these programs. All communications will be confidential.

FORM # 2 GMHS ATHLETIC USER FEE GUIDELINES 2016-2017 The Georgetown School District assesses user fees for athletics There is a maximum fee of $1500 per family

$475: Football, Golf, High School Basketball $425: HS Soccer, HS Field Hockey, Wrestling, LAX, Baseball, Softball $375: Cross Country, MS Basketball, MS Track, MS Soccer, MS Cross Country, MS Field Hockey, Cheering User Funded: Volleyball ($375 up front, any costs above will be split amongst all players and assessed midseason) For Cooperative sports with other communities, such as Ice Hockey the user fee is the fee charged by the sponsoring school and it does not apply towards the family cap.

• • • •

User Fees must be paid in full or at minimum the first installment needs to be paid., prior to any participation (tryouts, practices, or games). Checks will be held until rosters are posted. If the student-athlete gets cut from a sport, checks will be returned. In cases of incapacitating injuries which prevent further participation, or if a student-athlete moves out the district during the year, a prorated refund will be available. If a student-athlete quits after making a team, is removed from the team for disciplinary reasons, or becomes ineligible for academic reasons, there will be no refund. The fee allows the student-athlete the privilege of participating in athletic programs at Georgetown High School, but it does not guarantee playing time. WAIVER OF USER FEES

The following waivers of user fees are available: Waiver #1 - No user fee shall be assessed for student-athletes covered under the federal free lunch program. Waiver #2 - A discounted user fee shall be assessed for student-athletes covered under the federal reduced lunch program subject to the prepayment or installment option stated below. With the exception of waivers #1 and #2 above, no other waivers are available. PREPAYMENT OR INSTALLMENT OPTION Student-athletes shall have the opportunity to either a) prepay their user fee at the time of registration, or b) enter into an installment agreement and make a predetermined payment at the time of registration. Cooperative sports are not eligible for the installment options Under the prepayment option, checks or money orders are made out to the "Town of Georgetown" for the entire amount at the time of registration. NO CASH IS PERMITTED. Under the installment option, parents are to sign the enclosed installment agreement (Form 1-A) and issue a check or money order made out to the "Town of Georgetown" for the first payment as specified by the schedule. The remaining balance may be paid based on the enclosed installment agreement over two months subject to the terms and conditions contained therein. NO CASH IS PERMITTED.

Student-Athlete Name: ________________________________Grade:________Sport:__________________ / understand the guidelines indicated. ___________________________________________________ Parent Signature FOR BUSINESS OFFICE USE ONLY Payment Option Selected: W1_____ W2 _____ PrePaid_____ Installment _____ CAP______ Payment Received: $ ______ Payment Method: Check ____ No. _______ Online_______

FORM # 3

GMHS 2016-2017 ATHLETIC WAIVER Parental Consent, Release From Liability and Indemnity Agreement We, the undersigned father and mother or guardian of ____________________, a minor, do hereby consent to his/her participation in voluntary athletic programs, after school clubs, and/or all other extracurricular activities and do forever RELEASE, acquit, discharge, and covenant to hold harmless the Town of Georgetown, a municipal corporation of the State of Massachusetts, and its successors, departments, officers, employees, servants, and agents, of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which we/I may now or hereafter have as the parent(s) or guardian(s) of said minor, and also all claims or right of action for damages which said minor has or hereafter may acquire, either before or after he/she has reached his/her majority resulting or to result from his/her participation in the Georgetown Public Schools Physical Education Department’s athletic programs and/or extracurricular activities; FURTHERMORE, I understand that it may be necessary for my child to have medical treatment while participating in an activity and if I cannot be reached, my signature gives the school district personnel permission to use their judgment in obtaining medical service for my child and give permission to the physician to render medical treatment deemed necessary and appropriate. I understand that the school district has no insurance covering such medical or hospital costs incurred for my child; therefore, any cost incurred for such treatment shall be my sole responsibility, FUTHERMORE, we/I hereby agree to protect the Town of Georgetown and its successors, departments, officers, employees, servants, and agents against any claim for damages, compensation or otherwise on the part of said minor growing out of or resulting from injury to said minor in connection with his/her participation in the Georgetown Public Schools Physical Education Department’s voluntary athletic programs, and to INDEMNIFY, reimburse or make good to the Town of Georgetown or its successors, departments, officers, employees, servants and agents any loss or damage or costs, including attorney’s fees, the Town or its representatives may have to pay if any litigation arises from said minor’s intentional grossly negligent, or reckless acts or omissions while participating in sports programs. To the student, parent/guardian: By signing in the space provided you agree that you have read and understand all the rules and information presented in this handbook, and that you agree to abide by the rules set forth and are willing to face the consequences if you choose to violate them. You also acknowledge that you have read and will abide by the Hazing regulations, read and signed Form # 4, the State Law Regarding Sports-Related Head Injury and Concussions and completed one of the highlighted online courses per the requirements of this law. ________________________________________ Student Signature

_______________________ Date

_________________________________________ Parent/Guardian Signature

_______________________ Date

FORM # 4 Georgetown Middle High School Athletic Department STATE LAW REGARDING SPORTS-RELATED HEAD INJURY AND CONCUSSIONS The Commonwealth of Massachusetts Executive Office of Health and Human Services now requires that all schools subject to the Massachusetts Interscholastic Athletic Association (MIAA) rules adhere to the following law. StudentAthletes and their parents, coaches, athletic directors, school nurses, and physicians must learn about the consequences of head injuries and concussions through training programs and written materials. The law requires that athletes and their parents inform the athletic department about prior head injuries at the beginning of the season. If a student-athlete becomes unconscious during a game or practice, the law now mandates taking the student out of play or practice, and requires written certification from a licensed medical professional for "return to play". Parents and students who plan to participate in any athletic program at Georgetown High School must also take a free on-line course. Two free on-line courses are available and contain all the information required by the law. The first is available through the National Federation of High School Coaches. You will need to click the "order here" button and complete a brief information form to register. At the end of the course, you will receive a completion receipt. The entire course, including registration, can be completed in less than 30 minutes. http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000 The second on-line course is available through the Centers for Disease Control and Prevention at: www.cdc.gov/Concussion Please sign the form indicating you have read the information contained above, completed one of the highlighted online courses per the requirements of this law and that the information you have provided on this form is true and accurate. This form is required in order to participate on any athletic team at Georgetown Middle High School. Form 4A) Recent legislation in Massachusetts requires schools to screen students for potential risk factors and provide resources and information on the dangers of opioid misuse to parents, guardians and students prior to the start of each season. In an effort to support the prevention efforts of member schools, the MIAA has partnered with the Massachusetts Department of Public Health (DPH) and the Massachusetts Technical Assistance Partnership for Prevention (MassTAPP) to develop educational materials on this topic. The four fact sheets listed below can be accessed via the MassTAPP website – http://masstapp.edc.org/rx-student-athlete and include the following: A link to this information is available on our website. Click schools, GMHS, Athletics, Opiod Misuse and Prevention and Sports. • • • •

Preventing Prescription Opioid Misuse Among Student Athletes Injury Management: A Key Component of Prescription Opioid Misuse Prevention What to Know About Prescription Opioids Guidance on Communications After a Non-Concussion Sports Injury

By Signing below, I acknowledge that I have read and am in compliance of both the Concussion and Opiod Abuse Laws

_________________________________________________ Parent/Guardian _________________________________________________ Student-Athlete

________________________ Date ________________________ Date

FORM # 5

AUTHORIZATION FOR SPORTS MEDICINE SERVICES AND CONSENT FOR TREATMENT I, the undersigned, am the parent/legal guardian of, __________________________________________________________, a minor and student-athlete at (Student athlete name - please print) _______________________________________________________________________who plans on participating in ______________________________. (Name of school) (Sport) I understand that Northeast Rehabilitation Hospital Network (“NRHN”) is contracted by the school to provide sports medicine services for the school’s athletes. I, hereby give consent for a Certified Athletic Trainer and/or other NRHN sports medicine clinical staff to provide sports medicine services for the above minor. Sports medicine services include, but are not limited to: administrating first aid for athletic injuries, providing initial treatment and management of acute injuries, and assessing athletic injuries at the request of the athlete, the athlete’s coach, or the athlete’s parent/guardian. The Athletic Trainer and/or sports medicine clinical staff will perform only those procedures that are within their training, credential limitations and scope of professional practice to prevent, care for and rehabilitate athletic injuries. I understand that a written report of any athletic injury assessment for the athlete will be confidentially maintained in the files of the training room or school nurse’s office. I, hereby authorize the Athletic Trainer and/or other NRH clinical staff who provide services to the above-named athlete to disclose information about the athlete’s injury assessments and post- injury status. I understand such disclosures will be done, as needed, with the involved coaching staff, Athletic Director of the school, the school nurse, any treating healthcare provider and/or consulting concussion management specialist. I understand that there is no charge to me for the above listed athletic training services. If the athlete is in need of further treatment by a physician, or of rehabilitation services for the injury, he or she may see the physician or provider of his/her choice. Injured athletes that have been evaluated and/or treated by a physician must submit written clearance from that physician to the Athletic Trainer prior to the athlete being permitted to resume activity. In circumstances where an athlete has been removed from play because of a suspected head injury or concussion, the athlete will not be permitted to return to play until the athlete is evaluated by a healthcare provider, receives medical clearance and written authorization from that provider. This Authorization shall remain in effect for one sports season beginning with the date set forth below.

Parent/Guardian Name (print)_________________________________Signature______________________________ Date__________ Relationship to student athlete________________________________________ Cell/Work phone______________________________ Home Address_______________________________________________________ Home phone______________________________ Student Athlete Name____________________________________________ Sex_____ Grade_____ Date of Birth________________ Allergies_____________________________________________________________________________________________________ Current Medications (i.e. asthma inhalers, epi-pen, etc) ______________________________________________________________________ Physical impairments___________________________________________________________________________________________ Other pertinent medical history (surgeries, diabetes, seizures, heart condition, etc) ____________________________________________________ ______________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Physician Name_________________________________________ Physician Phone________________________________________ Pre-Participation Head Injury/Concussion Reporting: Has student ever experienced a traumatic head injury (a blow to the head)? Yes__ No__ If yes, when? Dates (month/year)______________ Has student ever received medical attention for a head injury? Yes__ No__ If yes, when? Dates (month/year)_____________________ If yes, please describe the circumstances:__________________________________________________________________________ Was student diagnosed with a concussion? Yes__ No__ If yes, when? Dates (month/year)____________________________________ Duration of symptoms (such as headache, difficulty concentrating, fatigue) for most recent concussion:____________________________________ ___________________________________________ _______________________________________________________ Student Athlete Signature

Parent/Guardian Signature

Statement Acknowledging Receipt of Education and Responsibility to Report Signs/Symptoms of Concussion: I, __________________________________ of _______________________________School hereby acknowledge having received education about the signs, symptoms and risk of sports related concussion. I also acknowledge my responsibility to report to the school athletic trainer, coaches, and my parent(s)/guardian(s) any signs/symptoms of a concussion. _______________________________________________________________________ _________________________________ Signature and Printed Name of student athlete

Date

I, the parent/guardian of the student athlete named above, hereby acknowledge having received education about the signs/symptoms and risks of sport related concussion and acknowledge my responsibility to report to the school athletic trainer, and coaches, any signs/symptoms of a concussion in the above minor. ________________________________________________________________________ _________________________________ Signature and Printed Name of parent/guardian

Date

rev.5/15

Form # 6

CONSENT FOR IMPACT TESTING

Dear Parent/Guardian, Northeast Rehabilitation Hospital Network and Georgetown Middle/ High School are currently implementing an innovative program for our student-athletes. This program will assist our athletic trainer and others involved with the healthcare of your son/daughter in evaluating and treating head injuries (e.g., concussion). In order to better manage concussions sustained by our student-athletes, we have acquired a software tool called ImPACT (Immediate Post Concussion Assessment and Cognitive Testing). ImPACT is a computerized exam utilized in many professional, collegiate, and high school sports programs across the country to successfully diagnose and manage concussions. If an athlete is believed to have suffered a head injury during competition, ImPACT is used to help determine the severity of head injury and when the injury has fully healed. The computerized exam is given to athletes at the beginning a contact sport season. Contact sports are defined by the American Academy of Pediatrics Classification of Sports According to Contact. The list of contact sports is as follows: football, girls and boys soccer, field hockey, cheerleading, girls and boys diving, girls and boys basketball, girls and boys ice hockey, wrestling, girls and boys gymnastics, girls and boys skiing, girls and boys lacrosse and ultimate Frisbee (if varsity sport). This non-invasive test is set up in “video-game” type format and takes about 15-20 minutes to complete. It is simple, and actually many athletes enjoy the challenge of taking the test. Essentially, the ImPACT test is a preseason physical of the brain. It tracks information such as memory, reaction time, speed, and concentration. It, however, is not an IQ test. If a concussion is suspected, the contact sport athlete will be required to re-take the test. Both the preseason and post-injury test data is given to the athletic trainer and consulting clinicians, to help evaluate the injury. If a limited contact sport athlete or a noncontact sport athlete is suspected of having a concussion they too will be tested and compared to baseline normative data. The information gathered can also be shared with your family doctor. The test data will enable these health professionals to determine when return-to-play is appropriate and safe for the injured athlete. If an injury of this nature occurs to your child, you will be promptly contacted with all the details. We wish to stress that the ImPACT testing procedures are non-invasive, and they pose no risks to your student-athlete. We are excited to implement this program given that it provides us the best available information for managing concussions and preventing potential brain damage that can occur with multiple concussions. The administration, coaching, and athletic trainer are striving to keep your child’s health and safety at the forefront of the student athletic experience. Please return the attached page with the appropriate signatures. If you have any further questions regarding this program please feel free to contact the Athletic Director or Athletic Trainer.

FORM # 6 (Continued)

Consent Form For use of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) I have read the attached information. I understand its contents. I have been given an opportunity to ask questions and all questions have been answered to my satisfaction. I agree to participate in the ImPACT Concussion Management Program.

Printed Name of Athlete

___________________________________

Athlete date of birth __________________________ Sports

___________________________________

__________________________________ Signature of Athlete

__________________________ Date

__________________________________ Signature of Parent

__________________________ Date

Form 7

Parent Permission Form for Travel – 2016-2017

This form must be handed in for each game a student athlete will not be traveling with the team. *Students are only allowed to travel with their teammates on the team bus unless this form is filled out and returned to their coach or Athletic Director. *Students may NOT drive with other students or coaches * Students may drive themselves with this form * Parents may drive other students or their own students only if they have Massachusetts car insurance Name of Student:________________________________________ Sport and Date(s) of Travel – Write “season” for whole season: _________________________________________ Student's Address: ________________________________________ ________________________________________ Phone: ________________________________________ Parent/Guardian: ________________________________________ I,______________ , as parent/guardian of the above named student give my permission for my student/athlete to travel from _____________________ to __________________ with (Name)____________________________ ____________________________________________ in their automobile. (Print full name, address, phone number)

Please check all the boxes that apply to you

□ □ □ □

My son/daughter is carpooling with _____________________. My son/daughter is going on their own with parent/guardian. My son/daughter is driving himself/herself. The car my child is traveling in has Massachusetts car insurance

I realize that while my son/daughter is traveling to, from, or at the location described above he/she is not the responsibility of Georgetown High School. _______________________________________ Date: ________________ Signature Print name ______________________________ THIS FORM CAN ONLY BE SIGNED BY THE PARTICIPANT'S PARENTS OR LEGAL GUARDIAN. All blanks must be completed. Athletic Department Georgetown High School