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 - 2017-2018 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: Concussion Protocol Form must be filled out and returned. One per year.

Form # 4A: Opioid Misuse Prevention and Sports One per year Form #5: Injury Concussion Reporting Form

must be filled out and returned every season

Form #6: Consent for Impact Testing must be filled out and returned. One per year.

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 2017/2018 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 2017-2018 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 studentathlete 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 Email:___________________________________ FOR BUSINESS OFFICE USE ONLY Payment Option Selected: W1_____ W2 _____ PrePaid_____ Installment _____ CAP______ Payment Received: $ ______ Payment Method: Check ____ No. _______ Online_______

Form # 3

GMHS 2017-2018 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 PARENT/GUARDIAN CONCUSSION PROTOCOL ACKNOWLEDGMENT FORM In order to help protect the student athletes of the Commonwealth of Massachusetts has mandated that all athletes, parents/guardians and coaches follow the State Concussion Policy. A concussion is a brain injury and all brain injuries are serious. They may be caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child/player reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following: 1. Headache 2. Nausea/vomiting 3. Balance problems or dizziness 4. Double vision or changes in vision 5. Sensitivity to light or sound/noise 6. Feeling of sluggishness or fogginess 7. Difficulty with concentration, short-term memory, and/or confusion 8. Irritability or agitation 9. Depression or anxiety 10. Sleep disturbance Signs observed by teammates, parents and coaches include: 1. Appears dazed, stunned, or disoriented 2. Forgets plays or demonstrates short-term memory difficulties (e.g. unsure of the game, score, or opponent 3. Exhibits difficulties with balance or coordination 4. Answers questions slowly or inaccurately 5. Loses consciousness 6. Demonstrates behavior or personality changes 7. Is unable to recall events prior to or after the hit.

Form #4 continued What can happen if my child/player keeps on playing with a concussion or returns too soon? Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athletes will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety. If you think your child/player has suffered a concussion Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear. Close observation of the athlete should continue for several hours. An athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time and MAY NOT RETURN TO PLAY UNTIL: 1. The athlete is evaluated by a medical doctor or doctor of Osteopathy 2. The Georgetown Athletics Office receives written clearance to return to play from that health care provider You should also inform you child’s Coach, Athletic Trainer (ATC), and/or Athletic Director, if you think that your child/player may have a concussion. And when it doubt, the athlete sits out. For current and up-to-date information on concussions you can go to: http://www.cdc.gov/ConcussionInYouthSports/ https://www.mass.gov/sports-related-concussions-and-head-injuries Opioid Misuse Prevention 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, Opioid 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 ________________________ Signature of Student-Athlete

__________________________ Print Student-Athlete’s Name

_____________ Date

________________________ Signature of Parent/Guardian

__________________________ Print Parent/Guardian’s Name

______________ Date

Form #5

The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619

PRE-PARTICIPATION HEAD INJURY/CONCUSSION REPORTING FORM FOR EXTRACURRICULAR ACTIVITIES CHARLES D. BAKER Governor KARYN E. POLITO Lieutenant Governor MARYLOU SUDDERS Secretary

This form should be completed by the student’s parent(s) or legal guardian(s). It must be submitted to the Athletic Director, or official designated by the school, prior to the start of each season a student plans to participate in an extracurricular athletic activity.

MONICA BHAREL, MD, MPH Commissioner

Student’s Name

Sex

School

Date of Birth

Grade

Sport(s)

Home Address

Has student ever experienced a traumatic head injury (a blow to the head)?

Telephone

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: _________________ Parent/Guardian: Name: _______________________________Signature/Date _________________________________ (Please print) Student Athlete: Signature/Date _______________________________________________________

Form # 6

CONSENT FOR IMPACT TESTING

Dear Parent/Guardian, Georgetown Middle/ High School is currently requiring 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 basketball, girls and boys ice hockey, wrestling, skiing, and girls and boys lacrosse. 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. This 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. 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

__________________________

Sport

___________________________________

__________________________________

__________________________

Signature of Athlete

Date

__________________________________

__________________________

Signature of Parent

Date