08-09 PHYSICAL FORM
May 29, 2008
CONESTOGA MIDDLE & HIGH SCHOOL ACTIVITIES REGULATIONS
TOBACCO / ALCOHOL / DRUGS
POLICY: Since participation in extra-curricular activities is a privilege for students, the following activity regulations have been adopted by the Board of Education to foster and promote school activities. Revised Sept 2001.
TOBACCO AND ALCOHOL: If a student is observed by a school district employee, ticketed or arrested for an alcohol-related offense, or admits to the use, possession, or sale of alcohol or tobacco (smoke or smokeless) on or off school grounds, the following will occur:
The student involved will appear before the activity council and his/her parents/guardian will also be invited (by a signed notice) to attend. The activity council will consist of the high school principal (or designee), activities director, and three (3) activity sponsors or coaches. Based on the evidence presented, the activity council will determine whether the student violated the activities regulations and will determine the action as outlined below.
If the activity council determines a violation was committed:
The student will be suspended for three -- six (3-6) weeks from the co-curricular activities of the current school year. (See District Rules for practice, traveling with team)
A second violation of the activities regulations will result in the student�s suspension from all extra-curricular activities for the remainder of the school year.
DRUGS AND/OR CONTROLLED SUBSTANCES: If a student is observed by a school district employee, ticketed or arrested for or admits to the use, sale, or possession of drugs, including but not limited to narcotics, illicit substance, inhalant or controlled substance, the following will occur:
The student will appear before the activity council and his/her parents/guardians will be invited (by a signed notice) to attend based on the evidence presented, the activity council will determine whether the student violated the activities regulations.
If the activity council determines a violation was committed, the student will be suspended from all extra-curricular activities for the remainder of the school year.
JUDICIAL SYSTEM
If a student is ticketed or arrested for a crime (other than minor traffic violations), the activity council will meet with the student, and his/her parents will be invited (by a signed notice) to attend in order to arrive at a suitable disciplinary course of action.
SPECIAL CONSIDERATION
Any student suspended from extra-curricular activities for any length of time will lose the right to letter in the sport or activity they are involved in at the time of the violation. The decision of the activity council will be made on the evidence presented at the hearing.
APPEALS PROCESS
In the event that a student is suspended for violation of the activities regulations, the student may choose the following appeals process:
The student and/or parents shall make an appeal in writing within two school days of the suspension to the superintendent (or designee). The superintendent must meet with the student and/or parents within two (2) school days after the request has been received. The decision of the superintendent must be made and conveyed to the student and/or parents within 24 hours in the meeting.
Until the decision of the superintendent, the student will be under temporary suspension from all activities.
________________________________ ______________________________ ____________
Student Parent / Guardian Date
May 2008
In order to represent a high school in interscholastic athletic competition, a student must abide by eligibility rules of the Nebraska School Athletic Association. A summary of the major rules is given below. Contact the principal or activities director for an explanation of the complete rule.
Student must be an undergraduate.
Student must be enrolled in at least 20 hours per week and regular in attendance, in accordance with the school�s attendance policy at the school he/she wishes to represent in interscholastic competition.
Student must be enrolled in some high school on or before the eleventh school day of the current year.
Student is ineligible if 19 years of age before August 1st of current school year
After a student�s initial enrollment in grade 9, he/she shall be ineligible after 8 semesters of school membership.
Student must have been enrolled in school the immediate preceding semester.
Student must have received 20 semester hours of credit the immediate preceding semester.
Once the season of a sport begins, a student shall compete only in athletic contests / meets in that sport, which are scheduled by his/her school. Any other competition will render the student ineligible for a portion of, or all of, the season in that sport. The season of a sport begins with the first date of practice permitted by NSAA rules. The Fall sport season begins August 13th 2007 with the exception of Football, which will begin August 6th 2007 and ends with the State meets in the Fall sport. The Winter sport season begins November 12th 2007 and ends with the State meets in the Winter sport. The Spring sport season begins February 25th 2008 and ends with the State meets in the Spring sport.
A student shall not participate in sports camps or clinics during the season of a sport in which he/she is involved, either as an individual or as a member of a team.
A student shall not participate on an all-star team while a high school undergraduate.
A student entering grade 9 for the first time after being promoted from grade 8 of a two-year junior high, or a three-year middle school, or entering a high school for the first time after being promoted to grade 10 from a three-year junior high school is eligible. After making a choice of high school, any subsequent transfer will cause the student to be ineligible for 90 school days.
When the parents of a student change their domicile from one school district, which has a high school to another school district which has a high school, the student is ineligible for ninety school day except
If the change in domicile by the parents occurs during a school year, the student may remain at the school he/she is attending and be eligible until the end of the school year or transfer to a high school located in the school district where the parents established their domicile and be eligible.
If a student has been attending the same high school since initial enrollment in grade nine and the school is located in the school district from which the parents moved, he/she may remain at that high school and retain eligibility or he/she is eligible at a high school located in the school district where his/her parents established their domicile.
If the parents moved during the Summer months and the student is in grade twelve, the student may remain at the high school he/she has been attending and retain eligibility.
Guardianship does not fulfill the definition of a parent. If a guardian has been appointed for a student, the student is eligible in the school district where his/her natural parents(s) have their domicile. Individual situations involving guardianship may be submitted to the Executive Director for his review and a ruling.
A student shall not participate in a contest under an assumed name.
A student must maintain his/her amateur status.
ATHLETIC INSURANCE COVERAGE
Athletes and Parents
The Conestoga School will be offering athletic insurance coverage. The purpose is to assist in the cost of treatment of accidental injury. The insurance company plan will be made available to those who wish to participate. The cost of athletic insurance will be borne totally by the parent.
Whether you wish to participate or not, please complete this form. No athlete may participate as a member of any team until this form has been completed.
CHECK THE STATEMENTS WHICH APPLY
______ I shall participate in the Athletic Benefit Injury Plan
______ I shall not participate in the Athletic Benefit Injury Plan and will assume all expenses for accidental injury. My son or daughter is covered by another policy
______ I choose not to enroll my son or daughter in an insurance program and understand I will be responsible for all expenses for treatment of any accident or injury.
_____________________________________________ __________________________________
Parent / Guardian Signature Date
HEALTH EXAMINATION FORM
Conestoga Jr. � Sr. High School
8404 42nd Street P.O. Box 40
Murray, NE 68409
402-235-2271 or 227-3745
Student Name_______________________________________ Age _________ Grade _________
Height ______Weight ________BP _____/_____ Lab UA _______Eyes R 20/______L 20/_______
Significant Past Illness or Injury ________________________________Hemoglobin ____________
Respiratory / Asthma _______________________________________________________________
Cardiovascular _________________________Liver __________________Spleen ______________
Musculoskeletal ________________________Hernia _________________ Skin _______________
Scoliosis ______________________________Thyroid ____________________________________
Comments _______________________________________________________________________
Immunizations:
DPT / Td ______;______;______(one dose must be after 4 years of age) Polio (3) ______;______;______
MMR (2) ______;______ (K-12 must have 2 doses) Hepatitis B ______;______;______
Varicella: ______; or evidence of disease (month/year) ____ ___ TB test _____; reaction: ______
�I certify that I am qualified to conduct all phases of the health examination of this student. If further certify that I have on this date examined the student and on the basis of the examination requested by the school authorities and the student�s medical history as furnished to me. I have found no reason which would make it medically inadvisable for this student to compete in supervised athletic activities,
EXCEPT THOSE CROSSED OUT BELOW�
BASKETBALL CROSS COUNTRY FOOTBALL TRACK SOFTBALL
VOLLEYBALL SOCCER GOLF WRESTLING
_______________ ____________________________________________________________
Date Examining Physician (MD), Physician Assistant (PA), or Nurse Practitioner (NP) Signature
_________________________________________________________ _____________________
Address Phone
SPORTS CANDIDATE�S QUESTIONNAIRE
(To be completed by parents or family physician)
Student Name ______________________Birth Date _________________Phone________________
Address ____________________________________ Place of Birth__________________________
Parent(s) Name _____________________________________________________________________
Comments
1) History of diabetes in family yes/no _____________________________________
2) History of epilepsy or other seizure disorder yes/no _____________________________________
3) Injury requiring medical attention yes/no _____________________________________
4) Illness lasting more than a week yes/no _____________________________________ 5) Under a physician�s care now yes/no _____________________________________
6) Takes medication now yes/no _____________________________________
7) Wears glasses --------yes/no Contacts -----yes/no _____________________________________
8) Has had a surgical operation yes/no _____________________________________
9) Has been in hospital yes/no _____________________________________
10) Any known allergies yes/no _____________________________________
11) Most recent tetanus booster (date) _____________________________________
12) Do you know of any reason why this student should not participate in all sports?______________
__________________________________________________________________________________
Parent or Physician (MD), Physician Assistant (PA), or Nurse Practitioner (NP) Signature
NEBRASKA SCHOOL ACTIVITIES ASSOCIATION (�NSAA�)
Student and Parent Consent Form
School Year: 200__ - 200__ School: ___________________________________________________
Name of Student: ___________________________________________________________________
Date of Birth: _________________ Place of Birth: _________________________________________
The undersigned(s) are the Student and the parent(s), guardian(s), or persons(s) in charge of the above named Student and are collectively referred to as �Parent�.
The Parent and Student hereby:
(1) Understand and agree that participation in NSAA sponsored activities is voluntary on the part of the Student and is a privilege;
(2) Understand and agree that (a) by this Consent Form the NSAA has provided notification to the Parent and Student of the existence of potential dangers associated with athletic participation; (b) participation in any athletic activity may involve injury of some type; (c) the severity of such injury can range from minor cuts, bruises, sprains, and muscle strains to more serious injuries to the body�s bones, joints, ligaments, tendons, or muscles, to catastrophic injuries to the head, neck and spinal cord, and on rare occasions, injuries so severe as to result in total disability, paralysis and death; and, (d) even with the best coaching, use of the best protective equipment, and strict observance of rules, injuries are still a possibility;
(3) Consent and agree to participation of the Student in NSAA activities subject to all NSAA by-laws and rules interpretations for participation in NSAA sponsored activities, and the activities rules of the NSAA member school for which the Student is participating; and,
(4) Consent and agree to the Student being photographed, video taped, audio taped, or recorded by any other means while participating in NSAA activities and contests, consent to and waive any privacy rights with regard to the display of such recordings, and waive any claims of ownership or other rights with regard to such photographs or recording or to the broadcast, sale or display of such photographs or recordings.
I acknowledge that I have read paragraphs (1) through (4) above, understand and agree to the terms thereof, including the warning of potential risk of injury inherent in participation in athletic activities.
DATED this ___day of ____________, _________.
________________________________________ _______________________________________
Name of Student (Print Name) Student Signature
(I am) (We are) the Student�s [circle appropriate choice] (Parent)(Guardian). (I)(We) acknowledge that (I)(We) have read paragraphs (1) through (4) above, understand and agree to the terms thereof, including the warning of potential risk of injury inherent in participation in athletic activities. Having read the warning in paragraph (3) above and understanding the potential risk of injury to my Student, (I)(We) hereby give (my)(our) permission for _______________________[insert student name] to practice and compete for the above named high school in activities approved by the NSAA, except those crossed out below:
Baseball Golf Tennis Play Production
Basketball Swimming Track Speech
Cross Country Soccer Volleyball Music
Football Softball Wrestling Debate
Journalism
DATED this ____day of _____________, _______. ___________________________________
Parent/Guardian Signature
