FREEDOM ELEMENTARY SCHOOL INSURANCE VERIFICATION FORM

Dear Parents:

The California Education Code, Sections 32220 and 32221,requires that any

student of any "Educational Institution" who practices for or participates in any inter-school athletic event MUST be insured for $1,500of insurance coveringthe medical expenses of accidental injuries.This appliesto all sports andto all participants of any age.

The mandatory insurance requirement isalso extended to students who accompany an athletic team to an extra-mural athletic event and while performing their function as a member of the band,songleaders,yellleaders,etc.

Consequently, students must be excluded from the team and from activities relative to an athletic event unlessthey have either purchased the school's regularly offered plan, or their parents can assurethe District that adequate insurance is inforce which meetsthe requirements of this law.

Ifyou have not purchased the accident plan offered through the school for your child, please fill in the following form and return to the school principal. Your child will not be allowed to practice or participate untilthis form has been completed and returned, or you have purchased the insurance planoffered through the school. Enrollment forms are available onthe CUSD website.

Eimear O’Farrell, Ed.D. District Superintendent

INSURANCEVERIFICATIONANDPARENTPERMISSION

This is to verify that my son/daughter ----------------------STUDENT'SNAME

is covered under -----------------------------NAMEOF INSURANCECOMPANY

EXPIRATION DATE	POLICY NUMBER

Benefitsinmypolicyareequaltoorbroaderthanthose requiredintheabovenotice. Igivemy son/daughterpermissiontoparticipatein:

NAME OF ACTIVITY. MULTI-SPORT ATHLETES, PLEASE LIST ALL SPORTS FOR THE YEAR

Icertifythatmyson/daughter hasnomedicalconditionsordisabilitiesthatwouldcauseparticipationin theabovementionedsporttobedangerousorharmful.

DATE	PARENT/GUARDIAN SIGNATURE

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FREEDOM ELEMENTARY SCHOOL CODE OF CONDUCT

Freedom Elementary School provides opportunities for 4th, 5th, and 6th grade students to be involved in an athletic program. Our athletes compete in the Clovis East Area League. Our athletic program goals are to teach and develop proficiency in the skills associated with each sport, to develop the personal qualities of self-discipline, team commitment and sportsmanship, and to exhibit school pride.

All students must have apparent permission, insurance verification, and abide by the Freedom Elementary Code of Conduct to participate. The insurance policy may be a family policy or purchased through the school. All teams are coached by Freedom staff members and/or walk-on coaches. Practice times are from 3:05 pm -4:05 pm. Game schedules and directions to participating schools are located on the Freedom website. Game days are subject to change.

As a participant in Freedom's co-curricular program I recognize that I have assumed certain responsibilities and obligations to the coach/advisor, to the other members of the activity, and to myself. As such, I understand and agree with the requirements of this code of participation.
I.	 I must maintain a certain level of scholarship (2.0 GPA and have no academic areas with an "F") and demonstrate satisfactory behavior and citizenship.
II.	I will abide by all practice, meeting, rehearsal, and game schedules for the activities I participate in during the school year. I will attend at least half the practice hours each week in order to be eligible to participate (make-up hours not allowed). I will inform my coach in advance when possible if I am going to miss a practice, meeting, and/or game.
III.	I will participate in the activity with a positive attitude and strive to learn the skills necessary to contribute to the effort of my team and or group.
IV.	I will respect and care for all property and/or equipment issued (A fee will be charged for lost or damaged items.).
V.	I will not quit an activity that I have started. (A one week grace period is allowed from the start of the activity for a student to drop an activity without conditions). After that time, if a student chooses to quit any time before the end of the season, participation points will bet be rewarded.

Student signature:	Date:	_

Parent signature: --------------------Date:------

Teacher signature:	Date:	_

In case of emergency please contact: ----------------------

1.NameIrelationship:	Phone:	_

2. NameIrelationship:	Phone:	_

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FREEDOM ELEMENTARY SCHOOL RELEASE OF STUDENT TO PARENT/GUARDIAN
AFTER FIELD TRIP OR ACTIVITY FORM 3204-2

I request that		during	_ STUDENT NAME                                         2016-2017 SPORTS SEASON

sports away games, be released to the custody of myself or any one listed below, after away games, rather than returning to school in the transportation provided by Clovis Unified School District. I have added all persons listed below to the emergency card located at school site office.

The following are additionally authorized individuals (also listed on Form 11-Student release authorization on file at school site) to whom the above referenced child may be released:

NAME	RELATIONSHIP	PHONE

NAME	RELATIONSHIP	PHONE

NAME	RELATIONSHIP	PHONE

WAIVEROFCLAIMS:

Waiver of Claims: Iagree that once my son/daughter is released to their custody, Iassume full responsibility for his/her health, safety and welfare and as provided for in California Education Code Section 35330. Iagree to waive all claims against the District and hold the District, its officers, agents and employees, harmless from any and all liability or claims, which may arise out of or inconnections with my child's participation in this activity. This waiver shall not apply to any occurrences which may arise solely out of the negligence of the District, its employees or agents.

PrintedName(Parent/Guardian):---------------------

ApprovalSignature(Parent/Guardian):-------------------

Home Phone Number:	Other Phone Number:	_

It is the responsibility of the designated school official to ensure all students are properly accounted for before transportation to or from school activity occurs.

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FREEDOM ELEMENTARY SCHOOL TEAM MANAGER
AGREEMENT OF RESPONSIBILITY

A Team Manager is an important part of any team. As a team manager, you are responsible for being the assistant to the coach. Only 4th graders are allowed to be Team Managers. Not only will you receive Block F points, but it also gives you the opportunity to see firsthand, what you can expect when you are able to participate as an athlete. The right team manager can make any school sports program more enjoyable for both the coach and team players and provides a wonderful, life-enriching opportunity for any student.

The following requirements must be met in order to qualify for the position.

• Must be a responsible, 4th Grade student ingood standing Eligibility -Meetingthe required 2.0 GPA with no academics areas with an "F", obligations, and behavior criteria. (Teacher signature required)

• Must fill out Insurance Verification/ Code of Conduct Team Manager

•Will receive a team uniform top to wear on game days. To be returned at the end of the season.

•Will attend all practices, games and assist coach inthe following areas: •	Help coach pass out/collect uniforms
•	Bring out and put away equipment •     Take attendance
•	Lead the daily conditioning. The first 10minutes of practice. BothVarsity andJV •	Helpcoachw/drills
•	Game Day prep, (fillwater bottles, get first aid kit, help set up equipment @ first recess. •	Attend away games
•	Ride the bus to and from away games to assist with equipment. This is very important.

Please sign and returnto coach.

I have read the above and Iwill do my best to follow all the responsibilities of the position as Team Manager.

STUDENTNAME(Print)

PARENTNAME(Print)

SIGNATURE	ROOM#

SIGNATURE

------------meetsallaboverequirementstoholdthepositionofTeamManager.

FREEDOM ELEMENTARY

2017-2018 Sports Loan Agreement for Uniform and/or Other Items

Student Name:

Address/City/Zip:

HomePhone:

Cell Phone:

Bysigningbelow,IagreetotheloanofFreedomsportsuniformsandotheritemsrelated tosportstothestudent listed.Iagreetoseethatthe uniformand/or sports equipment loaned isproperly caredfor and maintained.Ifurther agreethatthis/these item(s)is/are received ingood condition unless documented with athletic director. Pursant to Educational Code Section 48904, inthe event that this/these item(s) is/are damaged beyond normal wear and tear, altered, lost, or stolen, Iagree that Iam financially responsible and will be required to pay Freedom Elementary School of the Clovis Unified School Districtfor the full cost of repairsor replacement.Theassessed value and/or damageshall bedetermined
by Freedom Elementary School and/or by the maker of the item(s). Ifurther agree to return this/these item(s) at any time upon request of the school. Uniform pricing and equipment policiesonbackpage.

Parent/GuardianName:

Parent/Guardian Signature:

Student Signature:

Athletic Director:

Freedom Elementary School Copy Parent/Guardian Copy

Freedom Athletics Uniform and Equipment Policies

Studets and parents/guardians must agree to return uniforms and equipment in the condition they received it. When uniforms and equipment is returned it must be washed and dried according to the instructions, folded, and placed into a plastic bag with the student's first and last name. If the uniform is damaged, student and parent /guardian will be responsible for the cost
to replace the uniform and equipment. Students will not be allowed to participate in the next athletic season until the uniform and equipment has been turned in or paid for.

Approximate replacement costs for damaged or lost uniforms and equipment are as follows.

Boys' Basketball
	Girls' Basketball
		
Jersey$45.00 Shorts$30.00
	Jersey $45.00 Shorts $30.00
		
Boys' Volleball
	Girls' Volleyball
		
Jersey $37.00 Shorts $20.00
	Jersey $35.00 Shorts $20.00
		
Baseball Jersey$50.00 Pants $30.00
	Softball Jersey $50.00 Shorts $30.00
	
Wrestli ng Singlet$70.00 Headgear $25.00
	CrossCountrvLTrack
		
	Jersey $25.00 Shorts $20.00
		
Football Helmet $150.00 Jersey $50.00 Belt $2.00
	
Shoulder pads $75.00 Pants $30.00 Girdle/Pads $40.00

Parent/Athlete Concussion Information Sheet

A concussion is a type of traumatic brain injury

that changes the way the brain normally works. A concussion is caused by bump, blow, or jolt to the head or body that causes the head and brain to move

rapidly back and forth. Even a "ding/' "getting your bell rung/' or what seems to be a mild bump or blow

to the head can be serious.

Signs and symptoms of concussion can sl1ow up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one ormore symptoms of concussion listed below after a bump, blow, or jolt to

Appears dazed or stunned

Is confused about assignment or position

Forgets an instruction

ls unsure of game, score, or opponent Moves clumsily

Answers questions slowly

Losesconsciousness (evenbriefly)

Shows mood, behavior; or personality changes Can't recall events prior to hit or fall

Can't recalIevents after hit or falI

Did You Know?

• Most concussions occur without loss of consciousness.

Athletes who have, at any point in their lives,had a concussion have an increased risk for another concussion.

• Young children and teens are more likely to get a concussion and take longer to recover than adults.

the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Headache or "pressure" in head

Nausea or vomiting

Balance problems or dizziness Double or blurry vision

Sensitivity to light

Sensitivity to noise

Feeling sluggish, hazy,foggy, or groggy

Concentration or memory problems

Confusion

Just not"feeling right11 or "feeling down"

!n rare cases1 a dangerous blood clot may form on

the brain in a person with a concussion and crowd	Concussionsaffect	While the brain against the skull. An athlete should receive	most athletes with a concussion recover

immediate medical attention if after a bump1

or jolt to the head or body s/he exhibits any of the

and

that last for

some wil: have symptoms

or even weeks. A more seri-

following danger signs:

• One pupil larger than the other

• ls drowsy or cannot be awakened • A headache that not only does not

but gets worse

• Weakness, numbness1 or decreased coordination

• Repeated vomiting or nausea

• Slurredspeech

• Convulsions or seizures

• Cannot recognize people or places

• Becomes increasingly confused, restless, or agitated

• Has unusual behav r

• Loses consciousness (even a brief ioss of consciousness should be taken seriouslyJ

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their
brain. They can even be fatal.

ous concussion can last for months or longer.

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. l<eep the athlete out of play the day of the injury and until a health care professionai, experienced in evaluating for concussion, says s/he is symptom-free and it's 01< to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying,working on
the computer,or playing video games, may cause concussion symptoms to reappear or getworse.

After a concussion, returning to sports and school is a gradual process that should becarefully ncanaged
and monitored by a health care professional.

It's better to miss one game than the whole season. For more information on concussions1 visit: www.cdc.gov/Concussion.

StudentAthlete NamePrinted

P;irentorLegalGuardianPrinted

Student-Athlete Signature	Date

Parent0( Legal Guardian Signature	Date