PVPHS Athletic Packet 2005-06 - Edl · PDF filePrincipal’s Letter RE Participation...

PVPHS Athletic / Activity Packet 2017-2018 CLEARANCE

YOU MUST COMPLETE THE APPROPRIATE FORMS IN ORDER TO PARTICIPATE IN A SPORT AND/OR ACTIVITIES GROUP.

Winter or Spring Sports should turn in their paperwork closer to their season. (Due to accounting purposes, participation donations need to be

turned in when a student is clearing for a sport and/or activity or donate sometime after they have cleared.)

FALL SPORTS AND ACTIVITY CLEARANCES BEGIN IMMEDIATELY!

1) NOTE: If the Health Office is closed (UNTIL MID-AUGUST), you can go to the Hawthorne Office for the clearanceinitials. Normally, you would first proceed to the Health Office if you are a sport or non-sport that requires a physical. Turn in ORIGINAL physical form (pg 20) with ORIGINAL doctor’s signatures, OR have the Health Office record your physical date based on student data info.2) THEN proceed to the STUDENT STORE to complete your clearance. (Again, if the Student Store is closed, you can go to the Hawthorne Office to turn in your clearance papers.3) Have all the following required paperwork with you:

a) Yellow card or clearance form (online in packet – pg 19) – MAKE SURE THERE IS A PARENT SIGNATURE – INVALID IF NO SIGNATURE - signedb) Athletic/Activity Report – with health insurance policy number - signed (pg 21)c) Concussion form – if you are participating in a sport or activity that requires a PHYSICAL – signed(pg 24)d) Sudden Cardiac Arrest Information Sheet For Athletes and Parents/Guardians – if you are participating in a sport or activity that requires a PHYSICAL - signed (pg 27)e) Athletic and Co-Curricular Code of Conduct (for both sports and all non-sports) – signed (pg 28)

f) Waiver (form #F603) (1) parent uses his/her own veh icle and drives their own student or (2) student uses his/her own vehicle to drive him/herself only for a volunt ary sports or non-sports program - FOR SPORTS AND all NON-SPORTS – signed (pg 30)g) Waiver (form #F605) student may wish to attend and/or participate in an activity or program not during

the school day – FOR SPORTS AND ALL NON-SPORTS - signed (pg 32) (NEW FORM TO BE FILLED OUT)

4) Hazing Pledge form – FOR SPORTS AND ALL NON-SPO RTS – signed (pg 33); MANDATORY - MUST BE TURNED INTO THE COACH OR ADVISOR WHO WILL BE ACCOUNTABLE FOR ALL IN THEIR GROUP.

PLEASE MAKE SURE ALL MANDATORY FORMS ARE COMPLETE BEFORE THEY ARE TURNED IN. IF YOU DO NOT HAVE THE PROPER FORMS OR REQUIRED INFORMATION AND SIGNATURES, YOU CANNOT COMPLETE CLEARANCE.

NOTE: IF THE STUDENT STORE AND/OR HEALTH OFFICE ARE CLOSED, BRING ALL PAPERWORK TO THE HAWTHORNE OFFICE (MRS SHIOSAKI).

FOR YOUR CONVENIENCE AND FUTURE USE DURING THE 2017-2018 SCHOOL YEAR, SAVE YOUR COMPLETED DOCUMENT IF YOU USE ADOBE READER XI. IT WILL HELP SAVE TIME IF YOUR STUDENT PARTICIPATES IN SEVERAL SPORTS AND/OR ACTIVITIES.

Link: https://get.adobe.com/reader/

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Table of Contents

Pages 4-7 Athletic / Activity Clearance Instructions AUTO FILL-IN (pg 7) and Information (Procedure List - Print pg 4-6)

Page 8 Principal’s Letter RE Participation Donation Make check payable to: Page 9 Participation Donation Amounts Palos Verdes Peninsula HS (PVPHS) Page 10 Breakdown of Athletic Expenditures PLEASE REVIEW Page 11 Clearance Procedures Chart

Page 12 District Letter: Insurance Protection For Your Child

Pages 13-18 Myers-Stevens Insurance for Students Without Enrollment Form Pg 15 Insurance and Those Who Want Extra

Page 19 Clearance Form (AKA Yellow Card) Online form if Yellow Card not available - Signatures Mandatory—Pink Boxes

0 Physical Examination Report (F-1223) Doctor’s Signature (All Sports; Varsity Dance, Girls Choreo, (NO Chiropractor Signatures) Marching Band, Color Guard, Spirit Squad, NEED THE ORIGINAL COPY OF Cheer, Coed Choreo) THE PHYSICAL FORM; CANNOT ACCEPT

PHOTOCOPIES MANDATORY FORM FOR ALL TRYOUTS

Page 21 Athletic / Activity Report Signatures Mandatory—Pink Boxes (Please be sure to fill in the “Policy Numbers”.)

Page 22-25 Concussion Information Sheet Signatures Mandatory, if physical is required for sport or non-sport—Pink Boxes

Page 26-27 Sudden Cardiac Arrest Information Sheet for Signatures Mandatory, if physical is Athletes and Parents/Guardians required for sport or non-sport—Pink Boxes

Page 28 CIF Code of Ethics – Athletes; PVPHS Signatures Mandatory for SPORTS Athletic and Co-Curricular Code of Conduct and NON-SPORTS—Pink Boxes

FORM #F603 Page 29 Voluntary Sports or Non-Sports Program Letter Signatures Mandatory-FOR SPORTS Page 30 Voluntary Sports or Non-Sports Program Waiver and NON-SPORTS—Pink Boxes

(1) parent uses his/her own vehicle and drives theirown student or (2) student uses his/her own vehicleto drive him/herself only for a voluntary sports ornon-sports program

FORM #F605 – (NEW FORM THIS YEAR) Page 31 Voluntary Sports or Non-Sports Program Letter Signatures Mandatory-FOR SPORTS Page 32 Voluntary Sports or Non-Sports Program Waiver and NON-SPORTS—Pink Boxes

Student may wish to attend and/or participate in an activity or program not during the school day.

Page 2 of 37

3 Hazing Pledge Form Signatures Mandatory-FOR SPORTS and NON-SPORTS—Pink Boxes

FORM #F604 Page 34 Parent Volunteer Drivers Letter OPTIONAL FORM FOR PARENTS CARPOOLING Page 35 Board Policy E(2) 3541.1 – Transportation For STUDENTS OTHER THAN THEIR OWN.

School-Related Trips – Driver Instructions Page 36 Volunteer Driver Information Page 37 Volunteer Driver Assumption of Risk

(Need copy of the driver’s license.)

Page 3 of 37

PALOS VERDES PENINSULA HIGH SCHOOL 201 7- 201 8 ATHLETIC / ACTIVITY CLEARANCE INSTRUCTIONS (ONLINE)

1. “Clearance Card” (AKA Yellow Card) and School Health Insurance Brochure are included in thepacket for your convenience. Yellow cards can also be picked up on the counter in the HawthorneOffice.

2. Fill out the “Auto Fill-In” Section on Page 7 if you are working on the electronic copy. Informationwill automatically be filled in at the fields they are connected with in the packet. PRINT formsneeded – page 19 (clearance form, if no yellow card available), page 20 (physical form, ifneeded), pages 21, 24 (if physical required), 27 (if physical required), 28, 30, and 32.

3. FOR ATHLETIC TRYOUTS, PRINT the Physical Examination Report (page 20). Complete andshow the coach/advisor at the tryouts. Return completed form to the Health Office or theHawthorne Office for filing and clearance. If you have a valid and current physical on file in theHealth Office, that office will provide you with a physical verification slip.

4. Additional forms for STUDENT INSURANCE through Myers-Stevens are available in theHawthorne Office or Student Store. (Pages 13-18 in packet online.)

5. ELIGIBILITY:

WHO ELIGIBLE PROBATION * * INELIGIBLE* * Athletes C.I.F Rule - Pass 4 classes NONE C.I.F. Rule - Pass less

than 4 classes Athletes and

Students Maintain minimum 2.0 grade point average on quarter report card; no more than one “U” citizenship mark

First time – less than 2.0 grade average on quarter report card or 2 “U’s”

2 consecutive quarter report cards – less than 2.0 grade point average - 2 “U’s”

6. PARTICIPATION DONATION:See pages 8-10 for information from the principal, list of participation donations, andbreakdown of athletic expenditures. Checks should be made out to PVPHS and given tothe Student Store. Include a note with the check (or indicate in the memo section of thecheck) as to which activity the amount should go towards. NOTE: Advisors/Coaches onlysee the total amount donated and not the individual donors.

The fundraising goal, in order to continue to offer each sport/extra-curricular activity at the current level for the 2017-2018 school year, is determined by the previous year’s expenses plus coaches’ suggestions. These donations will be used to help fund the transportation costs, entry fees, and other expenses associated with the team and/or activity.

Donations are voluntary and students who choose not to make a participation donation or who make a donation in an amount different from that listed will NOT be denied the right to participate or otherwise be penalized in any way.

7. ATHLETIC BOOSTER CLUB:

THEY NEED YOUR SUPPORT. The Athletic Boosters buy uniforms and equipment for PantherAthletics and support our teams in many other ways. Come to a meeting each month in theLibrary (unless otherwise specified) (dates to be determined.) Most importantly, join the AthleticBooster Club:

Panther Booster Club- $150 Panther Silver Club - $250 Panther Gold Club - $400 Panther Platinum Club - $650 +

8. PRINT, SIGN, AND RETURN the following forms:a. Either Yellow Card or Clearance Form online (page 19).

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b. Physical Examination Report (F-1223) – completed by a doctor (no chiropractors)(page 20), if not already done, for sports or activities if physical required

c. Athletic/Activity Report (Ath/Act Rpt) (page 21)d. Concussion Information Sheet, if your sport or activity requires a physical (page 24)e. Sudden Cardiac Arrest Information Sheet for Athletes and Parents/Guardians (page 27)f. CIF Code of Ethics – Athletes; PVPHS Athletic and Co-Curricular Code of Conduct. This

form is for both sports and non-sports. (page 28)g. Sports or Non-Sport Waiver (F-603) (page 30)h. Sports or Non-Sport Waiver (F-605) (page 32) (NEW ADDITIONAL FORM)i. “Hazing Pledge” – signed by student and parent, GIVEN TO COACH OR ADVISOR. (page

33)j. Optional Form – Volunteer Driver – For parents who carpool students other than their

own student (F-604a and F-604b). Also need a copy of the driver’s license. Turn into theHawthorne Office. (page 36 & page 37, need both pages)

9. Processing Athletic / Activity Clearance Checkl i st :

TO: OFFICE FORM SIGNATURES 1 st SPORT/

ACTIVITY – submit

2nd or MORE – SPORT/

ACTIVITY – submit

__ TO: Hawthorne Office or get from Online Athletic Packet

PICK UP Yellow Card and/or Insurance information – Fill out FRONT and BACK of Yellow Card

OR Fill out Clearance Form Online (pg 19)

Yellow Card - Fill out card FRONT and BACK Parent / Guardian signs – front Clearance Form – Fill out form and Parent / Guardian signs

YES Need Yellow Card or Clearance Form online for every sport / activity

IMPORTANT

__ TO: Health Office – FIRST, if physical isrequired

Physical Form (pg 20) Yellow card – every sport / specific groups

YES NO - One Already on file

__ TO: Student Store AFTER GOING TO THE HEALTH OFFICE (if physical is required)

Yellow Card or online Clearance Form

ATHLETIC /ACTIVITY REPORT (Insurance) (pg 21)

CONCUSSION INFORMATION SHEET, turn in only if physical isrequired (pg 24).

SUDDEN CARDIAC ARREST INFORMATION SHEET FOR ATHLETES AND PARENTS / GUARDIANS, turn in only ifphysical is required (pg 27).

Yellow card – every sport / activity

Parent and Student signatures



YES

YES

YES, if physical required

YES, if physical required

YES - Need Yellow Card for every sport / activity NO - One already on file

YES – if not turned in previously. Need one on file. NO – if one is on file.

YES – if not turned in previously. Need one on file. NO – if one is on file.

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CIF CODE OF ETHICS / PVPHS CODE OF CONDUCT – BOTH SPORTS AND NON-SPORTS (pg 28)

SPORTS OR NON-SPORT WAIVER (F-603) (pg 30) (1) parent uses his/her own vehicle and drives their own student or (2) student uses his/her own vehicle to drive him/herself only for voluntary sports or non-sports program

SPORTS OR NON-SPORT WAIVER (F-605) (pg 32) Student may wish to attend and/or participate in an activity or program not during the school day. (NEW FORM)

PARTICIPATION DONATIONS

Parent and student signatures

Parent Signature

Parent Signature

YES

YES

YES

NO - One already on file



__ TO: COACHES / ADVISORS

HAZING PLEDGE: BOTH SPORTS AND NON-SPORTS (pg 33)

Parent and student signatures

YES – must be turned into coach /

advisor and accounted for

by them

YES – must be turned into coach / advisor and accounted for by them

__ TO: HAWTHORNE OFFICE - ATHLETICS

OPTIONAL: VOLUNTEER DRIVER FORM – Parent will be carpooling other students besides their own.

NEED COPY OF DRIVER’S LICENSE;

ALSO PAGES 36 & 37.

OPTIONAL OPTIONAL

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NOTE: Print out pages 5 and 6 as a reference for the distribution of forms during the regular school year. This page is not turned in.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTO FILL-IN INFORMATION (NOTE: if using a computer only)

(This Page is not turned in. It is for reference purposes only.)

NOTE: Information entered in the fields below will automatically be entered on every form in the packet that uses these fields if you are using your computer. Filling out this data can save a significant

amount of time. PLEASE NOTE: There will be areas where you will need to type in the information. You will need to sign at the PINK BOX areas in the documents that need to be turned in.

Student Last Name Home Telephone Number Student First Name School of Attendance

Grade Parent/Guardian Name Gender (male/female) Medical Insurance Co.

Date of Birth Medical Policy # Street Address Current Sport/Activity

City Today’s Date State

Zip

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IF PHYSICAL IS REQUIRED

1ST SPORT / ACTIVITY

2ND OR MORE SPORT / ACTIVITY

YELLOW CARD / CLEARANCE FORM - Make sure Parent/Guardian signed (pg 19) X X XPHYSICAL FORM - turn in or verify expiration (pg 20) XATHLETIC / ACTIVITY REPORT - Make sure policy number listed (pg 21) X- ONLY ONCE

TELL THEM YOU CLEARED

PREVIOUSLY

CONCUSSION FORM - FOR SPORTS OR NON-SPORTS REQUIRING PHYSICAL (pg 24) X

turn in if 1st sport / activity did not require

SUDDEN CARDIAC ARREST INFO SHEET - FOR SPORTS OR NON-SPORTS REQURING PHYSICAL (pg 27)

Xturn in if 1st

sport / activity did not require

ATHLETIC & CO-CURRICULAR CODE OF CONDUCT (pg 28) X- ONLY ONCE

WAIVER - FORM #603 - parent drives own student; student drives only themselves. (pg 30)

X- ONLY ONCE

WAIVER - FORM #605 - student wishes to participate in sport or activity during non-school hours (pg 32)

X- ONLY ONCE

STUDENT STORE INITIALS / DATES - YELLOW CARD / CLEARANCE FORM X XIF NO HEALTH INSURANCE, TURN IN THE MYERS-STEVENS FORMS. EVERYONE MUST HAVE MEDICAL INSURANCE.

X

HAZING PLEDGE - STUDENT GIVES TO COACH / ADVISOR

must be turned in for each and every sport /

activity

(rev 8/3/17)

HEALTH OFFICE STUDENT STORE COACH / ADVISOR

CLEARANCES PROCEDURES - ATHLETICS & ACTIVITIES

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Palos Verdes Peninsula High School 27118 Silver Spur Road Rolling Hills Estates CA 90274

310-377-4888 July 2017

Welcome to the start of the 2017-2018 school year! The beginning of school is one of my favorite times of year, because of the energy and excitement the students bring when they return to campus. As the new principal, I am looking forward to being a part of this journey and joining the Panther family. It is our goal here at Peninsula High to provide students with a balanced skill set that allows them to achieve their own personal academic best while also supporting them to become active participants in this dynamic and inclusive school culture. We strive to provide students with the skills for critical thinking and creativity, all within a safe and secure campus. Our goal is to have all Peninsula High students successfully engaged in a balanced combination of their studies and extracurricular activities, both at school and within community. We are also determined to ensure that students take advantage of the support personnel we have on campus, so that they are able to develop and maintain a healthy lifestyle. This generation of students is particularly unique because of the amount of information that bombards them daily from a variety of sources. It not only increases the size and scope of their global community but also increases the demands on their attention. We, as educators, have an obligation to assist this generation of students with their ability to not only manage these new demands, but embrace them as opportunities. I am honored to be the principal of a school with a diverse and vibrant student body, an incredibly talented and passionate staff, and the most supportive and committed parents in the world. Sincerely, Brent Kuykendall Principal

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The fundraising goal in order to continue to offer each sport/extra-curricular activity at the current level for the 2017-2018 school year is theamount listed multiplied by the number of students expected to participate in the sport/activity. These donations will be used to help fund thetransportation costs, officials, entry fees, and other expenses associated with the team and/or activity.

17-18 17-18 17-18 17-18

Baseball Boys & Girls Tennis Marching Band / Drama 1 AdvancedBoys & Girls Track & Field Colorguard Drama 2Girls Golf Speech & Debate Drama 3 Advanced

Boys & Girls Basketball Girls Lacrosse Drama 4 AdvancedSpirit (Song) & Cheer

Academic DecathlonBoys & Girls Water Polo MUN Advanced OrchestraFootball $200 Boys & Girls Cross Country Math TeamSoftball Orchestra

Jazz Band Solar EngineeringBoys & Girls Swimming Coed Choreo Science Bowl

$350 Boys & Girls Volleyball Surf Team

Choir Advanced DanceBoys & Girls Soccer Cyperpatriots Company Choreo DanceBoys Golf Robotics Intermediate DanceBoys Lacrosse Science Olympiad Varsity DanceWrestling Stellar Xplore

VEX Robotics

Donations are voluntary and students who choose not to make a participation donation or who make a donation in an amountdifferent from that listed above will not be denied the right to participate or otherwise penalized in any way.

(rev 7/21/17; 5:45PM)

$300 $100

$150

$75

$25

$250

EXTRA- CURRICULAR ACTIVITIES

PVPHS Participation Donation Amounts - 2017-2018

$400

ATHLETICS

$150

$90$200

$175

$500

$550

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(rev 7/13/17)

Peninsula High School Athletic Expenditures

Participation Donation Make donations in the Student Store; make checks payable to:

“PVPHS;” memo section: “Sport or Activity” & “Student’s Name.” Participation Donation accounts are in Student Store.

Participation Donation Expenses Include:

• Transportation – Buses, etc.

• All tournament entry fees

• Officials, field attendants, subs, etc.

• Certificate awards

Team Expenses (Please make checks payable to: “PVPHS” –

amount determined by coach/advisor for team jog-a-thon or club account)

• Banquet, team meals, and travel

• Sports Awards

• Team Expenses (gear, etc.)

• Equipment

Athletic Booster Club Donation (Please make checks payable to: “PVPHS ATHLETIC BOOSTER CLUB”)

• Membership - $150 (minimum and includes 3 Panther Card Apps)

• Additional Panther Card Apps - $20 each or 3 for $50Monies raised by the Athletic Booster Club go directly to support Peninsula High School Athletics by funding:

* Capital Improvements and Upgrades of our Sports Facilities and Venues, e.g.,* New Scoreboards* Athletic Storage Sheds* Batting Cages and Bullpens* Expanded Trainer, Equipment, and Team Rooms* Concession Stands

* Athletic Trainer* Field, Track, and Court Maintenance

Please support the ABC and your student-athletes by becoming an ABC member, buying Panther Card Discount Apps and attending our annual Black & Gold Affaire Gala on Saturday, March 17, 2018! Go Panthers! www.pvphsabc.com

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http://www.pvphsabc.com/

643

2017-2018

myers I stevens I toohey

640

Despite your best efforts to protect them, children get hurt and out-of-pocket expenses for medical care can be significant.

• Is your child already covered?• Does your plan have large deductibles

and co-insurance?• Do you want to be able to see the doctor

that YOU choose?

Student Accident Insurance is Now More Important Than Ever!

School Year

Sponsored by:

Arranged and Administered by:

Our Plans Can Help!Click Here to Enroll Now

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https://www.myers-stevens.com/enrollment-page

Affordable Rates Call (800) 827-4695 With Questions

Determine the Plan(s) you want to purchase

You may go to the doctor or hospital of your choice!

Student Accident & Sickness PlanOur Best Coverage!

Students (Grades P-12) may enroll in this plan. Covers Injuries sustained and Sickness commencing anywhere in the world, 24 hours a day, while your student is insured under this School Year’s plan (including interscholastic sports, except interscholastic high school tackle football). Repatriation and Medevac benefits are included. This plan does not cover routine or preventative care.

Benefits are payable according to the “Description of Benefits” up to $50,000 per Covered Sickness and $200,000 per Covered Accident.

Coverage begins at 11:59 p.m. on the day Myers-Stevens & Toohey & Co., Inc. (herein called “The Company”) receives the completed enrollment form and premium. Coverage ends at 11:59 p.m. on the last day of the month for which payment has been made. Coverage may be continued for up to 12 calendar months, or through Sept. 30, 2018, whichever comes first, provided the required payments are made. There is a $50 deductible per covered Accident or covered Sickness.

NOTE – Participation in commercial camps or clinics may be covered under this plan.

Interscholastic Tackle FootballAccident PlansStudents (grades 9-12) may enroll in these plans. Covers Injuries caused by covered accidents occurring:

• While practicing or playing in interscholastic high school tackle football activities which are School-sponsored and directly supervised, including spring practice and summer conditioning, weight training and passing league

• While traveling for football in a School Vehicle or traveling directly and without interruption between School and off-campus site for such activities provided travel is arranged by and is at the direction of the School

Coverage begins at 11:59 p.m. on the day the Company receives the completed enrollment form and premium. Coverage ends at 11:59 p.m. on the closing date of regular classes for the 2017-2018 School Year.

NOTE – Participation in commercial camps or clinics is not covered under these plans. See “Full=Time 24/7” plans. Practice or playing of football must be conducted under the regulations and jurisdiction of the applicable sports governing body

Benefit Levels: High Mid LowRates per School Year: $339 $295 $235

Full-Time 24/7 Accident PlansStudents (grades P-12 and school employees) may enroll in these plans. Covers Injuries caused by covered Accidents occurring 24 hours a day, anywhere in the world and while participating in all interscholastic sports except interscholastic high school tackle football.

Coverage begins at 11:59 p.m. on the day the Company receives the completed enrollment form and premium. Coverage ends at 12:01 a.m. on the date School begins regularly scheduled classes for the 2018-2019 School Year.

NOTE – Participation in commercial camps or clinics may be covered under this plan.


School-Time Accident PlansStudents (grades P-12) may enroll in these plans. Covers Injuries caused by covered Accidents occurring:

• On School premises during the hours and on days when the School’s regular classes are in session, including one hour immediately before and one hour immediately after regular classes, while continuously on the School premises

• While participating in or attending School-sponsored and directly supervised School Activities including interscholastic athletic activities and non-contact spring football (except interscholastic high school tackle football)

• While traveling directly and without interruption to or from residence and School for regular attendance; or School and off campus site to participate in School-sponsored and directly supervised School Activities, provided travel is arranged by and is at the direction of the School; and while traveling in School Vehicles at any time.

Coverage begins at 11:59 p.m. on the day the Company receives the completed enrollment form and premium. Coverage ends at 11:59 p.m. on the closing date of regular classes for the 2017-2018 School Year.

NOTE – Participation in commercial camps or clinics is not covered under these plans. See “Full-Time 24/7” plans.


Dental Accident Plan ($75,000 Maximum)Students (grades P-12) may enroll in these plans. Covers Injuries to teeth caused by covered Accidents occurring 24 hours a day, anywhere in the world, including participation in all sports and all forms of transportation.

Benefits are payable at 100% of the Usual, Customary and Reasonable charges for Treatment of Injured teeth, including repair or replacement of existing caps or crowns. We do not pay for damage to or loss of dentures or bridges or damage to existing orthodontic equipment.

The coverage provides a “Benefit Period” of Accident dental benefits for up to one year from the date of first Treatment. The benefit period for an Injury may be extended each year, provided that: coverage is renewed prior to October 1, the student remains enrolled in grades P-12, and written notice is received by the Company at the time of Injury that further Treatment will be deferred to a later date.

Coverage begins at 11:59 p.m. on the day the Company receives the completed enrollment form and premium. Coverage ends at 12:01 a.m. on the date School begins regularly scheduled classes for the 2018-2019 School Year.

$16.00 purchased separately $12.00 when added to any plan(s) purchased

Pharmacy SmartCardAvailable to students, their families and school staff through our partnership with National Pharmaceutical Services (NPS), the SmartCard offers savings of up to 95% of prescription drug costs and is accepted at over 63,000 pharmacies nationwide.

In addition, the program can provide “Instant Alerts” to potential medication interactions to better protect your family along with unique “Proof of Savings” reports mailed directly to you every six months.

After your payment has been processed, NPS will send you your ID card. Present your card each time you or a family member needs a prescription filled to receive your savings. For more detailed information, go to www.pti-nps.com or call 800-546-5677.

The SmartCard is not an insurance product and is not insured by BCS Insurance Company.

$36.00 for entire family, for one full year!

1st payment: $208.00(Covers remainder of month in which you enroll and 1 additional month)

Subsequent Payments: $169.00 a month, billed every 2 months

™

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Choose Your Own Doctor and Hospital

Determine the benefit level that best fits your needsWe urge you to consider the Student Accident & Sickness Plan or the High Option plans, especially if your child has no other insurance.

Call us at 800-827-4695 for help.

Description of Benefits (Applies to all plans except the Dental Accident Plan and Pharmacy SmartCard)We will pay benefits only for Covered Injuries sustained or Covered Sickness commencing while insured under this School Year’s plan. Benefits payable will be based on the Usual, Customary and Reasonable Charges incurred for covered medical and dental services, as defined by the Policy, subject to exclusions, requirements and limitations. We do not pay for a service or supply unless it is Medically Necessary and listed in the Description of Benefits below. Applicable benefits mandated by the state of residence will be included in the covered expenses. You may take your child to any provider you choose; however, seeking Treatment through a First Health contracted provider may reduce your out-of-pocket costs.

To find participating First Health medical providers nearest you, call 800-226-5116 or log on to www.myfirsthealth.com.

Covered Benefit Levels Low Option Mid Option High Option Student Accident & Sickness Plan

Plan Name MAXIMUMS PER ACCIDENT$50,000 Maximum per Sickness

$200,000 Maximum per Accident

Tackle Football Accident Plan $25,000 $50,000 $75,000

Full-Time 24/7 Accident Plan $50,000 $100,000 $150,000

School-Time Accident Plan $25,000 $50,000 $75,000

Deductible - per condition $200 $100 $50 $50

Covered Expenses BENEFIT MAXIMUMS BENEFIT MAXIMUMS

Hospital Room & Board - Semi Private Room Rate 80% 80% 90% 80%

Inpatient Hospital Miscellaneous Charges 80% to $2,000/Day 80% to $2,500/Day 90% to $3,000/Day 80% to $4,000/Day

Intensive Care Unit 80% to $2,000/Day 80% to $2,500/Day 90% to $3,000/Day 80%

Hospital Emergency Room (room & supplies) incurred within 72 hours of an Injury 100% 100%

Emergency Room Physician Charges 100% 100%

Outpatient Surgical (room & supplies) 80% to $2,000 80% to $2,500 90% to $5,000 80% to $4,000

Physician Non-Surgical Treatment & Exam (excluding Physical Therapy) Including consultation (when referred by attending Physician)

80% 80% 90% 80%

Surgeon Services 80% 80% 90% 80%

Assistant Surgeon Services 80% 80% 90% 80%

Anesthesiologist Services 80% 80% 90% 80%

Physiotherapy (includes related office visits) when prescribed by a Physician 80% to $500 80% to $750 90% to $1,000 80% to $2,000

X-Ray Examinations (including reading) 80% to $500 80% to $750 90% to $1,000 80%

Diagnostic Imaging MRI, Cat Scan 80% 80% 90% 80%

Ambulance (from site of an emergency directly to hospital) 100% 100%

Laboratory Procedures, Registered Nurse Services, and Rehabilitative Braces 80% 80% 90% 80%

Durable Medical Equipment 80% to $400 80% to $750 90% to $1,000 80%

Out-Patient Prescription Drugs (for Injuries only) 80% 80% 90% 80%

Dental Services (including dental x-rays) for Treatment due to a covered Accident 80% 80% 90% 80%

Eyeglass Replacement (for replacement of broken eyeglass frames or lenses resulting from a covered Accident requiring medical Treatment)

$300 $300 $300 80%

Medical Evacuation & Repatriation $0 $0 $0 100% to $10,000

Benefits for Accidental Death, Dismemberment, Loss of Sight, Paralysis and Psychiatric/Psychological Counseling

(Applies to all plans except the Dental Accident Plan and Pharmacy SmartCard)

In addition to medical benefits, if, within 365 days from the date of Accident covered by the policy, bodily Injuries result in any of the following losses, we will pay the benefit set opposite such loss. Only one such benefit (the largest) will be paid for all such losses due to any one Accident.

• Accidental Death $10,000• Single dismemberment or entire loss of sight in one eye $20,000• Double dismemberment or entire loss of sight in both eyes, or paraplegia or hemiplegia or quadriplegia $30,000Counseling - In addition to the AD&D benefits, we will pay 100% of the Usual, Customary and Reasonable costs of psychiatric/psychological counseling needed after covered dismemberment, loss of sight or paralysis up to $ 5,000

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X

2017 - 2018 Enrollment Form

Complete all information (please print) and return to Myers-Stevens & Toohey & Co., Inc.

Student Name First Middle Last

- -Student Birthdate

Mailing Address Apt.#

City State Zip Code

- -

Parent Daytime Phone Number

Parent E-mail Address

District Name

School Name Grade

Available for your convenience is the option to have your bi-monthly payments automatically charged to your credit card.

By initialing here ______________, I hereby authorize Myers-Stevens & Toohey to charge the above credit card $338, plus a 3% processing fee, on the 5th of the month that my payment is due. This authorization will remain in effect for the 2017/2018 school year until I notify Myers-Stevens & Toohey in writing prior to the next payment date.

Auto-Charge Option

Method of PaymentNote: $25.00 service charge for Returned Checks and declined Credit Cards

Check/Money Order (Make payable to: Myers-Stevens & Toohey & Co., Inc.) or Mastercard® or Visa®

Important: If paying by credit card, complete this form. Your amount of charge will appear as “M-S Student Insurance” on your statement.

- - -

Card Number 3 digitcontrol #

EXP. DATE MO. YR.

Signature of Cardholder

Amount

$

I authorize Myers-Stevens & Toohey & Co. Inc. to deduct the premium payment, plus a 3% processing fee, from my credit card. If enrolling in the Student Accident & Sickness Plan, I am authorizing the initial premium payment and understand that I will be invoiced every 2 months for the subsequent payments.

Print Name of Cardholder Zip Code

1

2

3

2

1

Easy Enrollment

Student Accident & Sickness 1st Payment $208.00

You will be billed $338.00 every 2 months thereafter. Coverage cannot exceed 12 calendar months or run past Sept. 30, 2018.

(One-Time Payment For Entire School Year)

PLANS: High Option Mid Option Low OptionTackle Football Only $339.00 $295.00 $235.00

Full-Time (24/7) $328.00 $276.00 $225.00

School-Time $79.00 $68.00 $53.00

Dental Accident $16.00 Purchased Separately

$12.00 When added to any plan(s) purchased

Pharmacy Smart-Card $36.00

Total Amount Due $

Print Parent or Guardian NameI have enrolled for the coverage checked above as provided by the Family Insurance Trust where applicable. I understand premiums cannot be refunded or converted.

X__________________________________________________Parent or Guardian Signature Date

Our BEST Plan

Our Accident Plans

PREMIUMS CANNOT BE REFUNDED OR CONVERTED

InstructionsThank you for enrolling your child!

To avoid any delay in coverage, please follow these 3 easy steps below: Select the plan(s) you wish to purchase below:

• The Student Accident & Sickness Plan will provide our highest level of coverage.

• Our Accident Plans may be purchased on an individual basis or combined with additional coverage (for example, Full-Time Accident + Dental).

Complete and detach the enrollment form on the reverse side or you may enroll online (see below). Please note, we are unable to accept enrollments over the phone.

Purchase and Return Apply online at www.myers-stevens.com for IMMEDIATE processing!

We accept VISA and MasterCard online.

If online enrollment is not available, you may either:• Fax both sides of the completed Enrollment Form to (949) 348-2630. You

may pay by credit card by completing the payment area on reverse or fax a personal check made payable to Myers-Stevens & Toohey & Co., Inc. Please do not mail original checks if faxing. We cannot accept Money Orders by fax.

• Email a scanned image of the completed Enrollment Form to [email protected]. You may pay by credit card by completing the payment area on reverse or scan a personal check made payable to Myers-Stevens & Toohey & Co., Inc. Please do not mail original checks if emailing. We cannot accept Money Orders by email.

• Mail both sides of the completed Enrollment Form in the enclosed envelope. You may pay by credit card by completing the payment area on reverse or enclose a check or Money Order made payable to Myers-Stevens & Toohey & Co., Inc.

PLEASE DO NOT SEND CASH

B

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How To File A Claim

1. Report School-related Injuries within 60 days to the School office. To find a First Health provider nearest you, call 800-226-5116 or log on to www.myfirsthealth.com.

2. Obtain a claim form from the School or the Company. Claim forms must be filed with the Company within 90 days after the date of first Treatment.

3. At the same time, please file a claim with your other family sickness and/or Accident carrier.

4. Follow ALL claim form instructions, attach all itemized bills and send to:

Myers-Stevens & Toohey & Co., Inc.26101 Marguerite Parkway

Mission Viejo, CA 92692-3203949-348-0656 or 800-827-4695

Fax 949-348-2630CA License #0425842

The Insurance Company

(Does not apply to the SmartCard)

This brochure contains a brief description of the benefits available. Complete details may be found in the Policies on file at your School or district office. Certain provisions may be different if required by state law. Please keep this information as a reference.

Policyholder: Family Insurance Trust, Sitused in District of Columbia

BCS Insurance Company Oakbrook Terrace, Illinois

Rated A- (Excellent) by A. M. Best,an independent insurance company rating agency

Master Policy form # 28.203

Frequently Asked Questions...

If I have other insurance, why do I need this coverage?

Our plans can expand your choice of providers for your child and can help cover deductibles, co-pays and other out-of-pocket expenses.

I’m in a hurry! What is the quickest way to enroll?We offer online enrollment at

www.myers-stevens.com.Simply click the orange “Enroll Now” button on the home page, complete the enrollment process and your ID card will be emailed to you immediately!

If my child has no other insurance, what’s my best buy?

Unless you need coverage for high school tackle football, the Student Accident & Sickness Plan is our broadest, best option. Next best is the Full-Time 24/7 Accident Plan with “High Option” benefits.

Can I take my child to any doctor or hospital?YES! However, your out-of-pocket costs could be less by using a First Health contracted provider. To find participating doctors/hospitals nearest you, call 800-226-5116 or log on to www.myfirsthealth.com

Are accident-only rates paid every month?NO! Accident-only rates are one-time charges for the entire School Year.

Can interscholastic high school tackle football be covered?

YES! But only under the Interscholastic Tackle Football Plan. “High Option” benefits are recommended.

Do the Interscholastic Tackle Football or School-Time plans cover camps and clinics sponsored and organized by groups other than my child’s school?

NO! However, such camps and clinics may be covered under our Full-Time 24/7 or Student Accident & Sickness plans. Call us for guidance!

Still need help or have questions?Go to www.myers-stevens.com or call us for prompt, personalized assistance at (800) 827-4695.

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Call (800) 827-4695 With Questions

Exclusions

Benefits are not payable for any of the following or loss that results from them: 1. Damage to or loss of dentures or bridges or damage to existing orthodontic equipment.

2. War or any act of war, declared or undeclared.

3. Participation in a riot or civil disorder; fighting or brawling, except in self-defense; commission of or attempt to commit a felony or violating or attempting to violate any duly enacted law.

4. Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane.

5. Injury or Sickness contributed to by the use of alcohol or drugs unless taken in the dosage and for the purpose prescribed by the Covered Person’s Physician.

6. Practice or play in interscholastic high school tackle football (unless separate football coverage is purchased), intercollegiate sports, semi-professional sports, or professional sports. (Does not apply to the Dental Accident Plan.)

7. Injury or Sickness covered by Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or required by law including, but not limited to group, group type, and individual automobile “No Fault” coverage (excluding School Vehicle coverage).

8. Treatment, services or supplies provided by the School’s infirmary or its employees, or Physicians who work for the School, or by any member of the Covered Person’s immediate family; or for which no charge is normally made.

9. Mental or nervous disorders (except as specifically provided by the Policy).

10. Treatment of Sickness, ailment, or infections (except pyogenic infections or bacterial infections which result from the accidental ingestion of contaminated substances). (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)

11. The diagnosis and Treatment of non-malignant warts, moles and lesions, acne or allergies, including allergy testing.

12. Injury sustained as a result of riding in or on, entering or alighting from, a two or three-wheeled motor vehicle. (Does not apply to the Dental Accident Plan.)

13. Treatment of osteomyelitis, pathological fractures and hernia. (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan

14. Detached retina (unless directly caused by an Injury). (Does not apply to the Sickness-Only Coverage under the Student Accident & Sickness Plan.)

15. Any expenses related to the Treatment of tonsils, adenoids, epilepsy, seizure disorder or congenital weakness; or expenses for Treatment of congenital anomalies and conditions arising or resulting directly there from.

16. Supplies, except as otherwise provided in the Policy.

Requirements and LimitationsAggravations of injuries which did not occur while insured under this plan are paid up to $500 maximum benefit per policy term. Injuries sustained as a result of riding in or on, entering or alighting from or being struck by a Motor Vehicle are limited to a $5,000 maximum benefit (up to $10,000 if vehicle is a School Vehicle). Some Motor Vehicle injuries are not covered - see exclusions above for details. School-time and high school tackle football injuries must be reported to the School within 60 days of the date of Injury. The first Physician’s visit must be within 120 days after the Accident occurs. This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit us from providing insurance, including but not limited to, the payment of claims. A claim form must be filed with Myers-Stevens & Toohey & Co., Inc. within 90 days after the date of loss. The plan pays for covered expenses incurred within up to a year from the date of the first Physician’s visit. However, should the Injury sustained require the removal of surgical pins, continued Treatment for serious burns, or Treatment of a non-union or mal-union fracture, the benefit period will be extended to 104 weeks. Each covered condition may be subject to a deductible - see plan details.

DefinitionsAn Accident is defined as a sudden, unexpected and unintended incident. Covered Accident means an Accident that results in Injury or loss covered by this Policy. An Injury is defined as Accidental bodily harm sustained by the Covered Person that results directly from an Accident (independently of all other causes) and occurs while coverage under the Policy is in force. Medically Necessary is defined as the services or supplies provided by a Hospital, Physician, or other provider that are required to identify or treat an Injury or Sickness and which, as determined by the Company, are: (1) consistent with the symptoms or diagnosis and Treatment of the Injury or Sickness; (2) appropriate with regard to standards of good medical practice; (3) not solely for the convenience of the Insured Person; (4) the most appropriate supply or level of service which can be safely provided. When applied to the care of an Inpatient, it further means that the Insured Person’s medical symptoms or condition requires that the services cannot be safely provided as an Outpatient. Sickness is defined as illness or disease contracted by and causing loss to the Insured Person whose Sickness is the basis of claim. Any complications or any condition arising out of a Sickness for which the Insured Person is being treated or has received Treatment will be considered as part of the original Sickness. School Activities means any activity that is sponsored and under the direct, immediate supervision of the School that: (a) the School requires the Insured Person to attend; or (b) is under the sole control and supervision of School authorities. It does not include an activity related to athletics or cheerleading that is under joint sponsorship or supervision arrangement with any non-School group.

Non-Duplication of Benefits (Excess Provision):In order to keep premiums as affordable as possible, these plans pay benefits on a non-duplicating basis. This means, if a person is covered by one or more of these plans and by any other valid insurance or health agreement, any amount payable or provided by the other coverages will be subtracted from the covered expenses and we will pay benefits based on the remaining amount.

IMPORTANT NOTICE: This Plan provides short-term limited duration sickness benefits. It does not constitute comprehensive health insurance coverage (often referred to as “major medical coverage”) and does not satisfy a person’s individual obligation to secure the requirement of minimum essential coverage under the Affordable Care Act (ACA). For more information about the ACA, please refer to www.HealthCare.gov.

Premiums Cannot be Refunded or ConvertedFor a brochure in Spanish, or for assistance in Spanish, please call 800-827-4695

Para un folleto en Español, o para asistencia en Español, por favor llame a 800-827-4695

CA PND 640 02/17

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PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT Sport/Activity HIGH SCHOOL SPORT / ACTIVITY CLEARANCE Coach/Advisor

Level (V/JV/10/9)

PRINT NAME (use ink) LAST FIRST MIDDLE

Grade Birthdate Age Student Cell #

Student Email

** I hereby give my permission for the administration of emergency first aid to the above student and approval for his/her participation in the above sport/activity. **

x

PRINT NAME – PARENT/GUARDIAN SIGNATURE - PARENT/GUARDIAN DATE SIGNED

CLEARANCE PROCEDURE:

Health Office (Physical Form) Physical Expires Initials Date Signed

Student Store (Athletic/Activity Report, Insurance, Code of Conduct, Waiver (F-603), Voluntary Participation Donation, Initials Date Signed Concussion form, if applicable)

NOTE: A new card must be completed for each sport or activity. Student may not participate until this card has been completed and turned in.

EMERGENCY INFORMATION ON BACK

PARENTS: This information is necessary in the event injury occurs while away from school or outside regular school hours. Please be as specific as possible.

Student Full Name

Home Address

Mother / Father Name(s)

Parent Email

Where Mother may Home be reached - Phone

Wk #

Cell #

Where Father may Home be reached - Phone

Wk #

Cell #

Contact if neither Mother nor Father can be reached - Name

Contact Phone Work # Cell #

Doctor Phone

Hospital Phone

CHECK ONE: SCHOOL INSURANCE PRIVATE INSURANCE Name – Insurance Company

History or Allergies, Injuries, Heart, or Other Medical Problems:

F-601 (8/15)

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PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT Health Services

PHYSICAL EXAMINATION REPORT

**PLEASE RETURN ORIGINAL FORM TO THE SCHOOL. NO COPIES.** Student’s Name___________________________________Birthdate_______________

Student’s Grade_________________

A physical examination of this student was performed on (Date)___________________.

He/she is physically fit to participate in all athletics.*

Date_____________________ ___________________________________________ Physician’s Signature

VALID ONLY WITH PHYSICIAN’S STAMP Telephone:__________________________________

* California Interscholastic Federation (CIF) policy 308 states . . . “schools will require

that a student receive an annual physical examination conducted by a medical practitioner certifying that the student is physically fit to participate in athletics. . . . The physical examination must be completed before a student may try out, practice or participate in interscholastic athletic competition…”

PVPUSD accepts physical examination reports from a M.D., D.O., Physicians’ Assistant, and Nurse practitioner with a MD’s stamp.

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Palos Verdes Peninsula Unified School District

Athletic/Activity Report

(Forgery of these forms will result in disciplinary action by the Associate Principal)

______________________________________________________________________________________Last Name (print) First Name (print) Grade Boy/Girl Sport

_______________________________________________________________________________________Address City/Zip Code Home Telephone Number

_______________________________________________________________________________________Age Birthdate Month and year started ninth grade

_______________________________________________________________________________________Did you transfer from another high school? If so, what date? List name, city, and state of the high school that you

transferred from.

Insurance RequirementsCalifornia Law (Education Code §§ 32220-32224) requires every member of an athletic team to have at least$1,500 medical and hospital coverage.

I ALREADY HAVE INSURANCE for my son/daughter which meets the requirements of CaliforniaLaw. The name of my insurance company is __________________________________________and the policy number is ______________________. I will promptly notify the school in theevent insurance coverage no longer applies to my son/daughter.

School InsuranceMyers/Stevens Insurance Company

I am purchasing Myers/Stevens insurance and returning the Myers/Stevens envelope with the Athletic Packetso the school can send it to the company. I am purchasing the following coverage: (check the appropriatecoverage.)

_____ Tackle Football (covers only tackle football) _____ School Time Low Med High

_____ Full Time Low Med High _____ Full Time Low Med High

_____ Student Health Care Payment Plan _____ Extra Dental

Athletic Commitments and ResponsibilitiesI have read and understand the following sections of the Athletic Packet:

• Academic Eligibility Standards• Athletic/Activity Code of Conduct• District Letter Regarding Insurance Coverage• Code of Ethics - Athletes• Emergency Card

• Physical Form• Student Insurance• Participation Donation Letter• Medical Treatment Authorization-Waiver, Release,

and Indemnity Agreement

___________________________________ ______________________________ ________________Signature of Parent/Guardian Signature of Student Date

Ath/Act Rpt 6/04, 4/05, 7/06, 7/10

Sport/Activity1._______________2._______________3.______________

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Why am I getting this Information sheet? You are receiving this information sheet about concussions because of California state law AB 25 (effective January 1, 2012), now Education Code § 49475.

1. The law requires a student athlete who may have a concussion during a practice or game to beremoved from the activity for the remainder of the day.

2. Any athlete removed for this reason must receive a written notice from a medical doctor trained in themanagement of concussion before returning to practice.

3. Before an athlete can start the season and begin practice in a sport, a concussion information sheetmust be signed and returned to school by the athlete and the parent or guardian.

Every 2 years all coaches are required to receive training about concussions (AB 1451), as well as certification in First Aid training, CPR, and AEDs (life-saving electrical devices that can be used during CPR).

What is a concussion and how would I recognize one? A concussion is a kind of brain injury. It can be caused by a bump or hit to the head, or by a blow to another part of the body with the force that shakes the head. Concussions can appear in any sport, and can look differently in each person.

Most concussions get better with rest and over 90% of athletes fully recover, but, all concussions are serious and may result in serious problems including brain damage and even death, if not recognized and managed the right way.

Most concussions occur without being knocked out. Signs and symptoms of concussion (see back of this page) may show up right after the injury or can take hours to appear. If your child reports any symptoms of concussion or if you notice some symptoms and signs, seek medical evaluation from your team's athletic trainer and a medical doctor trained in the evaluation and management of concussion. If your child is vomiting, has a severe headache, is having difficulty staying awake or answering simple questions, he or she should be immediately taken to the emergency department of your local hospital.

On the CIF website is a Graded Concussion Symptom Checklist. If your child fills this out after having had a concussion, it helps the doctor, athletic trainer or coach understand how he or she is feeling and hopefully shows progress. We ask that you have your child fill out the checklist at the start of the season even before a concussion has occurred so that we can understand if some symptoms such as headache might be a part of his or her everyday life. We call this a "baseline" so that we know what symptoms are normal and common. Keep a copy for your records and turn in the original. If a concussion occurs, he or she should fill out this checklist dally. This Graded Symptom Checklist provides a list of symptoms to compare over time to make sure the athlete is recovering from the concussion.

What can happen if my child keeps playing with concussion symptoms or returns too soon after getting a concussion? Athletes with the signs and symptoms of concussion should be removed from play immediately. There Is NO same day return to play for a youth with a suspected concussion. Youth athletes may take more time to recover from concussion and are more prone to long-term serious problems from a concussion.

Even though a traditional brain scan (e.g., MRI or CT) may be "normal", the brain has still been injured. Animal and human studies show that a second blow before the brain has recovered can result in serious damage to the brain. If your athlete suffers another concussion before completely recovering from the first one, this can lead to prolonged recovery (weeks to months), or even to severe brain swelling (Second Impact Syndrome) with devastating consequences.

There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological problems. One goal of this concussion program is to prevent a too-early return to play so that serious brain damage can be prevented.

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Signs observed by teammates, parents, and coaches include:

Symptoms may include one or more of the following:

• Looks dizzy• Looks spaced out• Confused about plays• Forgets plays• Is unsure of game, score, or opponent• Moves clumsily or awkwardly• Answers questions slowly• Slurred speech• Shows a change in personality or way of acting• Can't recall events before or after the Injury• Seizures or has a fit• Any change in typical behavior or personality• Passes out

• Headaches• "Pressure In head"• Nausea or throws up• Neck pain• Has trouble standing or walking• Blurred, double, or fuzzy vision• Bothered by light or noise• Feeling sluggish or slowed down• Feeling foggy or groggy• Drowsiness• Change In sleep patterns• Loss of memory• “Don’t feel right”• Tired or low energy• Sadness• Nervousness or feeling on edge• Irritability• More emotional• Confused• Concentration or memory problems• Repeating the same question/comment

What Is Return to Learn? Following a concussion, student athletes may have difficulties with short- and long-term memory, concentration and organization. They will require rest while recovering from injury (e.g., avoid reading, texting, video games, loud movies), and may even need to stay home from school for a few days. As they return to school, the schedule might need to start with a few classes or a half-day depending on how they feel. They may also benefit from a formal school assessment for limited attendance or homework such as reduced class schedule, if recovery from a concussion is taking longer than expected. Your school or doctor can help suggest and make these changes. Student athletes should complete the Return to Learn guidelines and return to complete school before beginning any sports or physical activities. Go to the CIF website (dfstate.org) for more information on Return to Learn.

How Is Return to Play (RTP) determined? Concussion symptoms should be completely gone before returning to competition. A RTP progression involves a gradual, step-wise increase ln physical effort, sports-specific activities and the risk for contact. If symptoms occur with activity, the progression should be stopped. If there are no symptoms the next day, exercise can be restarted at the previous stage.

RTP after concussion should occur only with medical clearance from a medical doctor trained in the evaluation and management of concussions, and a step-wise progression program monitored by an athletic trainer, coach, or other identified school administrator. Please see cifstate.org for a graduated return to play plan. [AB 2127, a California state law that became effective1/1/15, states that return to play (I.e., full competition) must be no sooner than 7 days after the concussion diagnosis has been made by a physician.]

Final Thoughts for Parents and Guardians: It is well known that high school athletes will often not talk about signs of concussions, which is why this information sheet is so important to review with them. Teach your child to tell the coaching staff if he or she experiences such symptoms, or if he or she suspects that a teammate has suffered a concussion. You should also feel comfortable talking to the coaches or athletic trainer about possible concussion signs and symptoms.

References: • American Medical Society for Sports Medicine position statement: concussion in sport (2013)• Consensus statement on concussion in sport: the 4th International Conference on Concussion In Sport held In Zurich, November 2012• http;//www.cdc.gov/concussion/HeadsUp/youth.html

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Please Return this Page

I hereby acknowledge that I have received the Concussion Information Sheet from my school and I have read and understand its contents. I also acknowledge that if I have any questions regarding these signs, symptoms and the “Return to Learn” and “Return to Play” protocols, I will consult with my physician.

_________________________ ________________________ _____________________ Student-athlete Name Printed Student-athlete Signature Date

_________________________ ________________________ _____________________ Parent/Guardian Name Printed Parent/Guardian Signature Date

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CA STATE LAW AB 2127 (Effective 1/1/15) STATES THAT RETURN TO PLAY (I.E., COMPETITION) CANNOT BE SOONER THAN 7 DAYS AFTER EVALUATION BY A PHYSICIAN (MD/DO) WHO HAS MADE THE DIAGNOSIS OF CONCUSSION.

Instructions: • This graduated return to play protocol MUST be completed before you can return to FULL COMPETITION.

o A certified athletic trainer (AT), physician, or identified concussion monitor (e.g., coach, athletic director),must Initial each stage after you successfully pass it.

o Stages I to II-D take a minimum of 6 days to complete.o You must be back to normal academic activities before beginning Stage II.o You must complete one full practice without restrictions (Stage Ill) before competing in first game.

• After Stage I, you cannot progress more than one stage per day (or longer if instructed by your physician).• If symptoms return at any stage in the progression, IMMEDIATELY STOP any physical activity and

follow up with your school’s AT, other identified concussion monitor, or your physician. In general, ifyou are symptom-free the next day, return to the previous stage where symptoms had not occurred.

• Seek further medical attention if you cannot pass a stage after 3 attempts due to concussionsymptoms, or if you feel uncomfortable at any time during the progression.

You must written physician (MD/OD) clearance to begin and progress through the following stages as outlined below (or as otherwise directed by physician)

Date & Initials

Stage Activity Exercise Sample Objective of the Stage

I No physical activity for at least 2 full symptom-free days AFTER you have seen a physician

No activities requiring exertion (weightlifting, jogging, P.E. classes)

Recovery and elimination of symptoms

II-A Light aerobic activity • 10-15 minutes of walking or stationary biking

• Must be performed under direct supervision by designated individual

• Increase heart rate to no more than 50%of perceived max. exertion (e.g., < 100 beats per minute)

• Monitor for symptom return II-B Moderate aerobic activity

Light resistance training

• 20-30 minutes jogging or stationary biking • Body weight exercises (squats, planks,

push-ups), max 1 set of 10, no more than 10 min total

• Increase heart rate to 50-75% max. exertion (e.g., 100-150 bpm)

• Monitor for symptom return

II-C Strenuous aerobic activity Moderate resistance training

• 30-45 minutes running or stationary biking • Weightlifting < 50% of max weight

• Increase heart rate to > 75% max. exertion

• Monitor for symptom return II-D Non-contact training with sport-specific drills

No restrictions for weightlifting • Non-contact drills, sport-specific activities

(cutting, jumping, sprinting) • No contact with people, padding or the

floor/mat

• Add total body movement • Monitor for symptom return

Minimum of 5 days to pass Stages I and II. Prior to beginning Stage III, please make sure that written physician (MD/OD) Clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor.

III Limited contact practice

Full contact practice

• Controlled contact drills allowed (no scrimmaging)

• Return to normal training (with contact)

• Increase acceleration, deceleration and rotational forces

• Restore confidence, assess readiness for return to play

• Monitor for symptom return MANDATORY: You must complete ONE contact practice before return to competition

(Highly recommended that Stage III be divided into 2 contact practice days as outlined above.) IV Return to play (competition) Normal game play Return to full sports activity without

restrictions

Athlete’s Name:_________________________________________Date of Concussion Diagnosis:______________________

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A Sudden Cardiac Arrest Information Sheet for Athletes and Parents/Guardians

What is sudden cardiac arrest? Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly.When this happens blood stops flowing to the brain and other vital organs. SCA is NOT aheart attack. A heart attack is caused by a blockage that stops the flow of blood to theheart. SCA is a malfunction in the heart’s electrical system, causing the victim to collapse.The malfunction is caused by a congenital or genetic defect in the heart’s structure.How common is sudden cardiac arrest in the United States? As the leading cause of death in the U.S., there are more than 300,000 cardiac arrestsoutside hospitals each year, with nine out of 10 resulting in death. Thousands ofsudden cardiac arrests occur among youth, as it is the #2 cause of death under 25and the #1 killer of student athletes during exercise.

Who is at risk for sudden cardiac arrest?SCA is more likely to occur during exercise or physicalactivity, so student-athletes are at greater risk. Whilea heart condition may have no warning signs, studiesshow that many young people do have symptoms butneglect to tell an adult. This may be because they areembarrassed, they do not want to jeopardize their play-ing time, they mistakenly think they’re out of shape and need to train harder, orthey simply ignore the symptoms, assuming they will “just go away.” Additionally,some health history factors increase the risk of SCA.

What should you do if your student-athlete is experiencing any of thesesymptoms? We need to let student-athletes know that if they experience any SCA-relatedsymptoms it is crucial to alert an adult and get follow-up care as soon as possiblewith a primary care physician. If the athlete has any of the SCA risk factors, theseshould also be discussed with a doctor to determine if further testing is needed.Wait for your doctor’s feedback before returning to play, and alert your coach,trainer and school nurse about any diagnosed conditions.

The Cardiac Chain of SurvivalOn average it takes EMS teams up to 12 minutes to arrive

to a cardiac emergency. Every minute delay in attending

to a sudden cardiac arrest victim decreases the chance

of survival by 10%. Everyone should be prepared to take

action in the first minutes of collapse.

Early Recognition of Sudden Cardiac ArrestCollapsed and unresponsive.Gasping, gurgling, snorting, moaning or labored breathing noises.Seizure-like activity.

Early Access to 9-1-1Confirm unresponsiveness.Call 9-1-1 and follow emergency dispatcher's instructions.Call any on-site Emergency Responders.

Early CPRBegin cardiopulmonary resuscitation(CPR) immediately. Hands-only CPR involves fastand continual two-inch chest compressions—about 100 per minute.

Early DefibrillationImmediately retrieve and use an automated external defibrillator (AED) as soon as possible to restore the heart to its normal rhythm. MobileAED units have step-by-step instructions for a by-stander to use in an emergency situation.

Early Advanced CareEmergency Medical Services (EMS) Responders begin advanced life support including additional resuscitative measures andtransfer to a hospital.

Cardiac Chain of Survival Courtesy of Parent Heart Watch

What is an AED? An automated external defibrillator (AED) is the only way to save a suddencardiac arrest victim. An AED is a portable, user-friendly device that automat-

ically diagnoses potentially life-threatening heartrhythms and delivers an electric shock to restore nor-mal rhythm. Anyone can operate an AED, regardless oftraining. Simple audio direction instructs the rescuerwhen to press a button to deliver the shock, whileother AEDs provide an automatic shock if a fatal heartrhythm is detected. A rescuer cannot accidently hurt a

victim with an AED—quick action can only help. AEDs are designed to onlyshock victims whose hearts need to be restored to a healthy rhythm. Checkwith your school for locations of on-campus AEDs.

A E D

FAINTINGis the

#1SYMPTOMOF A HEART CONDITION

Keep Their Heart in the Game

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Recognize the Warning Signs & Risk Factorsof Sudden Cardiac Arrest (SCA)

Tell Your Coach and Consult Your Doctor if These Conditions are Present in Your Student-Athlete

What is CIF doing to help protect student-athletes?CIF amended its bylaws to include language that adds SCA training to coach certification and practice and game protocol that empowers coaches toremove from play a student-athlete who exhibits fainting—the number one warning sign of a potential heart condition. A student-athlete who has beenremoved from play after displaying signs or symptoms associated with SCA may not return to play until he or she is evaluated and cleared by a licensedhealth care provider. Parents, guardians and caregivers are urged to dialogue with student-athletes about their heart health and everyone associatedwith high school sports should be familiar with the cardiac chain of survival so they are prepared in the event of a cardiac emergency.

I have reviewed and understand the symptoms and warning signs of SCA and the new CIF protocol to incorporate SCA prevention strategies into my stu-dent’s sports program.

STUDENT-ATHLETE SIGNATURE PRINT STUDENT-ATHLETE’S NAME DATE

PARENT/GUARDIAN SIGNATURE PRINT PARENT/GUARDIAN’S NAME DATE

For more information about Sudden Cardiac Arrest visit

California Interscholastic Federation Eric Paredes Save A Life Foundation National Federation of High Schoolshttp.www.cifstate.org http:www.epsavealife.org (20-minute training video)

https://nfhslearn.com/courses/61032

Potential Indicators That SCA May Occur� Fainting or seizure, especially during or

right after exercise

� Fainting repeatedly or with excitement orstartle

� Excessive shortness of breath during exercise

� Racing or fluttering heart palpitations or irregular heartbeat

� Repeated dizziness or lightheadedness

� Chest pain or discomfort with exercise

� Excessive, unexpected fatigue during orafter exercise

Factors That Increase the Risk of SCA� Family history of known heart abnormalities or

sudden death before age 50

� Specific family history of Long QT Syndrome, Brugada Syndrome, Hypertrophic Cardiomyopathy, orArrhythmogenic Right Ventricular Dysplasia (ARVD)

� Family members with unexplained fainting, seizures,drowning or near drowning or car accidents

� Known structural heart abnormality, repaired or unrepaired

� Use of drugs, such as cocaine, inhalants, “recreational” drugs, excessive energy drinks or performance-enhancing supplements

Keep Their Heart in the Game

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PALOS VERDES PENINSULA HIGH SCHOOL

ATHLETIC AND CO-CURRICULAR CODE OF CONDUCT

Students and parents shall be informed that a student who competes in athletics or extra and co-curricular activities is held to specific standards of conduct and citizenship. These standards apply throughout the school year. When students and parents sign and return the Code of Conduct, they are indicating that they understand the Code and the consequences that will follow if it is violated. VIOLATIONS OF THE CODE

A. Violations involving drugs, alcohol, and/or drug paraphernalia will result in a school suspension and four-week co-curricular suspension from athletics and all other school activities. The student will also be recommended to attend eight class sessions in “The Outlook Program,” which is an educational approach to substance abuse.

B. Any Category 1 or 2 violation of the “The Safe School Policy” may require removal of the student from Peninsula High School and/or referral to law enforcement.

C. Referring to Ed Code 48900 (A-E) infractions, excluding 48900 (C), the following consequences will be enforced: 1st Offense: Student misses any contest due to suspension. 2nd Offense: Four weeks social probation 3rd Offense: Eight weeks or removal from the remainder of the sport/activity season involved depending on which is greater.

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10932 Pine Street Telephone: 562-493-9500 Los Alamitos, California 90720 Fax: 562-493-6266

Code of Ethics - Athletes

Athletics is an integral part of the school’s total educational program. All school activities, curricular and extra-curricular, in the classroom and on the playing field, must be congruent with the school’s stated goals and objectives established for the intellectual, physical, social and moral development of its students. It is within this context that the following Code of Ethics is presented. As a condition of membership in the CIF, all schools shall adopt policies prohibiting the use and abuse of androgenic/anabolic steroids. All member schools shall have participating students and their parents, legal guardian/caregiver agree that the athlete will not use steroids without the written prescription of a fully licensed physician (as recognized by the AMA) to treat a medical condition (Article 523). By signing below, both the participating student athlete and the parents, legal guardian/caregiver hereby agree that the student shall not use androgenic/anabolic steroids without the written prescription of a fully licensed physician (as recognized by the AMA) to treat a medical condition. We recognize that under CIF Bylaw 202, there could be penalties for false or fraudulent information. We also understand that the _____PV Peninsula High School - PVPUSD_____ (school/school district name) policy regarding the use of illegal drugs will be enforced for any violations of these rules. A copy of this form must be kept on file in the athletic director’s office at the local high school on an annual basis and the Principal’s Statement of Compliance must be on file at the CIF Southern Section office. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - As a participant in athletics or extra-curricular activities, I understand that it is my responsibility to: 1. Place academic achievement as the highest priority.

2. Show respect for fellow students, teachers, school staff, teammates, opponents, officials and coaches. 3. Respect the integrity and judgment of teachers, school staff, and game officials. 4. Exhibit fair play, sportsmanship and proper conduct on and off the playing field, including extra-curricular

activities. 5. Maintain a high level of safety awareness. 6. Refrain from the use of profanity, vulgarity and other offensive language and gestures. 7. Adhere to the established rules and standards of the game to be played and of extra-curricular activities. 8. Respect all equipment and use it safely and appropriately. 9. Refrain from the use and/or possession of alcohol, tobacco, prescription drugs, non-prescriptive drugs,

anabolic steroids or any substance to increase physical development or performance that is not approved by the United States Food and Drug Administration, Surgeon General of the United States or American Medical Association.

10. Know and follow all state, section and school athletic and academic rules and regulations as they pertain to eligibility and sports or extra-curricular participation.

11. Win with character, lose with dignity. DATED:_________________________

____________________________________ ____________________________________ Parent / Caregiver Signature Student / Athlete Signature (rev 7/12/17) ____________________________________ Student / Athlete Printed Name of 37

PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT MEDICAL TREATMENT AUTHORIZATION

WAIVER, RELEASE AND INDEMNITY AGREEMENT ASSUMPTION OF RISK FOR PARTICIPATION IN A VOLUNTARY SPORTS OR NON-SPORTS PROGRAM

Participant:______________________________________________________________________________

Description of Activity: _____________________________ Name of School:_________________________

Date(s) of Activity:______________________________________________________________________

Transportation provided by District Transportation is parent responsibility

By my signature below, I hereby give permission for my son/daughter to participate in the above-described activity. I realize that this activity is voluntary as part of the PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT (District) sports or non-sports program. I understand that this activity could cause serious illness and/or injury or death, and I assume all risks for any such illness and/or injury or death. I am aware of the transportation arrangements for this activity and acknowledge that if the school is providing no transportation, the parent has complete and sole responsibility for all transportation arrangements. I am aware that the District does not provide coverage for medical treatment in connection with this activity. If a participant does not have private medical insurance, low-cost school insurance is available through the District.

For and in consideration of permitting the above named child to participate in the activity described above, the undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury, bodily injury, property damage or wrongful death occurring to his/her child/ward or him/herself arising in any way whatsoever as a result of engaging in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue. The undersigned does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive discharge and relinquish any action or causes of action, aforesaid, which may hereafter arise for him/herself and for his/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, bodily injury, property damage or wrongful death against the District or any of its officers, agents, or employees for any of said causes of action, whether the same shall arise by the negligence of any of said persons, or otherwise.

The undersigned hereby acknowledges that he/she knowingly and voluntarily assumes all risks of bodily injury to his/her child/ward or him/herself, as stated, and expressly acknowledges their intention, by executing this instrument, to exempt and relieve the District, its officers, agents, and employees, from any liability for personal injury, bodily injury, property damage or wrongful death that may arise out of or in any way be connected with the above-described activity. I have read and understand the foregoing and have voluntarily signed this agreement. I am aware of the potential risks involved in this activity and I am fully aware of the legal consequences of signing this instrument. I further acknowledge that the District does not automatically provide for medical coverage for participants in this activity.

Health or special needs: Check as appropriate.

Participant has no special health needs the staff should be aware of, and no medication is required. Participant has a special need, and instructions are attached. Number of attached pages:________.Other:

In the event of illness or injury, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care and emergency transportation considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.

__________________________________________ ___________________________ ___________________ Parent/Guardian Signature Participant Signature Date

__________________________________________ __________________________ ___________________ Parent/Guardian Name (Please Print) Phone Number Health Plan

_______________________________________________________ Plan # ___________________________Street Address City State Zip Code

F-603 – Voluntary Sports/Non-Sports Waiver (Rev 7-20-12) Principal / Designee Signature

PV Peninsula HS2017-2018 School Year

WAIVER: (1) parent uses his/her own vehicle and drives their own student;

(2) student uses his/her own vehicle todrive him/herselfonly for voluntarysports or non-sportsprogram.

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Date(s) of Activity/Program:. ___________________ _

By my signature below, I hereby give pennlssion for my son/daughter to participate In the abovedescribed adivity. I realize that this activity ls voluntary and ls not a mandated requirement of the Palos Verdes Peninsula Unified School District's CDlstrict) curriculum or extra curricular program. I further acknowledge that no supervision Is being provided by the District and that the District assumes no responslbillty for any transportation arrangements. The undersigned Is &pecifically aware, and confinns by executing this document that they are aware that participation in such an activity presents a risk of personal Injury, bodily injury, property damage or wrongful death, and that the undersigned's child may Injure himself or herself, or be injured by other participants related to the activity. The undersigned is aware and acknowledges being aware of the risk that he or she may be hurt or injured by participating In any aspect of this activity.

For and in consideration of permitting the above named child to participate in the activity described above, the undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal Injury, bodily Injury, property damage or wrongful death occurring to him/herself arising in any way whatsoever as a result of engaging in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue. The undersigned does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive discharge and relinquish any adlon or causes of adlon, which may hereafter arise for him/herself and for his/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal Injury, bodily Injury, property damage or wrongful death against the Palos Verdes Peninsula Unified School District, its Board, or any of its officers, agents, servants, or employees for any of said causes of action. The foregoing wavier does not apply in the event of the sole negligence or willful misconduct of the District.

The undersigned hereby acknowledges that he/she knowingly and voluntarily assumes all risks of bodlly injury to hlslher chlld, as stated, and expressly acknowledges their Intention, by executing this Instrument, to exempt and relieve the District, Its Board, officers, agents, and employees, from any llabllily for personal injury, bodily Injury, property damage or wrongful death that may arise out of or In any way be connected with the above-described activity. I have read the foregoing and have voluntarily signed this agreement I am aware of the potentral risks Involved In this activity and I am fully aware of the legal consequences of signing this Instrument. I further acknowledge that the District does not provide medical coverage for participants In this activity.

Parent/Guardian Signature Date Student's Signature

Parent/Guardian Name (Please Print) Student's Name (Please Print)

Street Address City State Zip Code

Home Telephone Number Work Telephone Number

Principal / Designee Signature ______________ _

F-605 -walver-wluntary adlvily (dubs)

PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT WAIVER, RELEASE AND INDEMNITY AGREEMENT

ASSUMPTION OF RISK FOR PARTICIPATION IN A VOLUNTARY ACTIVITY/PROGRAM

Student's Name:. ____________ ____:S:::;c:::1.h.1.:10:.:::0�1: ________ _

Description of Activity/Program:. ___________________ _ 2017-2018 School Year

PV Peninsula HS

WAIVER: Student may wish to attend and/or participate in an activity or program not during the school day.

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Palos Verdes Peninsula High SchoolHazing Pledge

"Hazing" means any method of initiation or pre-initiation into a student organization or student body, whether or not the organization or body is officially recognized by an

educational institution, which is likely to cause serious bodily injury to any former, current, or prospective student of any school, community college, college, university, or other

educational institution in this state. The term “hazing" does not include customary athletic events or school-sanctioned events.

‘Hazing’ is strictly prohibited by the Palos Verdes Peninsula Unified School District and is grounds for suspension and/or expulsion (AR 5144.1).

All students and parents must read and sign this card and return to their coach/teacher; thus acknowledging the pledge against ‘hazing’ acts.

If a student/parent does not sign the ‘hazing pledge’ the student will not be permitted to participate in the activity/sport.

Student Parent Signature

Print Student Name / Grade: Print Sport / Activity:

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F-604 (a) Volunteer Driver Form

PALOS VERDES PENINSULA UNIFIED SCHOOL DISTRICT

PARTICIPATION OF DISTRICT VOLUNTEER IN FIELD TRIP ACTIVITY ASSUMPTION OF RISK AND

MEDICAL TREATMENT AUTHORIZATION

Destination/Nature of Activity: ________________________________________________________________ (Please be specific, e.g., Attend concert at UCLA.)

Purpose of Your Attendance: _________________________________________________________________ (Chaperone, etc.)

Departure Return Date: _____________________ Time: _________________ Date: ______________________ Time: ______________

Method of Transportation: School Bus/Vehicle Walking Other: ___________________

As provided for in California Education Code Section 35330, I agree to hold the Palos Verdes Peninsula Unified School District ("District"), its officers, employees and agents harmless from any and all liability and claims arising out of or in connection with my participation in this activity. This waiver, however, shall not apply to any injuries or damages that arise solely out of the negligence of employees or agents of the District.

In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental or surgical diagnosis and/or treatment, emergency transportation and hospital care from a licensed physician and/or surgeon as deemed necessary for my safety and welfare. It is understood that the resulting expenses will be the responsibility of the participant.

________________________________________________________________ ______________________________ Signature Date

___________________________________________________________ Work ( ) _______________ Address: Number Street

Home ( ) ______________ ____________________________________________________________

City State Zip Code

Health Insurance Company: ______________________________ Policy Number: ______________________ (e.g., Kaiser)

In the event of illness or accident, please notify:

Name:__________________________________________________ Relationship: ______________________

____________________________________________________ Work Phone ( ) ____________________ Address: Number Street _____________________________________________________ Home Phone ( )_____________________ City State Zip Code

If there are any special medical instructions, kindly attach an explanation to this sheet.

CHECK BOX, IF APPLICABLE

Volunteer Driver for School Year 17-18

Name:___________________________________________________________________________________ List all Sports and/or Activities you may possibly drive for; if completed, apply once.

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PVPHS Athletic Packet 2005-06 - Edl · PDF filePrincipal’s Letter RE Participation...

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Transcript of PVPHS Athletic Packet 2005-06 - Edl · PDF filePrincipal’s Letter RE Participation...