Golden Valley USD Athletic Clearance Form

Golden Valley USD Athletic Clearance Form RESIDENCE QUESTIONNAIRE- Fill out completely to determine residence eligibility. Golden Valley USD Code of Ethics- Please read carefully and sign below. The following Code of Ethics applies to all students who represent Liberty High School in any co-curricular 1. Students Name: Birth-date: program. The student will be asked to make this commitment prior to the start of the season /activity, and abide by its conditions for one calendar year from the signing date. Code is enforced during summer. The Current Address: code is a statement of responsibility and understanding for a student who freely chooses to represent the school. Phone #: Work # Student/ Parent Commitment: We, the student and parent or guardian of the student, understand that the Student will abide by the G.V.U.S.D. Code of Ethics. We also understand that by signing the Code of Ethics 2. Have you attended any school other than Liberty Middle School in the past year? Yes No he/she will follow the stated rules 24 hours a day, 7 days a week, during one calendar year from the date signed. The student is also subject to the school rules at school or at a school related activity. If Yes, name of previous school Date left : Appearance : Each participating student of G.V.U.S.D. has a responsibility to uphold the G.V.U.S.D. dress code when at school and representing G.V.U.S.D. at a extra-curricular event. An individual coach/advisor 3. Have you lived at any other address in the past year? Yes No If Yes, list address below: may set a more strict dress code policy, but may not be more lenient than the district dress code as stated in board policy. If the coach/advisor chooses to set a more strict policy, he/she will furnish that policy in Address: Date left: writing to students/parents, with prior approval of the school site athletic/activities director Attendance : We understand regular attendance is expected of all our students and habitual absenteeism will 4. If you have moved within the last year, check which of these situations pertains to you: result in disciplinary action. A participating student must be in attendance the day of the performance ( half of the day unless he/she has a doctors appointment or is excused by the school principal) or in school the day prior a. My whole family moved from old address to new address performance on a non-school day, to be eligible for particip ation. Students are expected to attend all classes the b. I moved from one parent to live with another parent day following a school contest. c. I moved from one parent to live with a relative or guardian Academic Eligibility: We understand the academic eligibility requirements set forth by G.V.U.S.D.: d. I moved from a relative or guardian to a parent(s) e. A court order placed me at my new address *passing a minimum of 4 subjects every grading period *GPA Requirements- A student must earn at least a 2.0 grade point average in all enrolled classes for the prior grading period in order to participate in the current grading period. (Grade 7-12). A 5. Are you now, or have been in the past year, on an inter-district transfer to attend a school outside student who fails to achieve a 2.0 GPA will need to fill out an athletic appeal. A student who does your attendance area? Yes No not achieve at least a 2.0 GPA during the appeal period will be ineligible for t he subsequent grading period. 6. Are you changing schools because you were dismissed from your old school for disciplinary *Progress Towards Graduation Requirements- The following number of accumulated units towards graduation reasons? Yes No will be standard for minimum achievement. A student who does not accumulate the required number of units will be placed on probation for the current semester. Athletes who fail to achieve the 7. When was the first semester of your 9th grade year? Date: necessary number of units by the end of the probationary period will not be allowed to participate. Sophomore 10-50 units Junior 11-100 units Senior 12-150 units 8. At what school did you attend your first day of 9 th grade? Clearance: We agree to provide the correct information on the following forms requested: * Provide a signed informed consent for Football *Provide results of annual physical exam CIF By-Law, Article 2, Eligibility Requirement E: If it is discovered that any parent, guardian, * Date of Birth of student *Provide a signed informed consent form caregiver, or student has provided false information in regards to any aspect of eligibility status, the * Provide a signed residence questionnaire *Provide a signed CIF Code of Ethics student/athlete is subject to immediate ineligibility for CIF competition at any level in any sport for *Provide a signed dress code, if coach uses a more * Provide a signed G.V.U.S.D. Code of Ethics a period up to 12 calendar months. strict dress code than G.V.U.S.D. * Pay for Athletic Transportation Fee Behavior: The student, in representing themselves, their parents, school and community, are expected to Signature of Parent/Guardian: Date: conduct themselves in an exemplary manner. Conduct that is not acceptable: *Possession/Use of illegal drugs *Possession /Use of alcoholic beverages *Possession of Weapons Signature of Student/Athlete: Date: *Fighting(Battery) *Possession/Use of Tobacco *Unsportsmanlike Conduct ============================================================================= *Defiance of Adult Authority *Taunting of another Student *Misuse of Equip./Uniform MEDICAL INSURANCE: I have medical insurance that provides coverage of at least $1500.00 *Wearing Uniform Incorrectly *Violation of Law in Community accidental injury. I understand that if my insurance does not cover certain types of injuries, I will cover all injury expenses. Company Policy # Expiration Date or *** School Insurance: I have purchased the following type of insurance through Liberty High School. * Negative Behavior towards an Official ( Spoken or Physical Reaction) *Breaking of Rules established by Coach/Advisor I have read and understand the G.V.U.S.D. Code of Ethics. We agree to abide by the policies and related consequences while participating in interscholastic and co-curricular activities. I understand complete copies of the policy are available in the LHS Athletic Office. Signature Athlete Date School Time Tackle Football (only) 24 Hour Coverage Signature Parent Date

ATHLETICS - WARNING OF RISK California Interscholastic Federation Central Section SERIOUS, CATASTROPHIC, AND PERHAPS FATAL INJURY MAY RESULT FROM Ethics in Sports ATHLETIC PATICIPATION. By its very nature, competitive athletics may put students in I. Policy Statement : The Central Section C.I.F., is committed to the exhibition of sportsmanship and situations in which accidents may occur. Many forms of athletic competition result in violent ethical behaviors in and around all athletic contests. All contests must be safe, courteous, physical contact among players, the use of equipment, which may result in accidents, strenuous fair, controlled, and orderly for all athletes and fans alike. physical exertion, and numerous other exposures to risk of injury. Students and parents must It is the intent of the C.I.F. that violence in any form not be tolerated. In order to enforce this assess the risks involved in such participation and make their own choice to participate in spite policy, the Central Section has established rules and regulations that set forth the manner of of those risks. No amount of instruction, precaution, or supervision will totally eliminate all risk enforcement of this policy and the penalties incurred when violation of the policy occurs. The of injury. Just as driving an automobile involves choice of risks, athletic participation by students rules and regulations shall focus upon the responsibility of the coach to teach and demand high also may be inherently dangerous. The obligation of parents and students in making this choice standards of conduct and to enforce the rules and regulations set forth by the C.I.F. to participate cannot be overstated. There have been accidents resulting in serious permanent The Central Section requires the following Code of Ethics be issued each year and requires impairment as a result of athletic competition. Students will be instructed in proper techniques signing by student athletes, parent/guardians and coaches each year prior to participation as to be used in athletic competition and in proper utilization of all equipment worn or used in a guide to govern their behavior. practice or competition. Students must adhere to that instruction and utilization and must refrain from improper uses and techniques. By granting permission for your student to participate in II. CODE OF ETHICS athletic competition, you, as a parent or guardian, acknowledge that such a risk exists. By A. To emphasize the proper ideals of sportsmanship, ethical conduct and fair play choosing to participate, you, the student, acknowledge that such a risk exists. No helmet can B. To eliminate all possibilities which tend to destroy the best values of the game. prevent head or neck injuries a player might receive while participating in football, baseball, C. To stress the values derived from playing the game fairly. or softball. DO NOT use your helmet to butt, ram, or spear an opposing player. This is a viol- D. To show cordial courtesy to visiting teams and officials. ation of rules and such use can result in severe head or neck injuries, paralysis, or death to you E. To establish a happy relationship between visitors and hosts. and possible injury to your opponent. If any of the foregoing is not completely understood, F. To respect the integrity and judgment of sports officials. please contact the Liberty High School Athletic Director for further information. Ph. # 645-3500. G. To achieve a thorough understanding and acceptance of the rules of the game and the standards of eligibility. Signature Parent/Guardian Date H. To encourage leadership, use of initiative, and good judgment by players on a team. I. To recognize that the purpose of athletics is to promote the physical, mental, moral, Signature Student/Athlete Date social, and emotional well-being of the individual players. J. To remember that an athletic contest is only a game, not a matter of life and death for =================================================================== player, coach, school, official, fan or nation. Parent/Guardian Code of Ethical Conduct and Expectations: The purpose of this parent code is III. Violations and Minimum Penalties to develop parental support and positive role models in all co-curricular activities. In the tradition of excellence, ***See Last Page of document the purpose of all co-curricular activities at Liberty High School is to promote the physical, mental, moral, social, and emotional well-being of each student. Parents/guardians are an integral part of this process. I have read and understand the Policy Statement, the Code of Ethics and the violations and minimum penalties of the Ethics in Sports policy. I agree to abide the policy and related consequences while Expectations: As a Liberty High School parent/guardian, I agree to be a positive role model for my student, participating in interscholastic athletics, regardless of context, site or jurisdiction. I further agree not to us school, and community. I will display a positive attitude and behavior and understand adult behavior affects drugs, alcohol, steroids or other performance enhancing drugs while in high school. student behavior. I will show respect for all participants, officials, judges, advisors, and coaches. I will assist in providing for my students safety and welfare at all times. I will encourage my student to attend school regularly and excel academically. I will also inform my student of the dangers of using and discouraging the Print Student/Athlete Name: use of any illegal, drugs, steroids, alcohol, and tobacco. Grievance Procedure: It is Liberty High Schools policy that grievances should not be addressed during Student/Athlete Signature: Date or immediately following any practice, game, or activity. If a situation arises where a parent/ guardian wishes to meet with an advisor/coach, or address a specific issue or complaint, the following steps should be Parent/Guardian Signature: Date followed: request a meeting at school with the advisor/coach. If your concern is unresolved, arrange an appointment with the school administrator that is in charge of the specific sport or program. If your concerns are still unresolved, the appeals process outlined in the GVUSD Policy School Name: Liberty High School-Madera Ranchos will apply. We have read and agreed to the policies stated in the Code of Ethics regarding the conduct of parents/guardians of Liberty students participating in co-curricular activities. We agree to abide by these rules to help our student become good citizens with a sense of moral integrity, a competitive spirit, and the ability to be honest and forthright in all endeavors. School District: Golden Valley USD Signature Parent/Guardian Date

G.V.U.S.D./LIBERTY HIGH SCHOOL PARENT PERMISSION G.V.U.S.D. EXTRA-CURRICULAR HEALTH SCREENING FORM FOR STUDENT PARTICIPATION IN AND TRAVEL TO OFF-CAMPUS, SCHOOL SPONSORED EVENTS TRIPS/EVENTS Last Name: First Name: I give my son/daughter permission Sex: Age: Birth Date: to attend any Liberty High School event/activity/sport for the school year. Health History: To be completed by parent/guardian only-check yes or no I have checked all applicable sports and activities that my child may be involved with during YES NO Yes No the school year. 1. Chronic/Recurrent/Illness 12. Asthma/wheezing 2. Surgery other than tonsils 13. Chest Pain Cheer Cross Country Football Girls Volleyball Girls Tennis 3. Injuries treated by physician 14. Blood Problems Golf Boys Basketball Girls Basketball Boys Soccer 4. Currently taking medication 15. Problems w/liver, Wrestling Boys Tennis Baseball Softball Girls Soccer 5. Currently under physicians care kidney, spleen 6. Organs missing 16. Hernia Health Needs: 7. Heat exhaustion/stroke 17. Bone/joint injury My child has no special health/medical needs 8. Dizzy, faints, convulsions, headaches 18. Tetanus Booster last 9. Knocked out/unconscious 10 years My child has special health/medical needs. Explanation: 10. Diabetes 19. Immunized Current 11. Contacts or corrective lens 20. Allergy to meds. Please describe any YES answer above: My child will have medication on trips and and activities. This medication will be deposited with the my child s coach, who is in charge of the trips. I understand the CIF By-Law #306, requires an ANNUAL physical examination by a medical practition- Method of Transportation: I understand that school or district-hired bus or vans will transport er and the physical examination will not expire during the season of sport for which the student will be my child. I will sign a waiver prior to my child ever being transported to and from an activity participating. Also, the above information is current and correct to the best of my knowledge. in a private vehicle. I also understand that all students going on school-sponsored trips will be responsible in conduct to the bus driver, to teachers, to coaches, and/or adult sponsors. Signature Parent/Guardian Date Signature of Parent/Guardian Physical Examination ==================================================================== HT WT BP Eyes General Chest EMERGENCY CONTACT INFORMATION-(Parent Information) Heart Abdomen GU/Hernia Neck/Back Extremities Medical History: List any health conditi ons or previous injuries to be aware of. Limitations: Yes No If yes, list limitations here: In case of emergency, contact: Home Work Cell I verify that has been examined by me on Ph.# Ph.# Ph.# Students Name Date To the best of my knowledge, the athlete named above is physically able to Relationship: participate in interscholastic athletics. In case of emergency, contact: Home Work Cell Ph.# Ph.# Ph.# Physician Name -Print Physician Signature Relationship:

Extra-Curricular ++++++ Office use only++++++ Clearance/Eligibility Packet Golden Valley USD Athletics Transportation Fee: Check# Cash Student/Athlete Name: Total Amt Paid Balance Due Please Print Clearly Cleared to Participate: Yes No Circle Grade: 9 10 11 12 School Year The following forms need to be filled out completely. Students will Not be allowed to participate until All forms have been completed and turned in to the Liberty High School Athletic/Finance Office. Please follow the checklist while filling out the following 10 sections information. CIF Steroid Form will be completed after attending Reason: +++++++++Do Not Write in This Area++++++++++ GVUSD Athletic Transportation Fee Agreement In an effort to offset the cost of transportation for athletic competition, the G.V.U.S.D. Board of Trustees approved the implementation of a $45.00 transportation fee on December 8, 2003 for all Liberty High School athletes. presentation. The transportation fee of $45.00 is part of the Athletic Eligibility Packet for the 2007-2008 school year. The following are the guidelines regarding the Athletic Transportation Fee. Transportation Fee Agreement School Residence Questionnaire Medical Insurance Information GVUSD Code of Ethics Athletics Warning of Risk Parent/Guardian Code of Ethical Conduct C.I.F. Code of Ethics Parent Permission for Student Participation Emergency Contact Information Extra-Curricular Health Screening Form ***Please check to make sure all forms are filled out completely and signed. Return completed form to the Liberty High School Athletic Finance Secretary. ***Do Not Turn In To Coaches/Advisors**** LIST ALL SPORTS YOU PLAN TO PLAY FOR 2007-2008 1. All LHS athletes are required to pay a one time $45.00 fee, regardless of how many sports an athlete participates in during the school year. 2. The full amount of $45.00 is due as part of the Athletic Clearance Process before participating in the initial sport. 3. The transportation fee is payable in the Student Finance Office. Make checks payable to Liberty High School Athletics. 4. Refunds are given for one of the following reasons: A) Athlete does not make the team B) The athlete is removed from competition/travel due to an injury prior to 50% completion of season. (single sport athlete only)** C) Athlete moves out of District prior to a 50% completion of season** **Note: Refunds will be pro-rated. We understand, as part of the LHS Athletic Eligibility process, in order to participate in the 2007/2008 School Year we agree to the terms of the Transportation Agreement outlined above to receive Athletic Clearance. Any athlete quitting a sport after team rosters have been submitted will not be able to try our for the next season of sport until the previous season has been completed, including playoffs. Student/Athlete Signature Date Parent/Guardian Signature Date

III. Violations and Mini mum Penalties ACT: First ejection of player or coach from a contest or scrimmage for unsportsmanlike conduct. Penalty: Ineligible for next CIF contest ACT: Second ejection during same season for unsportsmanlike conduct Penalty: Ineligible for next two CIF contests ACT: Third ejection during the same season for unsportsmanlike conduct Penalty: Ineligible for all CIF contests for one calendar year(365 days) ACT: Any player that leaves the bench to begin a confrontation or leaves the area during an altercation Penalty: Ejection of those players or contest may be terminated or one or both teams forfeit ACT: When the above act occurs and in the opinion of the officials the situation is out of control Penalty: Contest stopped, ejection of players involved, team that left bench must forfeit and record a loss, team and players involved put on probationary status for remainder of season. Second similar infraction in same season will result in cessation of the sport for the team and/or players ACT: Illegal participation in next contest by player ejected in previous contest Penalty: Ineligibility for the remainder of the season for the player. Forfeiture of contest. ACT: Illegal placement of ejected player or illegal participation of coach ejected in previous contest. Penalty: Constitution and sports governing rules and procedures in effect for coach who knowingly violates CIF or Section rules. ACT: Acts of a more serious nature by individuals, teams, or situations not specifically covered by this policy or the constitution of the governing rules. Penalty: Area commissioner may determine and implement penalties for individuals or teams not otherwise specified by CIF Central Section Constitution and ByLaws. ACT: If act occurs in CIF Section Finals and both teams are charged with a forfeit. Penalty: After deliberation by the CIF, a double forfeit will result and there will be no section champion. ACT: Coach ejected from contest Penalty: Coach must leave the site of contest. Coach may have no contact with his/her team from that point on. If there is no certified replacement for the coach, the contest is halted and game is forfeited. The coach must sit out next contest and cannot attend the contest or have any contact with the team during the contest. ACT: Player ejected from contest Penalty: Player may stay on bench for the remainder of contest for supervision reasons. Further disruption by player may force them to be removed from the site. This could lead to a forfeit. Player must sit out next contest, but may sit on bench in street clothes. Appeals Procedure First and second ejection Unless otherwise specified, an appeal of the ineligibility of a player or coach may be made in writing to the players or coaches administrator. The site administrator or his/her designees decision on his/her athlete or coach shall be final and shall be conveyed to the site administrator of the schools involved, to the president of the leagues involved and the CIF Area and Section Commissioner. Physical Assault CIF State Constitution, Article 5, Section 522. Any student who physically assaults the person of a game or event official shall be banned from interscholastic athletics for the remainder of the student, eligibility. A game or event official is defined as a referee, umpire or any other official assigned to interpret or enforce rules competition at an event. A student may, after a lapse of 18 calendar months from the date of the incident, apply for reinstatement of eligibility to the State CIF Commissioner.