ATHLETIC PARTICIPATION CLEARANCE FORM

I hereby give consent form my child, ___________________________________________, to

participate in the Lowndes County School District’s athletic program during the 2018-2019 school
year.
I hereby authorize and give permission for emergency medical treatment to be rendered for and on
behalf of my child, ____________________________________, for any injury received while
participating in any supervised school related sports activity. This authorization includes, but is not
limited to, any treatment deemed necessary by certified personnel, physicians, hospital emergency
room physicians and hospitals.
I hereby release the Lowndes County School District and all school personnel from any and all liability
associated with such necessary treatment.
I hereby acknowledge that health and accident insurance is required for participation in all organized
athletic activities and further certify that my child is covered under the health and accident program
listed below.
School day insurance__________________________________________
Policy #_____________________________________________________

Other insurance______________________________________________
Policy #____________________________________________________
Name of agent_______________________________________________
The Lowndes County School District is prohibited by law from paying any expense incurred for any
accident involving a student on school property or participating in school activities and does not
provide health or accident insurance for participants in athletic programs.
In addition, I assume any expenses for liability not covered by the above required insurance policy for
injury received by the above named student while participating in sports authorized above. I accept
full responsibility for medical and hospital expenses and any other related expenses and hereby hold
harmless the Lowndes County School District and the board of Trustees, their agents or assignees, of
responsibility for any such injury athletics involves the potential for injury, which is inherent in all
sports, sometimes severe enough to result in total disability, paralysis and death.
I give the Mississippi High School Activities Association and its assigns, licensees, and legal
representatives the irrevocable right to use any picture or image or sound recording of the student in
all forms and media and in all manners, for any lawful purposes. In addition, I consent to the
disclosure, by my child’s/ward’s school, to the MHSAA, upon its request, of all records relevant to
his/her eligibility and participation including, but not limited to, his/her records relating to enrollment
and attendance, academic standing, age, discipline, residence, and physical fitness.

_____________________________________________ ______________
Parent/Legal Guardian Signature Date
 ATHLETIC PARTICIPATION CONSENT FORM
Student’s Name___________________________
As a student in the Lowndes County School District and an active participant in school sponsored
trips, I will abide by the following regulations stating that:
1. I have received a copy of written rules and regulations concerning my participation in
athletic events.
2. I fully understand that a violation of these rules can result in disciplinary action as stated in
the student handbook.

LEVEL OF OFFENSES & DISCIPLINARY ACTIONS

1. Minor offenses:
a. Inappropriate classroom behavior (per student handbook)
b. Tardiness or missed practices/meetings without proper excuse
c. Inappropriate dress
2. Disciplinary actions:
a. Verbal correction
b. Sitting out game or games
c. Conference with parent(s)
3. Major offenses:
a. Defacing or destroying school property
b. Fighting
c. Stealing
d. Committing forgery
e. Defying a coach or school authority
f. Causing disruption in school or on a school bus (per student handbook)
g. Leaving school grounds or assigned area without permission
h. Use of alcoholic beverages or controlled substances
i. Smoking
j. Display of poor attitude or lack of self-discipline
k. Boycotting team for any reason
4. Disciplinary actions:
a. Parental conference
b. Sitting out game or games
c. Dismissal from program for a specified period of time
d. Permanent dismissal from program
e. Any other action deemed appropriate by the administration

I further understand that a licensed physician must medically screen each student who participates in
the secondary athletic program. The screening is general in nature and limited in its scope and does
not indicate or assure me that my child is completely free from impairments, which may be affected
by athletic participation.
I further consent to the random testing of urine samples of my child to ensure that each athlete is drug
free and hereby release Lowndes County School District from legal responsibility or liability for the
release of such information and records as authorized by this form.
_____________________________________________ ______________
Parent/Legal Guardian Signature Date
 PARENTS’ PLEDGE
Cooperation among coaches, athletes, parents, and school personnel is essential if students are to
realize the values of athletic participation. Like coaches and athletes, parents must make
commitments to the athletic program to assure such cooperation. We ask that you read the following
pledge and, as needed, discuss your reactions with your child’s coach or the school’s athletic director.
Thanks for your help.

As a parent of an athlete in this school, I promise:

• To accompany my child to orientation and informational meetings offered by the athletic

department as my schedule will permit.

• To work closely with all school personnel to assure an appropriate academic as well as
athletic experience for my child while he or she is in middle school/high school.

• To assure that my child will attend all scheduled practices and athletic contests.

• To require my child to abide by the athletic department’s training rules.

• To acknowledge the ultimate authority of the coach to determine strategy and player
selection.

• To promote mature behavior from students and parents during athletic contests.

• To work cooperatively with other parents and school personnel to assure a wholesome and
successful athletic program for our school.

• To work closely with coaches and other school personnel to identify a reasonable and
realistic future for my child as a student athlete, both in school and in college.

_____________________________________________ ______________
Parent/Legal Guardian Signature Date

I give permission for my child’s picture and name to be published by various media and also on the
school’s website.

_____________________________________________ ______________
Parent/Legal Guardian Signature Date
 STUDENT TRAVEL PERMISSION FORM 2017-2018

As the parent/guardian of _______________________________________, I give him/her permission

to attend and participate in all athletic functions, on or off the Caledonia High School campus
(sporting events, competitions, etc.) with the Caledonia High School Athletic Department. I
understand that he/she will be traveling on transportation provided by the Lowndes County School
District. I also understand the rules and policies of Lowndes county Schools, Caledonia High School,
and the Caledonia High School Athletic Department are in effect on approved functions as a result of
any travel. As parent/guardian I hereby give the Caledonia High School Coaching Staff, Sponsor, or
other appropriate school authority permission to seek medical attention for him/her in the event of a
medical emergency.

__________________________________________ ___________________
Parent/Guardian Signature Date

List all allergies and medical concerns below:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Emergency numbers:
Home: _______________________________________
Cell: _______________________________________
Cell: _______________________________________
Work: _______________________________________
 MISSISSIPPI HIGH SCHOOL ACTIVITIES ASSOCIATION, INC.
Concussion Information Form
(Required by MHSAA Annually)

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the
head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild
to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all
concussions are potentially serious and may result in complications including prolonged brain damage
and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head
can be serious. You cannot see a concussion and most sports concussions occur without loss of consciousness.
Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear.
If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself,
seek medical attention right away.

Symptoms may include one or more of the following:

• Headaches Amnesia
• “Pressure in head” “Don’t feel right”
• Nausea or vomiting Fatigue or low energy
• Neck pain Sadness
• Balance problems or dizziness Nervousness or anxiety
• Blurred, double or fuzzy vision Irritability
• Sensitivity to light or noise More emotional
• Feeling sluggish or slowed down Confusion
• Feeling foggy or groggy Concentration or memory problems
• Drowsiness (forgetting game plays)
• Change in sleep patterns Repeating the same question/comment

Signs observed by teammates, parents and coaches include:

• Appears dazed
• Vacant facial expression
• Confused about assignment
• Forgets plays
• Is unsure of game, score, or opponent
• Moves clumsily or displays incoordination
• Answers questions slowly
• Slurred speech
• Shows behavior or personality changes
• Can’t recall events prior to hit
• Can’t recall events after hit
• Seizures or convulsions
• Any change in typical behavior or personality
• Loses consciousness

(Continued on next page)

 What can happen if my child keeps on playing with a concussion or returns too soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately.
Continuing to play with the signs and symptoms of a concussion leaves the athlete especially
vulnerable to greater injury. There is an increased risk of significant damage from a concussion
for a period of time after that concussion occurs, particularly if the athlete suffers another
concussion before completely recovering from the first one. This can lead to prolonged recovery,
or even to severe brain swelling (second impact syndrome) with devastating and even fatal
consequences. It is well known that adolescent or teenage athletes will often fail to report
symptoms of injuries. Concussions are no different. As a result, education of administrators,
coaches, parents and students is key to a student-athlete’s safety.

MHSAA Concussion Policy:

• An athlete who reports or displays any symptoms or signs of a concussion in a practice

or game setting should be removed immediately from the practice or game. The athlete
should not be allowed to return to the practice or game for the remainder of the day
regardless of whether the athlete appears or states that he/she is normal.
• The athlete should be evaluated by a licensed, qualified medical professional working
within their scope of practice as soon as can be practically arranged.
• If an athlete has sustained a concussion, the athlete should be referred to a licensed
physician preferably one with experience in managing sports concussion injuries.
• The athlete who has been diagnosed with a concussion should be returned to play only
after full recovery and clearance by a physician. Recovery from a concussion, regardless
of loss on consciousness, usually take 7-14 days after resolution of all symptoms.
• Return to play after a concussion should be gradual and follow a progressive return to
competition. An athlete should not return to a competitive game before demonstrating
that he/she has no symptoms in a full supervised practice.
• Athletes should not continue to practice or return to play while still having symptoms of a
concussion. Sustaining an impact to the head while recovering from a concussion may
cause Second Impact Syndrome, a catastrophic neurological brain injury.

Remember, it is better to miss one game than to miss the whole season.

I have reviewed this information on concussions and am aware that a release by a medical
doctor is required before a student may return to play under this policy.

____________________________ __________________________ __________

Student-Athlete Name Printed Student-Athlete Signature Date

______________________________ __________________________ __________

Parent Name Printed Parent Signature Date
 LOWNDES COUNTY SCHOOL DISTRICT
STUDENT DRUG TESTING CONSENT FORM

Statement of Purpose and Intent

Participation in school-sponsored extracurricular activities in the schools of the Lowndes County School District
is a privilege. Activity Students have a responsibility to themselves, their fellow students, their schools, their
families, and their community to set the highest possible examples of conduct by avoiding the use or
possession of illegal or performance-enhancing drugs.
Drug use of any kind is incompatible with participation in extracurricular activities in the Lowndes County
School District. For the safety, health, and well-being of all students, the Lowndes County School District has
adopted a policy of using an independent testing company to conduct random drug testing of all students at
middle and high schools (grades 7-12) in the District who participate in extracurricular activities. The testing of
Activity Students may occur at any time during the school year (“in-season” and /or “off-season”).

Participation in Extracurricular Activities

Each Activity Student shall be given a copy of the Activity Student Random Drug Testing Policy and Student
Drug Testing Consent. Both the student and the student’s parent or legal guardian must read, sign, and date
the Student Drug Testing Consent before the student shall be eligible to practice or participate in the listed
extracurricular activity. To be eligible to participate in or practice with certain extracurricular activities, the
consent shall be (a) to give a urine sample; (b) if chosen on a random selection basis; or (c) at any time
requested based on reasonable suspicion of the use or possession of illegal or performance-enhancing drugs.
No student shall be allowed to practice or participate in any activity governed by this policy unless the student
has returned the properly signed Student Drug Testing Consent.

____________________________ __________________________ __________

Student’s Last Name Student’s First Name Middle Name

I have read the “Student Activity Drug Testing Policy” and “Student Drug Testing Consent,” and I understand
that, our of care for my safety and health and the health and safety of others, the Lowndes County School
District enforces the rules applying to the use or possession of illegal and performance-enhancing drugs. As a
member of my school’s extracurricular activity, I realize that the personal decision that I make daily about the
use of or possession of illegal or performance-enhancing drugs may adversely affect my health and well-being,
possibly endanger those around me, and reflects poorly upon any organization with which I am associated. If I
choose to violate this policy regarding the use or possession of illegal or performance-enhancing drugs at any
time, whether during in-season or off-season, I understand upon determination of that violation I will be subject
to the restrictions on my participation and practice outlined in the Policy.

_____________________________ _______________
Signature of Student Date

We have read understand the Lowndes County School District “Activity Student Random Drug Testing Policy”
and “Student Drug Testing Consent.” We desire that the student named above participate in the extracurricular
activities of the Lowndes County School District, and we hereby voluntarily agree that we as parents and our
child or ward are subject to terms of the Activity Student Random Drug Testing Policy. We accept the method
of obtaining urine samples, testing and analysis of such specimens, and all other aspects of the policy. We
further agree and consent to the disclosure of the sampling, testing, and results as provided in the policy and
any regulation adopted by the administration of the District.

_____________________________ ________________
Signature of Parent or Legal Guardian Date