Northport Athletics Packet

*To be eligible to participate the athlete and their parent or guardian

must complete this packet and return in full to their coach or advisor.

Please check off each item when complete.

___________ Medical Release page is filled out completely

___________ Insurance page is filled out completely. If you have your

own coverage list the company and policy number. If you choose to

take school insurance, please fill include school insurance form and

include the money in this packet, a price guide is available in the office.

___________ Student/Parent warning page is read, curricular/cocurricular

handbook is read and signed on the form.

____________ Practice rules are read and signed.

____________ Testing Policy Signed and Returned

Athlete Name ______________________

The Date this packet is completely filled out and turned into your coach

or advisor ____________________

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MEDICAL EMERGENCY AUTHORIZATION FORM

TO BE COMPLETED BY PARENT/GUARDIAN AND RETURNED TO COACH

Name of student athlete _______________________ _______________________ ________________

(last) (first) (middle)

As a Parent or Legal Guardian, I authorize a qualified physician to examine the above-named

student/athlete and in the event of injury to administer emergency care and to arrange for any consultation

by a specialist, including a surgeon, deemed necessary to insure proper care of any injury. Every effort will

be made to contact parent or guardian to explain the nature of the problem prior to any involved treatment.

_________________________________ _________________________ ________________________

Parent/Guardian Date Home Phone

Name __________________________________________ Phone # _____________________

Father and Mother’s name________________________________________________________________

Home Phone _________________________________ Work Phone______________________________

Emergency Contact Person____________________Phone______________ Relationship_______________

Family Physician’s Name_________________________________ Phone_______________________

Dentist’s Name _______________________________ Phone # __________________________________

Blood Type______________________________ Allergies________________________________

Medication allergies ____________________________________________________________________

Medication currently being taken__________________________________________________________

Other important medical information (previous injuries, bee stings, etc.) __________________________

____________________________________________________________________________________

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FOR SCHOOL USE ONLY

Completed Form Received _________________________________ by ___________________________

Duplicate Copy Distributed to_______________________________ on ___________________________

Insurance coverage by parents? Yes____________ No ___________ Unknown ______________

One copy filed in Student Permanent Records

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======== ==============Northport high school

Proof of Insurance or Request for School Insurance

Family Insurance Coverage

I understand that my son/daughter cannot participate in boys’ and girls’ afterschool

extracurricular activities/athletics unless he/she is covered by the school accident

coverage plan or your family plan which meets minimum coverage provision.

Our son/daughter is covered by our accident insurance plan as follows:

1. Minimum death benefit of $10,000.

2. Medical coverage of costs of medical payment for any one injury of $20,000.

3. Coverage equivalent to the Washington State Industrial Insurance Fee

Schedule for Doctors’ services of hospitalization with a 30-day minimum for

the latter.

4. Minimum x-rays of 50% of usual and customary charges.

5. Dental Coverage equivalent to the Washington State Industrial Insurance Fee

Schedule of 200 per natural tooth.

Your Own Coverage

Name of Insurance Company ________________________ Policy # _______________

My son/daughter is covered by the insurance listed above and I will continue to keep it in

force throughout the season: therefore, I do not wish to

enroll____________________________ in the School Accident Coverage Plan. The

school administration is authorized to verify coverage limitations.

As required by law, I verify and attest accident coverage is provided by our policy and I

accept full responsibility for the cost of treatment for any injury, which he/she may suffer

while taking part in the program. Please permit him/her to participate in extracurricular

activities/athletics.

Guardian/Parent Signature___________________________ Date_________________

School Insurance Coverage

_____________________________ will enroll in the school insurance plan prior to the

(Name of son/daughter)

start of the athletic season.

The plan which I choose for my son/daughter is _________________ at a cost of

$_____________. I understand that the money for this plan must be turned in before my

son/daughter can participate.

Guardian/Parent Signature___________________________ Date_________________

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Student-Parent/Guardian Warning

It is the school district’s intent to provide any athlete with good instruction, safe equipment, and safe

transportation; but we cannot eliminate all risks involved in sports participation. ACCIDENTAL INJURY,

COMPLETELY UNRELATED TO ANY PREVENTABLE CAUSE, IS ALWAYS POSSIBLE.

This warning form is designed to provide this school district with a degree of protection. It is not designed

to deny the rights of an injured athlete. OUR SCHOOL DISTRICT PROVIDES WIAA CATASTROPHIC

MEDICAL INSURANCE COVERAGE TO PARTICIPATING STUDENTS. Participation in WIAA

sponsored activities are all voluntary and extracurricular. As a condition to participation in these activities,

you and your parent(s) /guardian(s) must understand the risks involved in these kind of activities.

“WARNING”

Participation in any athletic activity may involve injury of some type to either yourself or a fellow

student athlete. Such injury can include direct physical and possibly crippling injury to one’s

body and the possibility of emotional injury experienced as a result of witnessing or actually

inflicting injury on another. The severity of such can range from minor to catastrophic injury

such as complete paralysis or even one’s future ability to earn a living, to engage in other

business, social and recreational activities and generally to enjoy life.

Activity injuries can result from the incorrect or correct performance of playing techniques used

in tryouts, practices, warm-ups, games, drills, exercises and other similar undertakings. Injury

can also result from failing to follow game, training, safety or other team rules. Injury can result

from the use of transportation provided or arranged by the school district to and from

interscholastic activities. I acknowledge that training, practices, etc. may take place on and off of

school grounds.

Therefore, the purpose of this WARNING is to aid you in making an informed decision as to

whether you/your child or ward should participate in these activities. In addition, its purpose is to

make you aware that as a student participant, or as a parent of guardian of a student participant, it

is your responsibility to learn about and/or inquire of coaches, physicians, advisor or other

knowledgeable persons about any concerns that you might have at any time regarding

participant’s safety.

By signing this document, we acknowledge that we have read and understand its contents and

warnings related to the above mentioned risks and give our permission to our child/ward to

participate in the following interscholastic activities this school year.

CURRICULAR/CO-CURRICULAR HANDBOOK (ATLETIC CODE)

In the Northport School District, interscholastic activities and extracurricular activities are a

privilege, not a right. When an individual is involved in our school activities he/she represents

not only the school but also his/her family, student body, community and self. As a

representative of Northport, standards must be kept high. Therefore, it is important that students

of Northport School District conduct themselves in a professional manner. The Curricular/Co-

Curricular handbook (Athletic Code) is in effect during the entire school year. (There is no

“between seasons,” students are subject to the code all year.)

(PLEASE SIGN BELOW TO GIVE PERMISSION FOR YOUR CHILD TO PARTICIPATE IN

EXTRACURRICULAR ACTIVITIES THIS SCHOOL YEAR AND TO ACKNOWLEDGE THAT YOU

HAVE READ THE CURRICULAR/CO-CURRICULAR HANDBOOK AND WILL ABIDE BY ALL

RULES. I UNDERSTAND THE CONSEQUENCES OF NOT OBEYING THE HANDBOOK RULES.)

Parent Signature __________________________

Student Signature_________________________Date________________________

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General Extra-Curricular Activity Rules

The following set of rules and guidelines are to be followed by all coaches and advisors

at Northport School District. The purpose of a standardized set of rules is to help coaches

be fair and equitable in their rulings. This will also let participants in these activities

have a set of rules and guidelines they know will not change. We feel these standards

will improve practice attendance, dedication, and the overall quality of the extracurricular

programs offered at Northport School District.

Practice Attendance/Tardy Guidelines

Attendance at practice is vital if Northport wants to instill a winning tradition and have a

successful program. With this in mind, ALL ABSENCES FROM PRACTICE MUST

BE EXCUSED AND/OR PRE-APPROVED BY YOUR COACH/ADVISOR OR

THEY WILL BE UNEXCUSED.

The consequences for unexcused absences will be as follows:

􀂾 1st unexcused absence- Loss of playing time. Coaches decision

􀂾 2nd unexcused absence- One game suspension. (parent contact)

􀂾 3rd unexcused absence- Removal from team. (parent notification)

The consequences for tardiness to practice will be as follows:

􀂾 Dealt with by coach in an appropriate manner.

Note: excessive excused absences may also result in a loss of playing time.

Practice/Game Day Attendance at School

It is critical that student/athletes are a student first and athlete second. On days that

practices or games occur, students must be at school all day. Students must attend all

classes the day of a game or practice unless unforeseen or unsuspected circumstances

occur and in these cases eligibility may be reviewed by the coach or athletic director.

Practices the Day Before Games

Practices prior to games are critical to the success of the team. Consequences for missing

before the game practices, even if excused, may have harsher consequences than normal

and is up to the coach. If unexcused absence from practice occurs the day before the

game, you will not play.

Athlete Signature_________________________________

Parent Signature__________________________________

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