Athletic Registration

DRHS QUARRIERS

Athletic Information/Policies  2019-20

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STEP 1:   Read all policies and information below

STEP 2:   Provide information & submit signature of consent

STEP 3:   Download/Print off physical form (7th, 9th, 10th and 11th) or interim physical form (8th and 12th grades). Once this form is filled out, please return to the high school office. 
 

ATTENTION PARENTS/LEGAL GUARDIANS AND ACTIVITY PARTICIPANTS STUDENTS WILL NOT BE ALLOWED TO PRACTICE/PARTICIPATE IN AN ACTIVITY UNTIL ALL ITEMS HAVE BEEN REVIEWED, SIGNED AND RETURNED

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CONTENTS OF ATHLETIC INFORMATION (STEP 1)

#1 Contacts 

#2 Code of Conduct and Academic Eligibilty 

#3 SDHSAA Directory/Participation/Safety Consent

#4 Concussion Information

#5 Medical Consent for Treatment

#6 HIPAA

 

 
CONTACTS/QUESTIONS

Jeff Dvorak
Dell Rapids High School Activities Director
Email:  jeff.dvorak@k12.sd.us
School Phone:  (605) 428-5473

Drew Bunkers
Dell Rapids High School Assitant Activities Director
Email:  drew.bunkers@k12.sd.us
School Phone:  (605) 428-5473

Eve Pickard
Email:  eve.pickard@k12.sd.us
School Phone:  (605) 428-5473

 

STUDENT CODE OF CONDUCT & ATHLETIC ELIGIBILITY

 

Philosophy for Students Participating in Activities

 

We Believe:

  • In developing success through hard work, good attitude, good training, and heart and desire.
  • In giving students the opportunity to select activities to which they can dedicate themselves.
  • In students abiding by rules of conduct at all times once they have joined an activity. 
  • In promoting a Quarrier Spirit… which consists of courtesy, pride, sportsmanship, and loyalty. 
  • In treating officials, opponents and fans with respect.
  • In controlling our temper and being a good sport whether in victory or defeat.
  • In joining in our school song and cheers.
  • In respecting the property of others.

We Do Not Believe:

  • In activities consuming a student, but rather providing balance.
  • In interfering with our opponent’s cheers.
  • In using profane language.
  • In using negative chants or comments toward our opponents. 
  • In throwing objects, physically confronting others, or behaving in a reckless or dangerous way.
  • In using social media to criticize teammates, coaches, opponents, or programs.

 

Any student/athlete whose conduct during the school year is such to make him/her unworthy to represent the school may be ruled ineligible in extracurricular activities. Any such ruling of ineligibility will be determined by the administrators and/or coach/advisor.

 

 Parent/Coach Communication Q & A

 

What is appropriate behavior at an event or activity? 

  • Avoid all demeaning and derogatory comments toward officials, coaches, and players.
  • Encourage and be positive with your child and his/her Quarrier teammates.
  • Avoid any use of foul language.
  • Represent Dell Rapids School District with class and integrity.

What type of communication should parents expect from their child’s coach?

  • Philosophy of the coach (goals, objectives, expectations, discipline, special rules, etc.).
  • Location and times of all practices and contests.
  • Special team requirements (fees, special equipment, conditioning, team roles, etc.).
  • Policies regarding transportation, practice, vacations, lettering, etc.

What kind of communication do coaches expect from parents?

  • Notification of any schedule conflicts well in advance.
  • Specific information relating to the physical health and emotional well-being of your child.

What should parents do if they have specific sport/activity related concerns?

  • Student athlete/participant should first meet with the coach/advisor.
  • If resolution is not achieved, the parent should contact the coach during school hours. Please do not attempt to confront a coach before or after a contest or practice.
  • If resolution is not achieved, the parent should contact the athletic director during school hours. 

What are some issues which are not appropriate to discuss with coaches?

  • Playing time, starters, etc.
  • Specific offenses and defenses
  • Information about other students

Please remember the fields or gymnasiums are your child’s classrooms.  Many valuable lessons are learned within these athletic arenas.  Our program is an educational one in which students will grow from both positive and adverse situations.

 

Dell Rapids School District

Code of Conduct for Students in SDHSAA and DRSD Activities

 

Student participation in SDHSAA and DRSD sponsored activities (hereafter referenced as “activities”) is a privilege, not a right.  Students who choose to participate in activities are expected to positively represent their school by demonstrating appropriate behavior year round and also by adhering to the following training rules. 

 

Any middle school or high school student wishing to participate in school activities must adhere to the following training rules. Students cannot:

1) possess, sell, dispense, or use alcohol, tobacco, e-cigarettes or any vaping device.

2) commit any crime against a person or against property.

3) possess, sell, dispense, or use a controlled or mood-altering substance (such as steroids, marijuana, inhalants, and other drugs) and/or drug paraphernalia.

 

These training rules will be enforced year-round regardless of whether or not the student is participating in an activity at the time.  Students who violate these rules will be ineligible to participate according to the activity consequences listed below.

 

SCHOOL DISTRICT CONSEQUENCES FOR VIOLATIONS OF #1  AND #2 ABOVE:

 

  1. First Violation:
  • The student will be suspended for TEN PERCENT of the regular scheduled season during the season in which they are a participant* or the upcoming activity season in which they would be a participant. 
  • The number of suspended events may carry over into the next season that the student is a participant.
  1. Second Violation:
  • The student will be suspended for FORTY PERCENT of the regular scheduled season during the season in which they are a participant* or the upcoming activity season in which they would be a participant. 
  • The number of suspended events may carry over into the next season that the student is a participant.
  1. Third Violation and every subsequent violation:
  • The student will not participate in any activity for TWELVE CALENDAR MONTHS. 
  • The student will not be eligible for activity awards during the 12-month period
  •  
  • Student being deemed a participant in an activity will be determined by the High School Principal, High School Activities Director, and applicable coach(es). Examples include but are not limited to student manager, set designer, and videographer.

 

SCHOOL DISTRICT VIOLATIONS OF #1 AND #2 ABOVE WHILE ON SCHOOL PROPERTY OR ATTENDING SCHOOL SPONSORED ACTIVITIES:

                                                          ** PLEASE NOTE THE FOLLOWING:

  • The consequences below take precedence over Code of Conduct violations occurring off of school grounds or outside of a school-sponsored activity.
  • If a student is not in an activity during his/her suspension from school, the number of suspended days of practice/rehearsal/games/etc. will begin being counted on the first official day of practice.
  • For each violation below there is a required minimum number of games that would be missed by a student incurring these violations along with the suspension from team activities.
  • In addition to athletic/school activity consequences listed below, students will also be subjected to the requirements and consequences of the student code of conduct.
  • Suspension from team activities would roll into the next sports season or the next school year if the terms of the suspension were not met in the current season/year.

            1. First Violation:

  • The student will be ineligible to participate in any practice, game or team activity during his/her 3-day suspension from school.
  • Minimum games missed: 25% of the season

            2. Second Violation:

  • The student will be ineligible to participate in any practice, game or team activity during his/her 5-day suspension from school.
  • Minimum games missed: 75% of the season

            3. Third Violation:

  • Student will be ineligible to participate in any practice, game, or team activity during his/her 10-day suspension from school
  • Minimum games missed: One calendar year of all SDHSAA activities

 

SCHOOL DISTRICT CONSEQUENCES FOR VIOLATIONS OF #3 ABOVE:

                                                          ** PLEASE NOTE THE FOLLOWING:

  • Any student ingesting, inhaling or possessing controlled drugs/substances as well as any student possessing or found by law enforcement to be in possession of drug paraphernalia will be in violation of the Dell Rapids School District Code of Conduct
  • Evidence of a violation will be the same as other code of conduct violations outlined in the Dell Rapids School District policy (#8) and activity consequences would begin the day evidence of a violation is confirmed by school administration.
  • Students will also be governed by state law regarding controlled substance violations (SDCL 13-32-9). State law states “In addition to school district consequences…” The Dell Rapids School District policy and consequences are independent of any consequences set forth by state codified law.  For example, a 30-day suspension as the result of a court conviction and then an accredited treatment program, may run concurrently with the school district’s suspension and it may run after the school’s 40% suspension is over.  This is dependent on the timeline of the juvenile court system.
  • Consequences will roll over into the next season/year that the student is participating in if consequences are not met during the current season/year.

            1. First Violation:

  • The student will be suspended for FORTY PERCENT of the regular scheduled season.
  • The student must undergo a minimum of THREE SESSIONS of substance abuse counseling with a Carroll Institute counselor at DRSD

            2. Second Violation:

  • The student will be suspended for TWELVE CALENDAR MONTHS from all SDHSAA activities.
  • The student MUST COMPLETE a substance abuse program from a certified chemical dependency counselor.

 

SCHOOL DISTRICT CONSEQUENCES FOR NON-SDHSAA ACTIVITIES SPONSORED BY DRSD:

 

** Quiz Bowl, FFA, FCCLA and other school sponsored but not SDHSAA sanctioned activities

  • Though not SDHSAA activities, these will follow the same consequences as SDHSAA activities outlined above.
  • Note: suspensions will be pardoned in cases where a student’s grade would be affected. In such cases, alternative and appropriate consequences will be determined by the Principal, AD, and coach/director/advisor.

 

** Student Recognition activities such as, but not limited to, Homecoming Coronation, HOBY,

     Girls & Boys State, Student of the Month.

  • 1st Violation: Suspension for 45 school days from any such activities or recognition
  • 2nd Violation: Suspension for 90 school days from any such activities or recognition
  • 3rd  Violation: Suspension for ONE CALENDAR YEAR from any such activities or recognition
  •  

SCHOOL DISTRICT RULES REGARDING VIOLATIONS AND CONSEQUENCES:

 

  1. Student conduct rules and training rules for students will begin on the first day of class (or activity, if the activity starts before the first day of class) of student’s seventh grade or the first day of enrollment to the district after that time.
  2. Conduct violations accumulate over a student’s 7-12 grade middle school and high school career; however, students who have had only one violation and then remain violation-free for twelve consecutive months from the date of the last violation, start over with a clean record.  This opportunity applies only once during a student’s 7-12 grade school career.
  3. If the violation occurs at school, at a school event, on school property, or while under the supervision of the activity advisor, the district rules of student conduct and discipline will also be applied.    
  4. The following steps will be taken when suspending a student from an activity:
    1. The Activities Director and/or Principal will inform the student of the rule, regulation, or policy which has been allegedly violated and how the rule, regulation or policy was allegedly violated.
    2. The student will be given an opportunity to answer the charges and present evidence on his or her behalf.
    3. The Activities Director and/or Principal will render a decision as soon as possible after reviewing the case and inform the student and student's parents of the decision.
    4. Upon suspending a student the Activities Director and/or Principal will provide oral and written notice of the suspension to the student’s parent(s) or guardian(s).
  5. In the event the student or parents believe that the student has been suspended from an activity without just cause, the student or parent may appeal the decision within five school days to the Superintendent or Superintendent's designee.  The Superintendent or designee has five school days to respond to the appeal. The student will remain ineligible during the appeal process.  Should the parent or student disagree with the Superintendent's or Superintendent’s designee’s decision, the parent or student may appeal the decision within five school days to the Board of Education.  The School Board will schedule an executive session at the next regularly scheduled school board meeting, at which time the student, parent, and such other persons as may be deemed necessary must be present, and the Board will address the appeal.  
  6. Suspension begins with the date the student is informed by the Activities Director of the suspension. 
  7. Evidence of a violation may be the result of:
    1. information received from law enforcement or court services personnel provides reasonable cause to believe that an infraction has occurred.
    2. a student found guilty, pled guilty, or enters a no contest plea in either Juvenile Court or Adult Criminal Court.
    3. a self-reported violation by either the parent or student.
    4. an observed/confirmed violation reported by a staff member.
    5. an observed/confirmed violation reported by a person not a school district employee, provided the information has been verified to the satisfaction of the Activities Director.
  8. Students with pre-existing training rule violations will be allowed to join an activity once its first official day of practice (as outlined by the SDHSAA Calendar) has passed or has not passed. However, if they join an activity already in progress, the penalty/suspension from contests will be determined by the Athletic Director and coaches involved.  Students must complete that activity in good-standing of that activity’s head coach in order for suspensions served to be binding (if allowed to be served during that activity) and not carry over to the next season.
  9. Consequences/suspensions for violations will be administered in the next activity in which the student participates. That may mean consequences could roll over into the next season/year until they are fulfilled.
  10. Students in violation of activity rules during their season of participation will not be eligible for any district post-season or year-end awards.
  11. Students serving in-school or out-of-school suspension may not be eligible to participate in activity events on days they are suspended. This will be determined by the High School Principal and Athletic Director.

STATE LAW VIOLATION AND CONSEQUENCES PURSUANT TO SDCL 13-32-9

In addition to school district consequences, state law (SDCL 13-32-9) can also result in the student not being able to participate in any activity sanctioned by the South Dakota High School Activities Association (SDHSAA).  SDCL 13-32-9 requires:

· First Violation:   SDCL 13-32-9 states that any person adjudicated, convicted, the subject of  an informal adjustment or court approved juvenile diversion program, or the  subject of a suspended imposition of sentence for possession, use, or distribution of controlled drugs or substances or marijuana as defined in SDCL 22-42, or for ingesting, inhaling, or otherwise taking into the body any substances as prohibited by SDCL 22-42-15, is ineligible to participate in any extracurricular activity at any secondary school accredited by the DOE for one calendar year from the date of adjudication, conviction, diversion, or suspended imposition of sentence.  The one year suspension may be reduced to thirty calendar days (which must include two SDHSAA sanctioned events) if the person participates in an assessment with a certified chemical dependency counselor or completes an accredited intensive prevention or treatment program.  If the assessment indicates the need for a high level of care, the student is required to complete the prescribed program before becoming eligible to participate in extracurricular activities. In order for events to count toward the minimum number of events for which the student is ineligible following a reduction in the suspension, the student must participate in the entire activity season.

· Second Violation:  SDCL 13-32-9 states that any person adjudicated, convicted, the subject of  an informal adjustment or court approved juvenile diversion program, or the  subject of a suspended imposition of sentence for possession, use, or distribution of controlled drugs or substances or marijuana as defined in SDCL 22-42, or for ingesting, inhaling, or otherwise taking into the body any substances as prohibited by SDCL 22-42-15, is ineligible to participate in any extracurricular activity at any secondary school accredited by the DOE for one calendar year from the date of adjudication, conviction, diversion, or suspended imposition of sentence.  The one year suspension may be reduced to sixty calendar days (which must include six SDHSAA sanctioned events) if the person participates in an assessment with a certified chemical dependency counselor or completes an accredited intensive prevention or treatment program.  If the assessment indicates the need for a high level of care, the student is required to complete the prescribed program before becoming eligible to participate in extracurricular activities. In order for events to count toward the minimum number of events for which the student is ineligible following a reduction in the suspension, the student must participate in the entire activity season.

· Subsequent Violation:  SDCL 13-32-9 states that upon a subsequent adjudication, conviction, diversion, or suspended imposition of sentence for possession, use or distribution of controlled drugs or substances or marijuana as defined in SDCL 22-42, or for ingesting, inhaling, or otherwise taking into the body any substances as prohibited by SDCL 22-42-15, by a court of competent jurisdiction, that person is ineligible to participate in any extracurricular activity at any secondary school accredited by the Department of Education.

[The school will not reduce twelve-month suspensions from activities of students who have a second or third adjudication, conviction, diversion, or suspended imposition of sentence for possession, use, or distribution of controlled drugs or substances or marijuana as defined in SDCL 22-42, or for ingesting, inhaling, or otherwise taking into the body any substances as prohibited by SDCL 22-42-15.]

DEFINITIONS:

  1. SDHSAA Activity = All school and SDHSAA sanctioned student activities, including but not limited to football, cross country, golf, basketball, wrestling, volleyball, track & field, cheerleading, oral interpretation and one-act play.
  2. School Activity Event = A public presentation, performance, competition, or trip associated with participation in a school activity. Events and contests include, but are not limited to FFA and FCCLA.  Exemptions are made for any events considered to be part of a course curriculum for which a student’s grade would suffer negative consequences. 
  3. Year-round = 24-hours a day, 365 days a year

 

STUDENT ACADEMIC ELIGIBILITY (9-12)

Grade/Eligibility will be determined at the midterm and end of each quarter/semester. In order to be eligible, a student must pass all of his/her academic courses. Should a student become ineligible at midterm by receiving a failing grade in one or more courses, he/she won’t be allowed to participate in activities for a period of one week or one contest, whichever is greater, effective the Monday after midterm grades have been submitted. If he/she is still receiving a failing grade after one week, he/she will become ineligible for an additional week or contest. Ineligibility will continue until a student can maintain a passing grade in all courses. Students can regain eligibility by showing evidence of a passing grade to the principal or activities director. Students will then become eligible the following Monday after proof of passing all courses. The minimum requirement for ineligibility is one full week or one contest. If a student receives a failing grade in a course(s) for a quarter or semester, he/she will become ineligible for two weeks or two contests, whichever is greater. All SDHSAA requirements and policies must also be met. Students will still be allowed to practice during a period of ineligibility.

 

 
 
 
 

SDHSAA DIRECTORY/PARTICIPATION/SAFETY

The Parent and Student hereby:

1. Understand and agree that participation in SDHSAA sponsored activities is voluntary on the part of the student and is considered a privilege.

2. Understand and agree that (a) by this Consent Form the SDHSAA has provided notification to the parent and student of the existence of potential dangers associated with athletic participation; (b) participation in any athletic activity may involve injury of some type; (c) the severity of such injuries can range from minor cuts, bruises, sprains, and muscle strains to more serious injuries such as injuries to the body’s bones, joints, ligaments, tendons, or muscles. Catastrophic injuries to the head, neck and spinal cord and concussions may also occur. On rare occasions, injuries so severe as to result in total disability, paralysis and death; and (d) even with the best coaching, use of the best protective equipment, and strict observance of rules, injuries are still a possibility.

3. Consent and agree to participation of the student in SDHSAA activities subject to all SDHSAA bylaws and rules interpretations for participation in SDHSAA sponsored activities, and the activities rules of the SDHSAA member school for which the student is participating; and

4. Consent and agree that personally identifiable directory information may be disclosed about the student as a result of his/her participation in SDHSAA sponsored activities. Such directory information may include, but is not limited to, the student’s photograph, name, grade level, height, weight, and participation in officially recognized activities and sports. If I do not wish to have any or all such information disclosed, I must notify the above mentioned high school, in writing, of our refusal to allow disclosure of any or all such information prior to the student’s participation in sponsored activities.  

 

CONCUSSION FACT SHEET FOR ATHLETES

What is a concussion?
A concussion is a brain injury that:
  • Is caused by a bump, blow, or jolt to the head or body
  • Can change the way your brain normally works
  • Can occur during practices or games in any sport or recreational activity
  • Can happen even if you haven’t been knocked out
  • Can be serious even if you’ve just been “dinged” or “had your bell rung”
All concussions are serious.  A concussion can affect your ability to do schoolwork and other activities (such as playing video games, working on a computer, studying, driving, or exercising).  Most people with a concussion get better, but it is important to give your brain time to heal. 
 
What are the symptoms of a concussion?
You can’t see a concussion, but you might notice one or more of the symptoms listed below or that you “don’t feel right” soon after, a few days after, or even weeks after the injury. 

 
  • Headache or “pressure” in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Bothered by light or noise
  • Feeling sluggish, hazy, foggy, or groggy
  • Difficulty paying attention
  • Memory problems
  • Confusion
What should I do if I think I have a concussion?
  • Tell your coaches and your parents.  Never ignore a bump or blow to the head even if you feel fine.  Also, tell your coach right away if you think you have a concussion or if one of your teammates might have a concussion.
  • Get a medical check-up.  A doctor or other health care professional can tell if you have a concussion and when it is OK to return to play.
  • Give yourself time to get better.  If you have a concussion, your brain needs time to heal.  While your brain is still healing, you are much more likely to have another concussion.  Repeat concussions can increase the time it takes for you to recover and may cause more damage to your brain.  It is important to rest and not return to play until you get the OK from your health care professional that you are symptom-free.
How can I prevent a concussion?
Every sport is different, but there are steps you can take to protect yourself.
  • Use the proper sports equipment, including personal protective equipment.  In order for equipment to
  • protect you, it must be:
    • The right equipment for the game, position, or activity
    • Worn correctly and the correct size and fit
    • Used every time you play or practice
  • Follow you coach’s rules for safety and the rules of the sport
  • Practice good sportsmanship at all times

What is the Dell Rapids protocol for handling potential concussions?

  • All athletes will take a baseline IMPACT test
  • If a coach, player or trainer sees or suspects a potential head trauma, the player will be removed from that activity
  • At this point and following an evaluation, ONLY certified medical personnel can deem a player fit to return to that activity
  • Once a head trauma has occured, the student is required to be assessed by a health care professional
  • The health care professional will make contact and ask the school to administer a post-concussion IMPACT test
  • The results of the "post" test will accompany the athlete to the health care professional's evaluation/appointment
  • An athlete's return to participation is now in the hands of the doctor/h.c.p., who must provide written documentation (Return to Competition Form) to the school once the athlete is safe to return to activity.

It’s better to miss one game than the whole season.

CONCUSSION FACTS SHEET FOR PARENTS
 

What is a concussion?
A concussion is a brain injury. Concussions are caused by a bump, blow, or jolt to the head or body. Even or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms?
You can’t see a concussion, Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days after the injury. If your teen reports, one or more symptoms of concussion listed below, or if you notice the symptoms yourself, keep your teen out of play and seek medical attention right away.
 
Signs Observed By Parents or Guardians Symptoms Reported by Athlete
  • Appears dazed or stunned
  • Headache or “pressure” in head
  • Is confused about assignment or position
  • Nausea or vomiting
  • Forgets an instruction
  • Balance problems or dizziness
  • Is unsure of game, score, or opponent
  • Double or blurry vision
  • Moves clumsily
  • Sensitivity to light or noise
  • Answers questions slowly
  • Feeling sluggish, hazy, foggy, or groggy
  • Loses consciousness (even briefly)
  • Concentration or memory problems
  • Shows mood, behavior, or personality changes
  • Confusion
  • Can’t recall events prior to hit or fall
  • Just not “feeling right"
  • Can’t recall events after hit or fall
 

How can you help your teen prevent a concussion?
Every sport is different, but there are steps your teens can take to protect themselves from concussion and other injuries.
  •  Make sure they wear the right protective equipment for their activity. It should fit properly, be well maintained, and be worn consistently and correctly.
  •  Ensure that they follow their coaches’ rules for safety and the rules of the sport
  •  Encourage them to practice good sportsmanship at all times.

What should you do if you think your teen has a concussion?

1. Keep your teen out of play. If your teen has a concussion, her/his brain needs time to heal. Don’t let your teen return to play the day of the injury and until a health care professional, experienced in evaluating for concussion, says your teen is symptom-free and it’s OK to return to play. A repeat concussion that occurs before the brain recovers from the first – usually within a short period of time (hours, days, or weeks) – can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death.

2. Seek medical attention right away. A health care professional experienced in evaluating for concussion will be able to decide how serious the concussion is and when it is safe for your teen to return to sports.

3. Teach your teen that it’s not smart to play with a concussion. Rest is key after a concussion.  Sometimes athletes wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don’t let your teen convince you that s/he’s “just fine”.

4. Tell all of your teen’s coaches and the student’s school nurse about ANY concussion. Coaches, school nurses, and other school staff should know if your teen has ever had a concussion. Your teen may need to limit activities while s/he is recovering from a concussion. Things such as studying, driving, working on a computer, playing video games, or exercising may cause concussion symptoms to reappear or get worse. Talk to your health care professional, as well as your teen’s coaches, school nurse, and teachers. If needed, they can help adjust your teen’s school activities during her/his recovery.

What is the Dell Rapids protocol for handling potential concussions?

  • All athletes will take a baseline IMPACT test (7th and 10th grade)
  • If a coach, player or trainer sees or suspects a potential head trauma, the player will be removed from that activity
  • At this point and following an evaluation, ONLY certified medical personnel can deem a player fit to return to that activity
  • Once a head trauma has occured, the student is required to be assessed by a health care professional
  • The health care professional will make contact and ask the school to administer a post-concussion IMPACT test
  • The results of the "post" test will accompany the athlete to the health care professional's evaluation/appointment
  • An athlete's return to partcipation is now in the hands of the doctor/h.c.p., who must provide written documentation to the school once the athlete is safe to return to activity.
 
 
 

 

CONSENT FOR MEDICAL TREATMENT

This is the form that the South Dakota High School Activities Association recommends to those member schools that feel it is important to get consent from parents and/or legal guardians for medical treatment when away from home on road trips for various activities. This form should be kept on file at the school and another copy should travel with each team on which the athlete competes.

I, the Parent/Legal Guardian whose electronic signature appears in the next section hereby consent my child who participates in co-curricular activities for High School to any medical services that may be required while said child is under the supervision of an employee of the School District while on a school-sponsored activity and hereby appoint said employee to act on behalf in securing necessary medical services from any duly licensed medical provider. 

CONSENT FOR RELEASE OF MEDICAL INFORMATION (HIPAA)

1. I authorize the use or disclosure of the above named individual’s health information including the Initial and Interim Pre-Participation History and Physical Exam information pertaining to a student’s ability to participate in South Dakota High School Activities Association sponsored activities.  Such disclosure may be made by any Health Care Provider generating or maintaining such information. 

2. The information identified above may be used by or disclosed to the school nurse, athletic 
trainer, coaches, medical providers and other school personnel involved in the care of this student.   

3. This information for which I am authorizing disclosure will be used for the purpose of  determining the student’s eligibility to participate in extracurricular activities, any  limitations on such participation and any treatment needs of the student. 

4. I understand that I have a right to revoke this authorization at any time.  I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school administration.  I understand that the revocation will not apply to information that has already been released in response to this authorization.  I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.   

5. This authorization will expire on July 1, 2020. 

6. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
 
7. I understand authorizing the use or disclosure of the information identified above is voluntary.  However, a student’s eligibility to participate in extracurricular activities depends on such authorization.  I need not sign this form to ensure healthcare treatment.

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