Athletic Registration



 
STUDENT INFORMATION:
 
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(You are eligible for no more than 8 consecutive semesters from when you first enter the 9th grade.)
 
 
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(You may only have one “fixed and permanent home” for eligibility purposes.)
 
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* Have you applied for "Shared Housing" to attend Kempsville High School?
     
 
*If yes, have you completed all of your required documentation and returned it to the Guidance Office?
     
 
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* Do you live in this school's attendance zone?
     
 
(If no- answer the next four * questions)
 
 
 
 
 
C. *Have you been granted permission by the Va. Beach School Board and the principal to attend KHS?
     
 
 
 
* Did you attend an Academy Program last year at another VBCPS?
     
 
If you attended an Academy last year, you must apply for a waiver BEFORE YOU ARE ELIGIBLE – See SAC immediately!
 
* Have you moved within the last school year?
     
 
A. *Did you attend a VA Beach School?
     
 
 
 
(If you move during the school year, you must immediately provide proof of your new address to our Guidance Department (e.g., utility bill, mortgage statement/rental agreement, etc.).  It is your responsibility to notify the school of changes.)
 
* Have you taken a 2.0 Athletic Waiver in any VA Beach High School?
     
 
 
 
 
 
* Have you even been removed from a High School team because you did not meet the VBCPS 2.0 requirements?
     
 
* Did you take a class this year in summer school?
     
 
SUMMER SCHOOL INFORMATION  - Fall and Winter Athletes Only!
 
 
 
 
 
 
 
* Are you currently auditing a class?
     
 
(Auditing means you are taking a class to better understand the material, but will not receive credit for repeating the class.) 
 
* Did you audit a class last semester?
     
 
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If not Kempsville High School answer the next 3 questions:
 
 
PREVIOUS SCHOOL INFORMATION FOR TRANSFERS
(You must have enrolled no later than the 15th day of a semester unless there is a corresponding change of address)
 
 
 
 
 
 
C. Did you participate in any Varsity/JV sport(s) at your previous school during the current school year?
      
 
 
 

 
PLEASE READ THIS SECTION:
 
PENALTY FOR GIVING FALSE INFORMATION
VHSL Rule 30-4-3 - If any student or his/her parent(s) or guardian gives false information, written or verbal, relating to his/her residence, eligibility or any other aspect of these rules and regulations, the student shall be deemed ineligible at any VHSL school for a period of one (1) year from the date the information is certified as being false.

VIRGINIA GENERAL ASSEMBLY LAW AS OF JULY 1, 2005
It is a Class 4 misdemeanor charge for knowingly making a false statement concerning the residency of a child in a particular school division or school attendance zone for the purposes of avoiding tuition charges or enrollment in a school outside the attendance zone in which the student resides. This bill took effect on July 1, 2005, and is punishable by a fine of up to $250.
 
PARENTAL STATEMENT OF UNDERSTANDING
The Kempsville High School Athletic Handbook contains information concerning: Insurance, VHSL Eligibility Rules, Acknowledgment of Risk, Emergency Care Procedures, State and Local Laws, School and Team Policies, etc. I understand the policies governing Interscholastic Athletics in Virginia Beach City Public Schools through the Preseason Meeting, the KHS/VBCPS Athletic Handbook, or some other means, and through typing my name, I hereby grant permission for the student's participation. I also understand that participation in school-sponsored activities is a privilege and not a property right; and therefore, the school's principal may suspend my son/daughter from participation by declaring him/her not in good standing if the student's character or conduct is such as to reflect discredit upon his/her school. I further am aware of and understand the penalties and consequences printed in the KHS/VBCPS Athletic Handbook, and reviewed at the preseason meeting by the coach and Student Activities Coordinator.
 
ANABOLIC STEROIDS
A video regarding the dangers of Anabolic Steroids will be shown at the Parent Athletic Information Night (PAIN) and can be viewed online by clicking this link: http://www.youtube.com/watch?v=QKRg8MK-Wxo. By typing my name I acknowledge that I am aware of the dangers of Anabolic Steroids and will support the school to make sure no athletes are using this drug.
 
I verify that the information on this form is correct and I understand the above Parental Statement of Understanding.
 
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By typing my name, I grant permission for my son/daughter to participate in the Kempsville High School Athletic Program and for my athlete's picture and/or name to appear on the Kempsville High School website.
 
IF YOU HAVE ANY ELIGIBILITY QUESTIONS PLEASE CALL: 757-648-5471
 

 

PERMISSION FOR EMERGENCY CARE

 

PARENT/GUARDIAN INFORMATION
 
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Please provide contact information for Father where different from Mother.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
IN CASE OF AN EMERGENCY, CONTACT: (must be different from parents listed above, e.g., grandparent, family friend, etc.)
 
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ACKNOWLEDGEMENT OF RISK:
 
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and is familiar with his/her wishes to participate in the following sports at Kempsville HS.
 
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I am aware that with participation in sports comes the risk of injury to my child and that this risk increases in gymnastics, track and field and contact sports such as football and wrestling. I have had an opportunity to understand the risks inherent in this sport through meetings, written handouts, or some other means. In addition, I am aware that participation in this sport will involve travel with the team. I acknowledge and accept the risks inherent in the sport and with the travel involved, and with knowledge in mind, grant permission for my child to participate in the sport and travel with the team. The school has my permission, in an emergency, when I (or my physician) cannot be contacted, to take my child to the emergency room of a local hospital, at my expense. I authorize the hospital and its medical staff to provide treatment which a physician deems necessary for the well-being of my child. I have adequate insurance coverage as stated above, and I accept full responsibility for my child's medical expenses caused by injury through participation in athletics.
 
* By Clicking here you signify that you agree to the terms stated above:
     
 

 
PRIMARY CARE DOCTOR INFORMATION
 
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* Do you have private/military insurance?
     
     
 
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  * Is this an HMO policy?
     
     
 

 
 
 

 

Parental Statement of Understanding for Head Injuries

 
The Beach District Athletic Manual contains information concerning:
 
Insurance Permission for Emergency Care Collegiate Eligibility Requirements
Athletic Training Medical History Sportsmanship Guide
2.0 Mandate for Interscholastic Activities Physical Examination Team Policy and Specific Sports
Individual Eligibility Rules Participation Evaluation Parent/Coach Communication
Acknowledgement of Risk Anti-Hazing Statement Social Media Position Statement
Out-Of-Season Practice Rule  
 
 
Parental Statement of Understanding:

I understand the policies governing interscholastic athletics in the Virginia Beach City Public Schools through the preseason meeting, the Beach District Athletic Manual, or some other means, and by typing my name grant permission for the student’s participation.  I also understand that participation in school-sponsored activities is a privilege and not a property right; and therefore, the school’s principal may suspend my son/daughter from participation by declaring him/her not in good standing if the student’s character or conduct is such as to reflect discredit upon his/her school.
 
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Sport(s) 
     
     
     
     
     
     
     
     
     
     
 
Attended Preseason Meeting
     
     
 
CONCUSSION MANAGEMENT
 
ImPACT CONCUSSION MANAGEMENT PROGRAM
PERMISSION FORM
 
The Virginia Beach City Public Schools is utilizing an innovative concussion management program for our student-athletes in certain sports having a greater risk for head injuries (cheerleading, field hockey, football, basketball, gymnastics, wrestling, baseball, soccer, softball, diving, high jump, pole vault).  The program is called ImPACT (Immediate Post Concussion Assessment and Cognitive Testing) and involves an online computerized exam that each athlete takes prior to an athletic season.  In order to participate in any of the sports listed above, student athletes must be tested in the ImPACT program during the preseason.  If the athlete is believed to have suffered a concussion during participation, the exam is taken again and the data is compared to the baseline test.  This information is then used as a tool to assist the athletic training staff and treating physicians in determining the extent of the injury, monitoring recovery, and in making safe return-to-play decisions.  If an injury of this nature occurs, we will be in contact with you.  Post-concussion tests will be taken under our supervision at school.  Return-to-play decisions must be made by a physician.  Founded by the University of Pittsburgh Medical Center’s Sports Concussion Program, this software system is utilized throughout professional sports and at a number of colleges and high schools across the country.  Additional information can be found at www.impacttest.com.  The exam takes about 25-30 minutes and is non-invasive.  The program is set up in a “video game” type format.  It tracks neurocognitive information such as memory, reaction time, brain processing speed, and concentration.  For example, in one part of the exam, a dozen common words appear one at a time on the screen for about one second each.  The athlete is then later asked what words were displayed.  It is a simple exam and most who take it enjoy the challenge of the test.  One of the reasons concussions are so dangerous is a condition called Second Impact Syndrome.  If an athlete sustains a second concussion before completely recovering from the first, the results can be deadly.  We understand the competitive nature of sports; however, our top priority is ALWAYS the health and safety of our athletes.  Please sign and return this form indicating permission for your son/daughter to take this test.  If you have any questions regarding this program, please contact your school’s athletic trainer.
 
If you have questions regarding the ImPACT program, please contact:
 
Nancy Como-Lesko Ph.D.
Pediatric Clinical Neuropsychologist
Psychological Services, VBCPS
1413 Laskin Rd, Virginia Beach, 23457
757-263-2700
 
I have read and understood the above information and give permission for my son/daughter to participate in the ImPACT Concussion Management Program. VBCPS may release the ImPACT (Immediate Post-concussion Assessment and Cognitive Testing) results to my child’s primary care physician, neurologist, or other treating physician, as requested.
 
CONCUSSION IN SPORTS 
Information for Parents/Guardians
 
Parents/Guardians of Athletes: In order to help protect the student athletes of Virginia Beach City Public Schools, the Virginia General Assembly, in accordance with Senate Bill 652 (Concussion in Student-Athletes), has mandated that all student athletes, parents and coaches follow the Virginia Beach City Public Schools Concussion Policy. Please read and sign this fact sheet and return it to your school’s Student Activities Coordinator prior to the first date of competition. This form must be reviewed and signed on a yearly basis. 
 
What is a Concussion? 
 
A concussion is a brain injury and all brain injuries are serious. It is characterized by an onset of impairment of cognitive and/or physical functioning, and is caused by a blow to the head, face or neck, or a blow to the body that causes a sudden jarring of the head (i.e. a helmet to the head, being knocked to the ground). A concussion can occur with or without a 
loss of consciousness, and proper management is essential to the immediate safety and long-term future of the injured individual. 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 concussion can result in edema (brain swelling), permanent brain damage, and even death. 
 
What are the signs and symptoms of a concussion? 
 
*Signs observed by teammates, coaches, 
parents/guardians include:
1. Appears dazed or stunned 
2. Is confused about assignments and positions 
3. Forgets instructions and answers questions slowly or 
inaccurately 
4. Is unsure of game, score, or opponent 
5. Loss of balance/coordination and moves clumsily 
6. Shows mood, behavior, or personality changes 
7. Cannot recall events prior to hit or fall 
8. Cannot recall events after hit or fall 
 
*Symptoms reported by athlete may include one or 
more of the following:
1. Headache or “pressure” in head 
2. Nausea/vomiting 
3. Balance problems or dizziness 
4. Sensitivity to light or sound/noise 
5. Feeling sluggish, hazy, groggy, or foggy 
6. Difficulty with concentration, short-term memory and/or 
confusion 
7. Double vision or changes in vision 
8. Irritability 
9. Just not “feeling right” or is “feeling down” 
* adapted from CDC
 
How can you help your child prevent a concussion? 
 
Every sport is different, but there are steps your child can take to protect themselves from concussion: 
• Ensure that they follow their coach’s rules for safety and the rules of the sport. 
• Encourage them to practice good sportsmanship at all times. 
• Make sure they properly wear the right protective equipment that is required for their sport (such as helmets, 
padding, shin guards, eye and mouth guards). 
• Learn the signs and symptoms 

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

1. Seek medical attention right away. A licensed health care professional will be able to decide how serious the 
concussion is and when it is safe for your child to return to sports. 
2. Keep your child out of play. Concussions take time to heal. Don’t let your child return to play until a licensed health 
care professional gives clearance to return. Children who return to play too soon-while the brain is still healing – risk 
a greater chance of having a second concussion. Second or later concussions can be very serious. This can lead to 
prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal 
consequences. 
3. Tell your child’s coach about any recent concussions. School personnel should be notified if your child had a recent 
concussion in any sport. Your child’s coach may not know about a concussion your child received in another sport or 
activity unless you tell the coach. 
4. Refer to the Concussion Graduated Return to Play guidelines below to familiarize yourself with the process used to 
determine when it is safe for your child to gradually return to full activity.
 
CONCUSSION GRADUATED RETURN TO PLAY 
 
• When an athlete has been evaluated by an athletic trainer and/or a physician for a concussion the following graduated functional return to play will be followed. The return to play progression will not begin until the athlete is completely symptom free. Each stage is a minimum 24 hour period; therefore the return to play progression will be a minimum of 4-5 days. 
• If the athlete experiences any symptoms, at any point during the rehabilitation stages, the progression will stop immediately and the cycle will resume at the previous asymptomatic rehabilitation stage after 24 hours of rest. If symptoms continue to occur, the athlete will be referred back to the physician for a follow up evaluation.
Rehabilitation Stage Functional Exercise Objective of Each Stage
Stage 1 – No Activity Physical/Cognitive Rest Recovery
Stage 2 – Light Aerobic Exercise Walking, Swimming, Bike Increase Heart Rate
Stage 3 – Sport-Specific Exercise  Running Drills, NO Contact Add Movement
Stage 4 – Non-Contact Drills  Complex Drills, Resistance Training Exercise, Coordination, 
Cognitive Load/IMPACT
Stage 5 – Full Contact Following Clearance, Normal 
Training Activities
Restore Confidence, Assess 
Functional Skills by Coaches
Stage 6 – Return to Play Normal Game Play  
*Adapted from Table 1 McCrory et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport, Zurich, November 2008
 
• The treatment, management, and return to play determinations will be individualized to each athlete and dependent on circumstances of each specific case and injury. ImPACT testing may also be utilized in the return to play determination, treatment and evaluation of concussions. 
• A safe return to play is the ultimate goal regardless of age and level of play. 
• After being released for participation by a physician, the athlete must also be cleared by the school’s athletic trainer before beginning Stage 2 of the return to play progression above. The student-athlete must pass all six stages under the supervision of the certified athletic trainer before being allowed to return to play.
 
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SIGNATURE AND AUTHORIZATION

By clicking SEND on this form, you authorize that you are the legal parent or guardian of the student named in this form and that you recognize that this is your legal and binding electronic signature and that any fraud or inaccuracy will void this student's eligibility.
 




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