ATHLETE INFORMATION FORM

ATHLETE INFORMATION FORM

(Complete name exactly as it appears on School ID)
Athlete Name*

First NameLast Name
Athlete Address*

Street Address

Apartment/Unit #

CityState / Province

Postal / Zip Code
Athlete's Cell Phone (or Primary Guardian #)*
Please enter a valid phone number.
Athlete's Email (Not School Email)
example@example.com
Graduation Year blanks.
Athlete's Shirt Size
Parent Name

First NameLast Name
Parent/Guardian Email #1*
example@example.com
Parent/Guardian Email #2
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone #1*
Please enter a valid phone number.
Emergency Contact Phone #2
Please enter a valid phone number.
Emergency Contact Email
Insurance Policy Company Name*
Insurance Policy Number*
Medical Conditions

Grant High School Water Polo Club Waiver

This waiver is for a Chartered Club Team that is affiliated with, but not sponsored by Grant High School/Portland Public School District.
As a parent(s) or legal guardian(s) of blanks* or as the student member of the Grant High School Water Polo Club, I/We, undersigned, hereby release and agree to defend and hold harmless School District No. 1, Multnomah County, Oregon (district), its officers, agents, employees and their assigns and the team, coaches and volunteer parents from any claims from any person, entity or estate, in any forum that may arise against them by reason of property loss or injury and/or death resulting from any cause including, but not limited to, the student or other students having failed to properly carry out instructions from the club leadership.
Date*
Signature of Parent/Guardian*

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Name of Parent/Guardian*

First NameLast Name
Athlete Signature*

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Athlete Name*

First NameLast Name
Photo Release
I, {parentName}, Parent/Guardian of {athleteName}, hereby authorize and consent to the use of his/her visual image by GHS Water Polo taken during team activities for appropriate purposes to support and promote Grant High School Water Polo, including but not limited to: still photography & videotape used in print publications and websites. I give this consent with no claim for payment. No images will ever be used for commercial purposes without the express and separate consent of the parent or guardian. I understand the images posted on the Grant High School Water Polo website or shared by other team members carry the same restrictions and will be shared in a sportsmanlike fashion.
Parent/Guardian Signature

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Athlete Signature

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I want/do not want the athlete's image used in any print publications or on the website or social media.

Acknowledgement of Concussion Guidelines and Materials

In accordance with Senate Bill 721 ("Jenna's Law"), new concussion training and procedural guidelines are now in effect for Oregon coaches, referees, players under the age of 18, and their parents or legal guardians. For each year of participation, and prior to a player under the age of 18 participating, at least one parent or legal guardian must acknowledge receipt and review of the guidelines and materials related to concussions as described in the law. If the player is age 12 or older, the player must also acknowledge receipt and review of the guidelines and materials. Please review and acknowledge receipt of the three CDC documents listed below and/or any other related materials by signing below. Together we can help ensure better outcomes for athletes who sustain concussions.
Parent Concussion Information Sheet

Fact Sheet for Athletes

Fact Sheet for Parents
Parent/Guardian

I have received and reviewed the guidelines and materials regarding the warning signs of a concussion. I agree that my child must be removed from a practice or a game if a concussion is suspected and that it is my responsibility to see medical treatment if a suspected concussion is reported to me. I understand that my child can not return to practice or play until providing written clearance from an appropriate health care provider to his/her coach or team manager and I understand the possible consequences of my child returning to practice/play too soon.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

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Date

MonthDayYear
Date
Relationship to Athlete
Preferred Contact Information
Player

I have received and reviewed the guidelines and materials regarding the warning signs of a concussion. I understand the importance of reporting suspected concussion to my coaches and to my Parents (or guardian) and that I must be removed from practice or a game if a concussion is suspected. I understand that I must provide written clearance from an appopriate health care provider to my coach or team manager before returning to practice or play and I understand the possible consequences of returning to practice/play too soon and that my brain needs time to heal.
Player Name

First NameLast Name
Player Signature

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Date

MonthDayYear
Date
Preferred Contact Information
Birth Year

Grant High School Water Polo Athlete Code of Conduct
Water Polo Club members are representatives of Grant High School community and shall conduct themselves in a positive and appropriate manner. All rules and procedures in the Code of Conduct shall be followed. A student who violates the Code of Conduct risks loss of eligibility for participation in practices and games.
Athletes agree and understand the following:

I will respect and show courtesy to my teammates, coaches and officials at all times.I will demonstrate good sportsmanship at all practices and tournaments.I will set a good example of behavior and work ethic for my younger teammates.I will show respect for all facilities and other property (including locker rooms) used during practices, tournaments, and team activities.I understand that my behavior and actions impact not only myself, but my teammates, the club and Grant High School.I understand that social media can have a powerful impact on the club. Positive and encouraging posts are welcome. Any posts, chats, messages, etc, that reflect negatively on the club or any of your teammates will not be tolerated.Violations will result in disciplinary action determined by the coach.
Drug, Alcohol, and Substance Use

The use or posession of drugs, alcohol, or tobacco, or any related paraphernalia, when participating in ANY club related activity or practice will not be tolerated.

Consequences for Drug, Alcohol and Substance use violations are specified below.

First Offense-Athlete may not attend any practice, team event or competition for five school days. A parental notification at the time of the violation is required and the parent will need to transport the athlete home from the event or activity.

Second Offense-Athlete may not attend any practice, team event or competition for ten school days. A parental notification at the time of the violation is required and a parent will need to transport the athlete home from the event or activity. In addition, the athlete must undergo an assessment for chemical dependency at the expense of the athlete's family before being allowed to rejoin club activities.

Third Offense-Athlete may not attend any practice, team event or competition for the remainder of the water polo season. A parental notification at the time of the violation is required and a parent will need to transport the athlete home from the event or activity. In addition, the athlete must undergo an assessment for chemical dependency at the expense of the athlete's family before being allowed to rejoin club activities the following year.
Student Signature

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Date

MonthDayYear
Date
Parent/Guardian Signature

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Date

MonthDayYear
Date
Should be Empty:

ATHLETE INFORMATION FORM

Emergency Contact Information

Grant High School Water Polo Club Waiver

Photo Release

Acknowledgement of Concussion Guidelines and Materials

Grant High School Water Polo Athlete Code of Conduct