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East Limestone High School 15641 East Limestone Rd Athens Al 35613 Star Sportsmanship Program Directions to take the test Step 1: Go to http://www.starsportsmanship.com/ Step 2: Click Student Sign In Step 3: Enter Star code, star00483 Step 4: Click "ok" for East Limestone Step 5: Select grade Step 6: Select name (If your name does not appear, then go to register) Step 7: Take all Sections. (YOU MUST COMPLETE ALL CHAPTERS) Step 8: Print certificate Step 9: Turn in certificate to Coach Tribble "Home of the Indians"
East Limestone High School 15641 East Limestone Rd Athens Al 35613 ATHLETIC INSURANCE FORM (2010-11) TO THE PARENTS OF:____________________________________ Grade: ____________ Please circle all sports of participation during the 2010-11 Athletic Season: Girls - Volleyball Cross Country Basketball Softball Soccer Golf Cheer Boys - Football Cross Country Basketball Baseball Soccer Golf It is necessary that each student trying out for a sport have a current physical exam on file and have appropriate medical insurance coverage. They must be listed on our school's eligibility list in the office of the Alabama High School Athletic Association prior to competition. The state office purchases for each person on this list a major catastrophic insurance policy which has a $10,000 deductible. At the local level the Limestone County Schools' Policy states that each squad member be covered by an adequate medical insurance policy before he/she is allowed to participate in scheduled games or practices. This gives each athlete's parents the option of using their family policy or purchasing an insurance policy through the school. PLEASE COMPLETE & RETURN TO COACH My family medical insurance coverage is adequate _________________________________________________________ Name of the Insurance Company _________________________________________________________ Policy Number I wish to purchase the accident policy offered by the Guarantee Trust Life Insurance Company. The policy provides coverage while participating in or attending activities organized, sponsored, and supervised by the school. Cost - $75.00 for all sports, excluding Football Cost -$130.00 for all sports, including Football In any event, I accept full responsibility, financially, and otherwise, for any injury my son/daughter may incur while participating in the athletic program of East Limestone High School. SIGNED:_______________________________________ DATE:___________________ Parent or Guardian This form expires on May 30 of the school year. "Home of the Indians"
East Limestone High School 15641 East Limestone Rd Athens Al 35613 Disclosure of Protected Health Information and Consent for Treatment I hereby authorize the athletic trainers, sports medicine staff and other health care personnel working with Encore Rehab to release information regarding the student-athlete's protected health information and related information regarding ant injury or illness during the student-athlete's training for and participation in athletics at that school. I further understand that it is at my request to comply with the requirements of his/her school official in connection with participation in interscholastic sports. This protected health information may concern the student-athlete's medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and related personally identifiable health information. This protected health information may be released to other health care providers, hospital and/or medical clinics and laboratories, athletic coaches, medical insurance coordinators, athletic and /or school administrators, chaplains and/or clergy members, officials of the Alabama High School Athletic Association and the Alabama Independent School Association. I, _______________________________, parent or guardian, of _________________________ (student's name) understand that as a parent/guardian give authorization/consent for the disclosure of the student-athlete's protected health information is a condition for participation as an interscholastic athlete at EAST LIMESTONE HIGH SCHOOL for the purpose of the undersigned student-athlete to participate in interscholastic sports. I understand that my protected health information is protected by the federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either parental/legal guardian authorization under HIPAA or consent under the Buckley Amendment. I the parental/legal guardian understand that once information is disclosed per authorization or consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment. I, the parent/legal guardian, understand that I may revoke this authorization/consent at any time by notifying in writing to the school's athletic director, but if I do, it will not have any effect on the actions the school officials took in reliance on this authorization/consent prior to receiving the revocation. I further have been given a copy of the Privacy Notice, which explains my rights under the HIPAA Act. This authorization/'consent expires one year from the date it is signed. I HEREBY AUTHORIZE THE ATHLETIC TRAINER AND SPORTS MEDICINE STAFF AT ENCORE REHAB TO ADMINISTER TREATMENT AND FIRST AIF PERTAINING TO SCHOOL SPORTING ACTIVITIES AS NESSARY, TO _______________________________________________________.(student's name) Required signature & return to coach ___________________________________ __________________________________ (print athlete's name) Parents/Guardian signature ___________________________ Date
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