Student Athlete Forms

LeFlore Public Schools Student Athlete Forms
Name of School
Concussion and Head Injury Acknowledgement
In compliance with Oklahoma Statute Section 24-155 of Title 70, this acknowledgement form is to confirm that you have read and understand the CONCUSSION FACT SHEET related to potential provided to you by concussions and head injuries occurring during participation in athletics.
STUDENT ATHLETE'S NAME
NAME OF SCHOOL
PARENT/LEGAL GURADIANS NAME
NAME OF SCHOOL
SIGNATURE OF STUDENTATHLETE

Clear
DATE

MonthDayYear
Date
SIGNATURE OF PARENTLEGAL GUARDIAN

Clear
DATE

MonthDayYear
Date
Sudden Cardiac Arrest Acknowledgement Statement
I have received and read the Sudden Cardiac Arrest Information Sheet for Student Athletes and Parents/Guardians. I understand the warning signs and seriousness of sudden cardiac arrest (SCA) related to participation in athletic programs and the need for immediate evaluation for any suspected condition.
Signature of StudentAthlete

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Print Student Athletes Name
Date

MonthDayYear
Date
Signature of ParentGuardian

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Print ParentGuardians Name
Date

MonthDayYear
Date
BIOLOGICAL SEX AT BIRTH AFFIDAVIT FOR STUDENTS UNDER THE AGE OF 18
In accordance with 70 Okla. Stat. §27-106, prior to the beginning of each school year the parent or legal guardian of a student under the age of 18 competing on a school athletic team is required to sign an affidavit acknowledging the biological sex of the student at birth. By signing this affidavit the parent or legal guardian is affirming the biological sex of the child at birth in compliance with State Statute. If the student is 18 years of age or older, the student who competes on a school athletic team shall sign an affidavit acknowledging his or her biological sex at birth.
COUNTY OF
Parent or Gaurdian
Student
Name of School
Sex
Date

MonthDayYear
Date
Signature

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STUDENT DRUG TESTING PROGRAM POLICY FOR EXTRACURRICULAR ACTIVITIES CONSENT AND RELEASE DOCUMENT
Name of Student
I, __________ understand that I am required to give a sample of my urine and/or saliva and/or breath to be tested in accordance with the LeFlore Public School, "Student Drug Testing Program Policy for Extracurricular Activities". The purpose of these tests is to determine if there are any drugs, alcohol, or other prohibited chemicals in my body. The urine analysis will be done by an approved kit from Bio Tech "RediScreen." Furthermore, should the approved test kit indicate a positive result for any drug of abuse, another, separate test shall be conducted. Should the second kit test indicate a positive for the same drug of abuse, the sample will be packaged and sent to a SAMSHA approved laboratory for testing. I agree to provide a sample of my urine, saliva and/or breath as requested. I also agree that the results of these test(s), and the procedures that follow may be released to LeFlore Schools, or any of its agents. By signing this paper, I understand that I give my Permission to collect the sample(s) talked about above and to the release of these results of the test(s) to the LeFlore Public School, under the Student Drug Testing Program Policy for Extracurricular Activities and also acknowledge that I have received a copy of the Student Drug Testing Program Policy for Extracurricular Activities.
Signature of student

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Date

MonthDayYear
Date
Signature of Parent or Legal Guardian

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Date

MonthDayYear
Date
Leflore Public School Medical Information Form for Extracurricular Activities
Student Name
Grade
Date of Birth

MonthDayYear
Date
Address
State
Zip Code
Parent Name
Allergies or Health Concerns
Emergency Contact 1
Phone Number
Relationship to Student
Emergency Contact 2
Phone Number
Relationship to Student
Primary Physician
Insurance Provider
CDIB Card
Parent Signature

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Date

MonthDayYear
Date
Student Signature

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Date

MonthDayYear
Date
*By signing above I am voluntarily releasing the student's information provided in case of an emergency and I consent to allow school personnel to utilize the above information and take necessary actions in case of an emergency.*
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LeFlore Public Schools Student Athlete Forms

BIOLOGICAL SEX AT BIRTH AFFIDAVIT FOR STUDENTS UNDER THE AGE OF 18