Pomolita Middle SchoolUkiah Unified School District

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Student’s Name






ID #



I have read and understand the following documents that are available on the Pomolita website https://pomolita.uusd.net/















Health Examination and Parent Consent










CIF Code of Conduct










UUSD Extra-Curricular Rules & Regs / Student Contract










Acknowledgement/Assumption of Potential Risk










NCS Ejection Policy



Signature of Parent














Signature of Athlete













1. There were no history or physical findings on this exam which would prohibit this


student from participating in competitive athletics.




2. This student should have the following health problems evaluated or treated prior to


participating in competitive athletics.




3. This student has health problems which would prohibit him or her from participating in


competitive athletics.






Are there apparent cavities in teeth?










Is there a bridge or false teeth?           







Has the above had any injury or physical condition that should be watched?


If yes, please list



I hereby certify that


was examined by me on





and found physically fit to participate in sports in the school year 2023 – 2024.



Physician’s Signature






Please Print Name










Students taking part in the school athletic program must be fully insured against injury and death. You must have insurance covering sports including contact football, for your child. If you do not have insurance, you may obtain it through your own agent or purchase (student) insurance available to all students.  See the Athletic Director for information.











  1. Ten (10 days written notice to the Principal of Pomolita Middle School, Ukiah Unified School District, 740 N Spring St, Ukiah, California) must be given prior to cancellation.
  1. Deductible insurance does not fulfill the legal requirements for participation.

I will maintain this coverage during the current school year or will immediately notify the school if the coverage terminates or does not meet the stated requirements.




FOR YOUR INFORMATION: Tattoos Predict Hepatitis C Risk (from The Physician and Sportsmedicine).

Tattooing appears to be a major route of hepatitis C infection and is perhaps the biggest contributor to the spread of the disease – even bigger than injection-drug use, according to a study in the March issue of Medicine.

Researchers from the University of Texas Southwestern Medical School in Dallas surveyed and tested 626 patients who sought treatment at an orthopedic spinal clinic. Patients were surveyed and tested in 1991 and

1992, before widespread hepatitis C testing began. Of the 113 patients who had a tattoo, 25 (22%) were infected with hepatitis C. (Of the 513 patients who did not have tattoos, 18 (3.5%) were infected.) Few of the tattoo-associated infections could be traced to injection-drug use, transfusions, or other known exposure sources.

The authors found that the hepatitis C risk was increased in people who had several tattoos or had ones that were large and complex. Tattoos acquired in commercial tattoo parlors were also associated with a higher risk of infection. Hepatitis C and other infectious diseases can be spread by reuse of needles or dye and by inadequate sterilization technique. The authors write that few states have laws addressing safe tattooing practices, and even fewer monitor and enforce the standards.

Nearly 4 million Americans have chronic hepatitis C infection, and an estimated 10,000 deaths occur each year from hepatitis-C related cirrhosis and liver cancer.



Pomolita Middle School

Concussion Information Sheet


A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works.

Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly.  In other words, even a “ding” or a bump on the head can be serious.  You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.



Symptoms may include one or more of the following:

•     Headaches

•     “Pressure in head”

•     Nausea or vomiting

•     Neck pain

•     Balance problems or dizziness

•     Blurred, double, or fuzzy vision

•     Sensitivity to light or noise

•     Feeling sluggish or slowed down

•     Feeling foggy or groggy

•     Drowsiness

•     Change in sleep patterns

•     Amnesia

•     “Don’t feel right”

•     Fatigue or low energy

•     Sadness

•     Nervousness or anxiety

•     Irritability

•     More emotional

•     Confusion

•     Concentration or memory problems

(forgetting game plays)

•     Repeating the same question/comment




Signs observed by teammates, parents and coaches include:

•     Appears dazed

•     Vacant facial expression

•     Confused about assignment

•     Forgets plays

•     Is unsure of game, score, or opponent

•     Moves clumsily or displays incoordination

•     Answers questions slowly

•     Slurred speech

•     Shows behavior or personality changes

•     Can’t recall events prior to hit

•     Can’t recall events after hit

•     Seizures or convulsions

•     Any change in typical behavior or personality

•     Loses consciousness




Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 5/20/2010


Pomolita Middle School

Concussion Information Sheet


What can happen if my child keeps on playing with a concussion or returns to soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences.  It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.


If you think your child has suffered a concussion


Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately.  No  athlete  may  return  to  activity  after  an  apparent  head  injury  or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new CIF Bylaw 313 now requires implementation of long and well-established return to play concussion guidelines that have been recommended for several years:


“A student-athlete  who  is  suspected  of  sustaining  a  concussion  or  head  injury  in  a practice or game shall be removed from competition at that time and for the remainder of the day.”




“A student-athlete who has been removed may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion  and  received  written  clearance  to  return  to  play  from  that  health  care provider”.


You should also inform your child’s coach if you think that your child may have a concussion. Remember it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out.


For current and up-to-date information on concussions you can go to:









Student-athlete Name Printed


Student-athlete Signature













Parent or Legal Guardian Printed


Parent or Legal Guardian Signature





Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 5/20/2010


To be completed by student and parents prior to examination






Last Name, First Name


Middle School





Sex:  Male





Student No.









Has this student had any:





Does this Student:




Chronic or recurrent illness?





Wear eyeglasses?




Illness lasting over one week?





Wear dental bridges, braces, plates?









Take any medication?




Surgery other than tonsillectomy?









Missing organ (eye, kidney, testicle)?





Is there any history of:




Allergy to any medication?









Problems with heart or blood





Injuries requiring MD treatment?









Neck injury?




Chest pain with exercise?





Knee injury?




Dizziness or fainting with exercise?





Knee surgery?




Concussion or unconsciousness?





Ankle injury?




Heat exhaustion, heat stroke?





Other serious joint injury?




Cortisone taken in last year?





Broken bones (fractures)?




Health concerns/questions you





Any reason why this student should




wish to discuss with an MD?





not participate in sports?




Anyone tell you not to participate





Has any family member died




in a sport?





suddenly  younger than 40 years old




Habits that might affect your





of causes other than an accident?




athletic performance?








Date of last known Tetanus (lockjaw) shot:



Use this space to explain any of the above numbered YES answers or to provide additional information:




I have read the General Information Bulletin of the C.I.F.P.F. and agree to the provisions contained therein.  I hereby give my consent for the above named (son, daughter, or ward) to compete in sports and go with a representative of the school on any athletic trips.  In case this pupil is injured, you are authorized to have him treated.



I hereby give my consent for the above named student to represent his or her school in the athletic activities except those indicated on this form by the examining physician provided that such athletic activities are approved by the State Association.  I also give my consent for the student to accompany the school team on any of its local or out-of-town trips.

The Ukiah School Board of Education has no responsibility to provide first aid at any of the games and parents understand that risk of injury is assumed by student and parents when they are executing this form.  However, in the even physicians, physical therapists, physician’s assistants, nurses or other persons trained in the rendering of the first aid are available as volunteers or otherwise, and render aid to any student injured during the course of any such activities or travel, the parents do hereby release and forever discharge such persons and the Ukiah School Board of Education from any liability arising out of any first aid or treatment of injuries.















w/o glasses









with glasses


















w/o glasses









with glasses









Ears / Nose / Throat


Mouth / Teeth


Neck (Soft Tissue)




Chest / Lungs




Genitalia – Hernia Sexual Maturity


Skin and Lymphatics








Arms and Hands















Based on this history and physical exam, the following abnormalities were found and may need treatment:












CIF – Pomolita Middle School

Code of Conduct for Interscholastic Student-Athletes


Interscholastic athletic competition should demonstrate high standards of ethics and sportsmanship and promote the development of good character and other important life skills. The highest potential of sports is achieved when participants are committed to pursuing victory with honor according to six core principles: trustworthiness, respect, responsibility, fairness, caring, and good citizenship (the “Six Pillars of Character”). This Code applies to all student- athletes involved in interscholastic sports in California. I understand that, in order to participate in high school athletics, I must act in accord with the following:



Trustworthiness – be worthy of trust in all I do.

Integrity – live up to high ideals of ethics and sportsmanship and always pursue victory with honor; do what’s right even when it’s unpopular or personally costly.

Honesty – live and compete honorably; don’t lie, cheat, steal or engage in any other dishonest or unsportsmanlike conduct.

Reliability – fulfill commitments; do what I say I will do; be on time to practices and games.

Loyalty – be loyal to my school and team; put the team above personal glory.



Importance of Education – be a student first and commit to getting the best education I can. Be honest with myself about the likelihood of getting an athletic scholarship or playing on a professional level and remember that many universities will not recruit student-athletes that do not have a serious commitment to their education, the ability to succeed academically or the character to represent their institution honorably.

Role Modeling – Remember, participation in sports is a privilege, not a right and that I am expected to represent my school, coach and teammates with honor, on and off the field. Consistently exhibit good character and conduct yourself as a positive role model. Suspension or termination of the participation privilege is within the sole discretion of the school administration.

Self-Control – exercise self-control; don’t fight or show excessive displays of anger or frustration; have the strength to overcome the temptation to retaliate.

Healthy Lifestyle – safeguard your health; don’t use any illegal or unhealthy substances including alcohol, tobacco and drugs or engage in any unhealthy techniques to gain, lose or maintain weight.

Integrity of the Game – protect the integrity of the game; don’t gamble. Play the game according to the rules.



Be Fair – live up to high standards of fair play; be open-minded; always be willing to listen and learn.



Concern for Others – demonstrate concern for others; never intentionally injure any player or engage in reckless behavior that might cause injury to myself or others.

Teammates – help promote the wellbeing of teammates by positive counseling and encouragement or by reporting any unhealthy or dangerous conduct to coaches.



Play by the Rules – maintain a thorough knowledge of and abide by all applicable game and competition rules.

Spirit of Rules – honor the spirit and the letter of rules; avoid temptations to gain competitive advantage through improper gamesmanship techniques that violate the highest traditions of sportsmanship.

I have read and understand the requirements of this Code of Conduct. I understand that I’m expected to perform according to this code and I understand that there may be sanctions or penalties if I do not.











I authorize my son/daughter to participate in the District-sponsored activities.

I understand and acknowledge that these activities, by their very nature, pose the potential risk of serious injury/illness to individuals who participate in such activities.

I understand and acknowledge that some of the injuries/illnesses, which may result from participating in these activities, include, but are not limited to the following:

  1. Sprains / Strains
  2. Fractured bones
  3. Unconsciousness
  4. Head and/or back injuries
  5. Paralysis
  6. Loss of eyesight
  7. Communicable diseases
  8. Death

I understand and acknowledge that participation in these activities is completely voluntary and as such is not required by the District for course credit or for completion of graduation requirements.

I understand and acknowledge that in order to participate in these activities, my son/daughter and I agree to assume liability and responsibility for any and all potential risks, which may be associated with participation in these activities.

I understand, acknowledge and agree that the District, its employees, officers, agent, or volunteers shall not be liable for any injury/illness suffered by my son/daughter which is incident to and/or associated with preparing for and/or participating in this activity.

I acknowledge that I have carefully read this PARTICIPATION AGREEMENT FOR CIF VOLUNTARY ACTIVITIES and that I understand and agree to its terms.



Ukiah Unified Schools


Students who participate in extra-curricular activities serve in the capacity of role models, ambassadors of good will, and assume a posture of high expectations as representatives of Ukiah High School, Pomolita Middle School, or Eagle Peak Middle School.

Students who participate in extra-curricular activities are representatives of Ukiah High School, Pomolita Middle School, or Eagle Peak Middle School and are subject to the rules and  regulations outlined below.   Participation in extra-curricular activities is a privilege given to students, not a right of students.  Extra-curricular activities are defined as athletics, after- school band, after-school drama, and other activities in which the student represents the school.  Violation of the rules and regulations outlined below will result in exclusions from such activities as specified:


31.1. Students are expected to perform well in the classroom, attend class regularly and comply with all school policies and regulations.


31.2. Good citizenship, defined generally as behavior expected of a student who is also a representative of Ukiah Unified School District, Pomolita Middle School, or Eagle Peak Middle School, must be practiced at all times even when not under the direct supervision of school authorities. Anyone involved in acts detrimental to the best interests of the school or activity group will be excluded from the activity for times specified (first offense, four weeks; second offense, sixteen weeks; third offense, the entire year).


31.3. Students who participate in extra-curricular activities as defined may not be involved in possession and/or using drugs or alcohol during the school term which is defined as during school hours, after school hours, weekends, or vacations during the school term (including Christmas, Easter vacations, and other holidays).


31.4 Students suspended or iced for being under the influence of drugs or alcohol will be excluded from extracurricular activities for four weeks of competition which may span two (2) seasons; a second offense will result in exclusion for the remainder of the semester or 45 days, whichever is greater. Any exclusion will also include the student being enrolled in a prevention program, including attendance at substance abuse classes and/or participation in a peer-counseling program, when appropriate.

Note: Students expelled for sales, possession, or use of drugs or alcohol, whose expulsion is suspended, will be excluded by the Board of Education from all extracurricular activities for the entire term of their suspended expulsion.


31.5. Students placed on a behavior contract for first time possession of marijuana and/or alcohol will be suspended from extra-curricular activities for the remainder of the present season and the term of the contract. School administration may develop criteria which allows participation in the following sports season (fall, winter, spring) if student(s) successfully meets criteria delineated in the behavioral contract, including completion of increased community service hours and substance abuse counseling.


31.6. Use of either smoking or chewing tobacco will result in exclusion from extra-curricular activities for a period of one week; a second offense will result in an eight-week exclusion; a third offense will result in elimination from extra- curricular activities for the remainder of the school term.


31.7. If a coach determines that a player has been involved in a gratuitous act of violence during or after a game or if a player is red-carded or ejected from a game, the coach must report the incident to the principal. The player involved will be removed from the next game. If that student is involved in a second act or if the coach thinks that the initial act was extreme, the student will be removed from that sport for the remainder of the season.   No rewards or recognition will be given that player for the season.


31.8. All school rules are in effect during travel to and from as well as during extra-curricular activities.


31.9. Please note that eighteen-year old students or older are obligated to follow the listed rules and regulations applicable to participation in extra-curricular activities.


31.10. A student who is suspended from school is also suspended from all extra-curricular activities during the period of suspension.


31.11. All students must travel to and from activities in school-provided transportation. (EXCEPTION: With prior arrangement, a  student may  return from  an  out-of-town  activity  with  his/her parent/guardian,  providing  the parent/guardian makes such a request in person to the coach while at the out-of-town site.


Additional rules:


31.12. In accordance with District Board Policy 610.2(d) and 610.4 participation in an extracurricular activity includes "preparation for performance".  This means that students are expected to participate in events or activities which support or promote the extracurricular activity.   Preparatory activities provide important educational and social training and are considered integral to the extracurricular experience.   These activities may include:   planning, developing or advertising the program; organizing performances or transportation; assisting with fundraising; and creating or obtaining costumes, equipment, uniforms or other props.


(a) Students who participate in an extracurricular activity must contribute to all facets of the activity including preparation.   Certificated staff supervising the extracurricular activity are responsible for equitably allocating preparation duties and assignments for students.

(b) Certificated staff supervising an extracurricular activity may establish to the preparatory stages of an activity. However, a student may not be denied participation in an extracurricular activity solely on the basis of failing to meet an individual target, standard, or goal, if the student can show he/she has put forth the expected effort is provided by sponsors and other participants to assist each student.

31.13. When a student makes a commitment to participate within a given activity, he/she has made this commitment for the entire season of the activity. A great deal of time, planning and effort is provided by sponsors and other participants to assist each student.
31.14. A student must be in attendance at all practices unless he/she is excused by the activity sponsor prior to the practice by a telephone message or previous arrangement. In case of illness, please have your parent telephone the activity sponsor and indicate the participant will not be at practice on that particular day.
31.15. If practices are to be meaningful, instructional and well planned, it is essential that each participant be on time and in attendance at each practice. Tardiness and absenteeism cause delays in practice and will result in exclusion from the following event and/or dismissal from the activity.
31.16. Since activities entail  a  great  deal  of  time  involving practicing  with  specific  personnel,  and  since  detailed preparation is given to each event, a student who misses an event for an unexcused reason may be dismissed from the activity.
31.17. A student may not participate in another activity if either he/she quits or is dropped from an activity, for cause, until that activity is completed.
31.18. Any student who is officially dropped from or quits an activity, forfeits his/her right for any award.
31.19. A student must be in attendance all day on event days and practice days. Waivers may be given for unusual causes by principal or designee.
31.20. All participants are responsible for uniforms and equipment issued to them. Uniforms are not to be worn for any purpose other than scheduled events. Students will be billed for lost or damaged uniforms or equipment.
31.21. Continued or persistent violation of any of these procedures will result in disciplinary action, including conferences with parents, suspension, and/or dismissal from an activity.
31.22. All activity sponsors shall have the final authority for setting criteria for selection, participation, and activity rules other than listed. A written copy of these rules will be given to each participant.
31.23. When one or more players leave the bench to begin or to participate in an altercation, the player(s) will be ejected from that game and will become ineligible for the next contest.






The following rules and minimum penalties are applicable to players (and coaches as adopted by the NCS Board of Managers on April 21, 1995, in accordance with national Federation Rules).  This policy was in effect at the beginning of the 1995-96 school year (and will include non-league, league, invitational tournaments/events, post-season; league, section or state playoffs, etc.)


  1. Ejection of a player from a contest for unsportsmanlike or dangerous conduct. Penalty:  The player shall be ineligible for the next contest (non-league, league, invitational tournament/event, post season play whether it is league, section or state).
  2. Illegal participation in the next contest by a player ejected in a previous contest. Penalty:  The contest shall be forfeited and the player shall be ineligible for the next contest.
  3. Second ejection of a player for unsportsmanlike or dangerous conduct from a contest during one season. Penalty:  The player shall be ineligible for the remainder of the season.
  4. When one or more players leave the bench (or dugout, etc.) to begin or participate in an altercation. Penalty:  The player(s) shall be ejected from the contest-in-question and become ineligible for the next contest, non-league, league, invitational tournament/event, post-season play including league, section, state playoffs (matches/events).


I have read and understand the rules and regulations of the Ejection Policy.  Athletes may not participate in any contest until this document is acknowledged.