Download INSTRUCTIONS: - Diamond Bar High School

■■■ Sports Physical Packet
DIAMOND BAR HIGH SCHOOL
Dear Athletes and Parents/Guardians, Thank you for your interest in participating in athletics here at Diamond Bar High School. We hope that your experience is both educational, beneficial, and rewarding—physically, mentally, and socially. In order to begin participation, all athletes must complete the following packet in its entirety on a yearly basis, with all necessary information and signatures. Athletes will not be allowed to practice, condition, weightlift, or compete in any amount until all of the requirements are fulfilled. Below is a checklist of items that must be turned in to the Athletics Office (room 513) 48 hours prior to the first scheduled practice, conditioning session, or competition. Forms to turn in: 
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Athlete Demographic form Medical History Form Physician Clearance Form Physical Exam Form Signature Page A copy of the athlete’s medical insurance card We look forward to your child having an outstanding experience while participating in athletics. Sincerely, DBHS Athletics INSTRUCTIONS:
1. Please complete all pages in blue or black ink, leave no blank spaces, and sign all pages as
necessary!
2. All pages should be filled out prior to seeing a physician.
3.
Per CIF bylaw 503 the Physical Exam and Physician’s Clearance are only valid if
completed by a licensed healthcare practitioner, defined as a medical doctor or doctor of
osteopathy (MD or DO only). No other healthcare practitioner may clear an athlete for
participation.
ATHLETE DEMOGRAPHIC FORM
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PLEASE PRINT CLEARLY STUDENT INFORMATION LAST SCHOOL ID # ADDRESS FIRST HOME PHONE ( INSURANCE COMPANY DOB / / MIDDLE/ENGLISH AGE ) STUDENT EMAIL POLICY # GRADE 9 10 11 12 ZIP CODE **A COPY THE STUDENT’S MEDICAL INSURANCE CARD IS REQUIRED** PARENT/GUARDIAN #1 INFORMATION PARENT/GUARDIAN #2 INFORMATION NAME NAME CELL PHONE ( ) CELL PHONE ( ) OTHER PHONE ( ) OTHER PHONE ( ) EMAIL EMAIL 3RD PARTY EMERGENCY CONTACT INFORMATION (DIFFERENT FROM PARENT/GUARDIAN INFORMATION)
NAME RELATIONSHIP CELL PHONE ( ) OTHER PHONE ( ) CIF ELIGIBILITY STATUS Falsification of any portion of this document may result in forfeiture of individual and team eligibility and loss of record. All items must be completed before application will be accepted for consideration. New Transfer student: Yes  No  Date of Transfer / / School(s) attended Sport(s) & Level Played Year 9th Grade 10th Grade 11th Grade 12th Grade I reside with:  Both Parents  My Father  Myself (age 18)  Court Appointed Guardian  My Mother  Relative  A Friend  Other My Residence is within the school’s attendance boundaries: Yes  No  If no, please explain MEDICAL HISTORY FORM
■■■ Sports Physical Packet
PLEASE COMPLETE PRIOR TO SEEING THE PHYSICIAN. LAST FIRST MIDDLE/ENGLISH MEDICATION TAKING: LIST ALL PRESCRIPTION & OVER‐THE‐COUNTER MEDICINES & SUPPLEMENTS (HERBAL & NUTRITIONAL) CURRENTLY TAKING DO YOU HAVE ANY ALLERGIES?  YES  NO IF YES, PLEASE IDENTIFY SPECIFIC ALLERGY BELOW.  MEDICINES  POLLENS  FOOD  INSECTS ***EXPLAIN “YES” ANSWERS BELOW. CIRCLE QUESTION #s YOU DON’T KNOW THE ANSWERS TO.*** YES NO GENERAL QUESTIONS 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have any ongoing medical conditions? If so, please identify below:  Asthma  Anemia  Diabetes  Infections  Other:__________________ 3. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU 4. Have you ever passed out or nearly passed out DURING or AFTER exercise? 5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 6. Does your heart ever race or skip beats (irregular beats) during exercise? YES NO 7. Has a doctor ever told you that you have any heart problems? If so, check all that apply:  High blood pressure  High cholesterol  A heart murmur  A heart infection  Kawasaki disease  Other:__________ 8. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) 9. Do you get lightheaded or feel more short of breath than expected during exercise? 10. Have you ever had an unexplained seizure? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY 11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)? 12. Does anyone in your family have HCM, Marfan syndrome, ARV, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? 13. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 14. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? BONE AND JOINT QUESTIONS 15. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? Circle area below: 16. Have you ever had any broken or fractured bones or dislocated joints? Circle area below: 17. Have you ever had an injury that required x‐rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? Circle area below: 18. Have you ever had a stress fracture? Circle area below: 19. Do you regularly use a brace, orthotics, or other device? 20. Do you have a bone, muscle, or joint injury that bothers you? Circle area below: 21. Do any of your joints become painful, swollen, feel warm, or look red? Circle area below: 22. Any history of juvenile arthritis or connective tissue disorder? Circle area below: Head Neck Shoulder Upper Arm Upper Back Lower Back Hip Thigh Elbow Knee YES NO MEDICAL QUESTIONS 23. Do you cough, wheeze, or have difficulty breathing during or after exercise? 24. Have you ever used an inhaler or taken asthma medicine on a regular basis? 25. Is there anyone in your family who has asthma? 26. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? 27. Do you have groin pain or a painful bulge or hernia in the groin area? 28. Have you had infectious mononucleosis (mono) within the last month? 29. Do you have any rashes, pressure sores, or other skin problems? 30. Have you had a herpes or MRSA skin infection? 31. Have you ever had a head injury or concussion? 32. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? 33. Do you have a history of seizure disorder? 34. Do you have headaches with exercise? 35. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? 36. Have you ever been unable to move your arms or legs after being hit or falling? 37. Have you ever become ill while exercising in the heat? 38. Do you get frequent muscle cramps when exercising? 39. Do you or someone in your family have sickle cell trait or disease? 40. Have you had any problems with your eyes or vision? 41. Have you had any eye injuries? 42. Do you wear glasses or contact lenses? 43. Do you worry about your weight? 44. Are you trying to or has anyone recommended that you gain or lose weight? 45. Are you on a special diet or do you avoid certain types of foods? 46. Have you ever had an eating disorder? 47. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY 48. Have you ever had a menstrual period? 49. How old were you when you had your first menstrual period? 50. How many periods have you had in the last 12 months? EXPLAIN “YES” ANSWERS HERE:
Forearm Hand/ Fingers Chest Calf/Shin Ankle Foot/ Toes YES NO YES NO PHYSICIAN CLEARANCE FORM
■■■ Sports Physical Packet
LAST SCHOOL ID # FIRST INSURANCE COMPANY: DOB / / POLICY #: MIDDLE/ENGLISH AGE GRADE 9 10 11 12 TO BE COMPLETED BY PHYSICIAN (MD, DO, ONLY) PER CIF BYLAW 503 ATHLETE PARTICIPATION STATUS (CHECK ONE):  CLEARED FOR ALL SPORTS WITHOUT RESTRICTION  CLEARED FOR ALL SPORTS WITHOUT RESTRICTION WITH RECOMMENDATIONS FOR FURTHER EVALUATION OR TREATMENT FOR:  CLEARED FOR SPORT WITH RESTRICTION  NOT CLEARED  PENDING FURTHER EVALUATION  FOR ANY SPORTS  FOR CERTAIN SPORTS REASON: RECOMMENDATIONS: I HAVE EXAMINED THE ABOVE‐NAMED STUDENT‐ATHLETE. THE ATHLETE DOES NOT PRESENT APPARENT CLINICAL CONTRAINDICATIONS TO PRACTICE AND MAY PARTICIPATE IN THE SPORT(S) AS OUTLINED ABOVE. A COPY OF THE EXAM IS ON RECORD IN MY OFFICE AND CAN BE MADE AVAILABLE TO THE SCHOOL AT THE REQUEST OF THE STUDENT‐
ATHLETE. IF CONDITIONS ARISE AFTER THE ATHLETE HAS BEEN CLEARED FOR PARTICIPATION, THE PHYSICIAN MAY RESCIND THE CLEARANCE UNTIL THE PROBLEM IS RESOLVED AND THE POTENTIAL CONSEQUENCES ARE COMPLETELY EXPLAINED TO THE ATHLETE (AND PARENTS/GUARDIANS). NAME OF PHYSICIAN (PRINT) SIGNATURE OF PHYSICIAN MD/DO LICENSE # DATE / / PLACE PHYSICIAN’S STAMP HERE
PHYSICAL EXAM FORM
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LAST FIRST SCHOOL ID # MIDDLE/ENGLISH DOB / / AGE GRADE 9 10 11 12 PHYSICIAN REMINDERS 1. Consider additional questions on more sensitive issues • Do you feel stressed out or under a lot of pressure? • Do you ever feel sad, hopeless, depressed, or anxious? • Do you feel safe at your home or residence? • Have you ever tried cigarettes, chewing tobacco, snuff, or dip? • During the past 30 days, did you use chewing tobacco, snuff, or dip? • Do you drink alcohol or use any other drugs? • Have you ever taken anabolic steroids or used any other performance enhancing supplement? • Have you ever taken any supplements to help you gain or lose weight or improve your performance? • Do you wear a seat belt, use a helmet, and use condoms? 2. Consider reviewing questions on cardiovascular symptoms (questions 5–14). EXAMINATION Height Weight __ Male __ Female BP / Pulse Vision R 20/ L 20/ Corrected __ Y __ N MEDICAL NORMAL ABNORMAL FINDINGS Appearance • Marfan stigmata (kyphoscoliosis, high‐arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat • Pupils equal • Hearing Lymph nodes a
Heart • Murmurs (auscultation standing, supine, +/‐ Valsalva) • Location of point of maximal impulse (PMI) Pulses • Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only)b Skin • HSV, lesions suggestive of MRSA, tinea corporis Neurologicc MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional • Duck‐walk, single leg hop SIGNATURE OF PHYSICIAN aConsider
MD/DO DATE OF EXAM / ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
GU exam if in private setting. Having third party present is recommended.
cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
bConsider
/ SIGNATURE PAGE
■■■ Sports Physical Packet
_______ Parent/Guardian Initials PROOF OF INSURANCE COVERAGE State laws and CIF by‐laws require that in order to be eligible to participate in any athletic activity, the student must be insured as per the following guideline: 1. At least a $1,500 insurance protection for medical and hospital expenses in case of accident or injury. 2. Large deductible insurance in excess of $100 deductible does not fulfill the legal requirement for participation. 3. The principal to be notified immediately in case of cancellation. I certify that my son/daughter is covered by valid insurance which meets or exceeds the above requirements to compete in any sport/activity. I will maintain this coverage during the current school year or will immediately notify the school if the coverage is altered or terminated. **A COPY THE STUDENT’S MEDICAL INSURANCE CARD IS REQUIRED** _______ Parent/Guardian Initials CONSENT TO TREAT In the event that my son/daughter requires emergency attention, I hereby authorize the athletic trainer, doctor in attendance, or the supervising school official to obtain or render any necessary aid. _______ _______ MEDICAL HISTORY FORM Parent/Guardian Initials Student Initials _______ _______ WVUSD WAIVER & RELEASE Parent/Guardian Initials Student Initials _______ _______ BRAHMA CODE OF CONDUCT Parent/Guardian Initials Student Initials _______ _______ POLICY & AGREEMENT ON STEROIDS Parent/Guardian Initials Student Initials _______ _______ CONCUSSION INFORMATION SHEET Parent/Guardian Initials Student Initials _______ _______ CIF CODE OF ETHICS Parent/Guardian Initials Student Initials _______ _______ CIF SUDDEN CARDIAC ARREST FORM Parent/Guardian Initials Student Initials I hereby state that, to the best of my knowledge, my answers to the questions on the Medical History Form are complete and correct. I hereby acknowledge that I have received the WVUSD Waiver & Release – Parent from my school and I have read and understand its contents. I hereby acknowledge that I have received the Brahma Code of Conduct and I have read and understand its contents. I hereby acknowledge that I have received the Policy & Agreement on Steroids and I have read and understand its contents. I hereby acknowledge that I have received the Concussion Information Sheet and I have read and understand its contents. I also acknowledge that if I have any questions regarding these signs, symptoms and the “Return to Learn” and “Return to Play” protocols I will consult with my physician. I hereby acknowledge that I have received the CIF Code of Conduct and I have read and understand its contents. I hereby acknowledge that I have received the CIF Sudden Cardiac Arrest Form and I have read and understand its contents. STUDENT SIGNATURE
PARENT/GUARDIAN SIGNATURE
STUDENT NAME
PARENT/GUARDIAN NAME
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DATE
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WVUSD WAIVER & RELEASE
I, _______________________________, am parent/guardian of___________________________________.
I am aware that trying out, practicing, or any other form of participation in any sport can be a dangerous activity
involving MANY RJSKS OF INJURY.I understand that the risks of engaging in the sport of ________________
include, but are not limited to, death, serious neck and spinal injuries which may result in complete or partial
paralysis, brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other
aspects of the musculoskeletal system and serious injury or impairment to other aspects of the body, health and
well-being.
I also understand that the dangers and risks of engaging in the above sport may result not only in serious injury,
but in a serious impairment of the future abilities of my child/ward to earn a living, and to engage in business,
social and recreational activities and generally to enjoy life.
Because of the risks described above, I recognize the importance of my child/ward listening to and following all
of the coach's instructions and warnings regarding playing techniques, training methods, rules of the sport and
other team rules. I also recognize the importance of my child/ward reading and adhering to all written instructions
and written warnings regarding playing techniques, training methods, rules of the sport and other team rules. I
therefore expressly agree to direct and to encourage my child/ward to obey all of the coach's instructions and
warnings.
In consideration of the Walnut Valley Unified School District permitting _______________________________
to try out, practice, play, or in any other way participate for the Diamond Bar High School _________________
team, and to engage in all activities related to the team, including practicing, conditioning, playing, and traveling,
– I HEREBY ACKNOWLEDGE THAT MY CHILD/WARD ASSUMES ALL THE RISKS ASSOCIATED WITH
SUCH PARTICIPATION, I EXPRESSLY CONSENT TO SUCH PARTICIPATION BY MY CHILD/WARD AND I
AGREE TO WAIVE ALL CLAIMS OF WHATEVER NATURE, fully and finally, now and forever, for my
child/ward, for myself, my estate, my heirs, my administrators, my executors, my assignees, my successors, and
for all members of my family, and to release, exonerate, discharge and hold harmless the Walnut Valley Unified
School District, school, Trustees, officers, agents, servants, employees, successors and assigns, their athletic
staffs, all coaches, assistant coaches, athletic trainers, physicians, and other practitioners of the healing arts
from any and all liability, claims, causes of action or demands arising out of any injuries to my child/ward or to
his/her property or losses of any kind which may result from or in connection with his/her participation in any
activity related to the Diamond Bar High School ___________________________ team.
■■■ Sports Physical Packet
BRAHMA CODE OF EXTRA-CURRICULAR CONDUCT
Diamond Bar High School students who participate in athletics, student government, performing arts, and other
extra-curricular activities are in the public eye and are highly visible on and off campus and represent Diamond
Bar High School. Participation is a privilege that our staff is committed to providing for our students because of
our strong belief in the importance of extra-curricular activities. It is important that students understand this
responsibility and behave off campus as they would while on campus during regular school days. Students
who participate in extra-curricular activities are expected to behave in a way that brings honor to their school,
organization, family, and community they represent. Behaviors that do not meet expectations include (but are
not limited to) involvement in the use of ANY controlled substance or a “look alike”, weapons, hazing,
inappropriate use of social media, offensive conduct, or any behavior that is prohibited by law, school rules or
district policies.
All students who are a participant on a team or are part of another extra-curricular activity who violate a school
policy or rule could be in violation of the Brahma Code. Violating this code will result in the student being
suspended from their team, or organization for a period of three weeks on the first offense. If the student is a
member of more than one organization, their omission will be from all extra-curricular organizations during the
period of suspension. Eligibility to participate will be restored at the end of the three weeks, but it must be
understood that a three week suspension from that activity will cause adjustments to be made by the
organization; therefore, this restoration of eligibility to participate does not necessarily ensure the place
previously held in the organization or team in competitions, or performances within the organization.
Subsequent offenses will result in further disciplinary action that may include removal from the organization or
team. Any other rules and regulations specific to the extra-curricular organization shall be seen as
supplemental to the Brahma Code.
The above consequences for violation of the Brahma Code will be the MINIMUM consequences and additional
consequences/penalties may be levied by the individual organizations or school administration.
Student acceptance and adherence to the Brahma Code will ensure that the student has a positive experience
and that Diamond Bar High School will be a school that we can all be proud of and a school that is always
represented in the most positive way possible.
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POLICY & AGREEMENT ON STEROIDS
As a condition of membership in the CIF, the Governing Board of the Walnut Valley Unified School District has
adopted Board Policy 5131.63 prohibiting the use and abuse of androgenic/anabolic steroids. CIF Bylaw 524
requires that all participating student-athletes and their parents/legal guardians sign this agreement.
By signing, we agree that the student-athlete will not use androgenic/anabolic steroids without the written
prescription of a fully-licensed physical (as recognized by the AMA) to treat a medical condition.” (CIF Bylaw
503.I)
We recognize that under CIF Bylaw 200.D the student may be subject to penalties, including ineligibility for any
CIF competition, if the student or his/her parent/guardian provides false or fraudulent information to the CIF.
We understand that the student’s violation of the district’s policy regarding steroids may result in discipline
against him/her, including, but not limited to, restriction from athletics, suspension, or expulsion.
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CONCUSSION INFORMATION SHEET
Why am I getting this information sheet? California state law AB 25 (effective January 1, 2012), now Education Code § 49475 states: 1. The law requires a student athlete who may have a concussion during a practice or game to be removed from the activity for the remainder of the day. 2. Any athlete removed for this reason must receive a written note from a medical doctor trained in the management of concussion before returning to practice. 3. Before an athlete can start the season and begin practice in a sport, a concussion information sheet must be signed and returned to the school by the athlete and the parent or guardian. Every year all coaches are required to receive training about concussions (AB 1451) and sudden cardiac arrest; and every 2 years received certification in First Aid training and CPR What is a concussion and how would I recognize one? A concussion is a kind of brain injury. It can be caused by a bump or hit to the head, or by a blow to another part of the body with the force that shakes the head. Concussions can appear in any sport, and can look differently in each person. Most concussions get better with rest and over 90% of athletes fully recover, but, all concussions are serious and may result in serious problems including brain damage and even death, if not recognized and managed the right way. Most concussions occur without being knocked out. Signs and symptoms of concussion may show up right after the injury or can take hours to appear. If your child reports any symptoms of concussion or if you notice some symptoms and signs, seek medical evaluation from the certified athletic trainer and a medical doctor trained in the evaluation and management of concussion. If your child is vomiting, has a severe headache, is having difficulty staying awake or answering simple questions, he or she should be immediately taken to the emergency department of your local hospital. Signs observed by teammates, parents and coaches include:  Looks dizzy  Looks spaced out  Confused about plays  Forgets plays  Is unsure of game, score, or opponent  Moves clumsily or awkwardly  Answers questions slowly Symptoms may include one or more of the following:  Headaches  “Pressure in head”  Nausea or throws up  Neck pain  Has trouble standing or walking  Blurred, double, or fuzzy vision  Bothered by light or noise  Feeling sluggish or slowed down  Feeling foggy or groggy  Drowsiness  Change in sleep patterns 
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Slurred speech Shows a change in personality or way of acting Can’t recall events before or after the injury Seizures or has a fit Any change in typical behavior or personality Passes out 
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Loss of memory “Don’t feel right” Tired or low energy Sadness Nervousness or feeling on edge Irritability More emotional Confused Concentration or memory problems Repeating the same question/comment References:
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American Medical Society for Sports Medicine position statement: concussion in sport (2013)
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Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012
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http://www.cdc.gov/concussion/HeadsUp/youth.html
■■■ Sports Physical Packet
CONCUSSION INFORMATION SHEET
A baseline test of the SCAT3 (Sideline Concussion Assessment Tool 3) will be administered by the certified athletic trainer and athletic training students to each athlete at the beginning of the season for athletes who participate in: football, wrestling, basketball, and soccer, due to their elevated risk of concussion. Athletes will not be permitted to participate in practices, scrimmages, or games without a completed baseline test on file in the athletic trainer’s office. Athletes who participate in these sports will also be required to complete a concussion awareness program consisting of video lectures to be given by the certified athletic trainer, prior to the start of each season. What can happen if my child keeps playing with concussion symptoms or returns too soon after getting a concussion? Athletes with the signs and symptoms of concussion will be removed from play immediately. There is NO same day return to play for a youth with a suspected concussion. Youth athletes may take more time to recover from concussion and are more prone to long‐term serious problems from a concussion. Even though a traditional brain scan (e.g., MRI or CT) may be “normal”, the brain has still been injured. Animal and human studies show that a second blow before the brain has recovered can result in serious damage to the brain. If your athlete suffers another concussion before completely recovering from the first one, this can lead to prolonged recovery (weeks to months), or even to severe brain swelling (Second Impact Syndrome) with devastating consequences. There is an increasing concern that head impact exposure and recurrent concussions contribute to long‐term neurological problems. One goal of this concussion program is to prevent a too early return to play so that serious brain damage can be prevented. What is Return to Learn? Following a concussion, student athletes may have difficulties with short‐ and long‐term memory, concentration and organization. They will require rest while recovering from injury (e.g., avoid reading, texting, video games, loud movies), and may even need to stay home from school for a few days. As they return to school, the schedule might need to start with a few classes or a half‐day depending on how they feel. They may also benefit from a formal school assessment for limited attendance or homework such as reduced class schedule if recovery from a concussion is taking longer than expected. Your school or doctor can help suggest and make these changes. Student athletes should complete the Return to Learn guidelines and return to complete school before beginning any sports or physical activities. Go to the CIF website (cifstate.org) for more information on Return to Learn. How is Return to Play (RTP) determined? Concussion symptoms should be completely gone before returning to competition. A RTP progression involves a gradual, step‐wise increase in physical effort, sports‐specific activities and the risk for contact. If symptoms occur with activity, the progression should be stopped. If there are no symptoms the next day, exercise can be restarted at the previous stage. RTP after concussion should occur only with medical clearance from a medical doctor trained in the evaluation and management of concussions, and a step‐wise progression program monitored by the certified athletic trainer. AB 2127, a California state law that became effective 1/1/15, states that return to play (i.e., full competition) must be no sooner than 7 days after the concussion diagnosis has been made by a physician. Final Thoughts for Parents and Guardians: It is well known that high school athletes will often not talk about signs of concussions, which is why this information sheet is so important to review with them. Teach your child to tell the coaching staff if he or she experiences such symptoms, or if he or she suspects that a teammate has suffered a concussion. You should also feel comfortable talking to the coaches or athletic trainer about possible concussion signs and symptoms. References:
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American Medical Society for Sports Medicine position statement: concussion in sport (2013)
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Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012
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http://www.cdc.gov/concussion/HeadsUp/youth.html
10932 Pine Street
Los Alamitos, California 90720
Telephone: 562-493-9500
Fax: 562-493-6266
Code of Ethics - Athletes
Athletics is an integral part of the school’s total educational program. All school activities, curricular and extracurricular, in the classroom and on the playing field, must be congruent with the school’s stated goals and
objectives established for the intellectual, physical, social and moral development of its students. It is within this
context that the following Code of Ethics is presented.
As an athlete, I understand that it is my responsibility to:
1.
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9.
Place academic achievement as the highest priority.
Show respect for teammates, opponents, officials and coaches.
Respect the integrity and judgment of game officials.
Exhibit fair play, sportsmanship and proper conduct on and off the playing field.
Maintain a high level of safety awareness.
Refrain from the use of profanity, vulgarity and other offensive language and gestures.
Adhere to the established rules and standards of the game to be played.
Respect all equipment and use it safely and appropriately.
Refrain from the use of alcohol, tobacco, illegal and non-prescriptive drugs, anabolic steroids or
any substance to increase physical development or performance that is not approved by the
United States Food and Drug Administration, Surgeon General of the United States or American
Medical Association.
10. Know and follow all state, section and school athletic rules and regulations as they pertain to
eligibility and sports participation.
11. Win with character, lose with dignity.
As a condition of membership in the CIF, all schools shall adopt policies prohibiting the use and abuse of
androgenic/anabolic steroids. All member schools shall have participating students and their parents, legal
guardian/caregiver agree that the athlete will not use steroids without the written prescription of a fully licensed
physician (as recognized by the AMA) to treat a medical condition (Article 523).
By signing below, both the participating student athlete and the parents, legal guardian/caregiver hereby agree
that the student shall not use androgenic/anabolic steroids without the written prescription of a fully licensed
physician (as recognized by the AMA) to treat a medical condition. We recognize that under CIF Bylaw
202, there could be penalties for false or fraudulent information.
(school/school district name)
We also understand that the
policy regarding the use of illegal drugs will be enforced for any violations of these rules.
Printed Name of Student Athlete
Signature of Student Athlete
Date
Signature of Parent/Caregiver
Date
A copy of this form must be kept on file in the athletic director’s office at the local high school on an annual basis
and the Principal’s Statement of Compliance must be on file at the CIF Southern Section office.
Revised 7/11
Keep Their Heart in the Game
A Sudden Cardiac Arrest Information Sheet for Athletes and Parents/Guardians
What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly.
When this happens blood stops flowing to the brain and other vital organs. SCA is NOT a
heart attack. A heart attack is caused by a blockage that stops the flow of blood to the
heart. SCA is a malfunction in the heart’s electrical system, causing the victim to collapse.
The malfunction is caused by a congenital or genetic defect in the heart’s structure.
How common is sudden cardiac arrest in the United States?
As the leading cause of death in the U.S., there are more than 300,000 cardiac arrests
outside hospitals each year, with nine out of 10 resulting in death. Thousands of
sudden cardiac arrests occur among youth, as it is the #2 cause of death under 25
and the #1 killer of student athletes.
The Cardiac Chain of Survival
Who is at risk for sudden cardiac arrest?
SCA is more likely to occur during exercise or physical
activity, so student-athletes are at greater risk. While
a heart condition may have no warning signs, studies
show that many young people do have symptoms but #
neglect to tell an adult. This may be because they are
embarrassed, they do not want to jeopardize their play- OF A HEART CONDITION
ing time, they mistakenly think they’re out of shape and need to train harder, or
they simply ignore the symptoms, assuming they will “just go away.” Additionally,
some health history factors increase the risk of SCA.
to a sudden cardiac arrest victim decreases the chance
What should you do if your student-athlete is experiencing any of these
symptoms?
We need to let student-athletes know that if they experience any SCA-related
symptoms it is crucial to alert an adult and get follow-up care as soon as possible
with a primary care physician. If the athlete has any of the SCA risk factors, these
should also be discussed with a doctor to determine if further testing is needed.
Wait for your doctor’s feedback before returning to play, and alert your coach,
trainer and school nurse about any diagnosed conditions.
Early Access to 9-1-1
Confirm unresponsiveness.
Call 9-1-1 and follow emergency
dispatcher's instructions.
Call any on-site Emergency Responders.
FAINTING
is the
1SYMPTOM
What is an AED?
An automated external defibrillator (AED) is the only way to save a sudden
cardiac arrest victim. An AED is a portable, user-friendly device that automatically diagnoses potentially life-threatening heart
rhythms and delivers an electric shock to restore normal rhythm. Anyone can operate an AED, regardless of
training. Simple audio direction instructs the rescuer
when to press a button to deliver the shock, while
other AEDs provide an automatic shock if a fatal heart
rhythm is detected. A rescuer cannot accidently hurt a
victim with an AED—quick action can only help. AEDs are designed to only
shock victims whose hearts need to be restored to a healthy rhythm. Check
with your school for locations of on-campus AEDs.
AED
On average it takes EMS teams up to 12 minutes to arrive
to a cardiac emergency. Every minute delay in attending
of survival by 10%. Everyone should be prepared to take
action in the first minutes of collapse.
Early Recognition of Sudden Cardiac Arrest
Collapsed and unresponsive.
Gasping, gurgling, snorting, moaning
or labored breathing noises.
Seizure-like activity.
Early CPR
Begin cardiopulmonary resuscitation
(CPR) immediately. Hands-only CPR involves fast
and continual two-inch chest compressions—
about 100 per minute.
Early Defibrillation
Immediately retrieve and use an automated
external defibrillator (AED) as soon as possible
to restore the heart to its normal rhythm. Mobile
AED units have step-by-step instructions for a bystander to use in an emergency situation.
Early Advanced Care
Emergency Medical Services (EMS)
Responders begin advanced life support
including additional resuscitative measures and
transfer to a hospital.
Cardiac Chain of Survival Courtesy of Parent Heart Watch
Keep Their Heart in the Game
Recognize the Warning Signs & Risk Factors
of Sudden Cardiac Arrest (SCA)
Tell Your Coach and Consult Your Doctor if These Conditions are Present in Your Student-Athlete
Potential Indicators That SCA May Occur
Factors That Increase the Risk of SCA
쏔 Fainting or seizure, especially during or
right after exercise
쏔 Family history of known heart abnormalities or
sudden death before age 50
쏔 Fainting repeatedly or with excitement or
startle
쏔 Specific family history of Long QT Syndrome,
Brugada Syndrome, Hypertrophic Cardiomyopathy, or
Arrhythmogenic Right Ventricular Dysplasia (ARVD)
쏔 Excessive shortness of breath during exercise
쏔 Racing or fluttering heart palpitations or
irregular heartbeat
쏔 Family members with unexplained fainting, seizures,
drowning or near drowning or car accidents
쏔 Known structural heart abnormality, repaired or
unrepaired
쏔 Repeated dizziness or lightheadedness
쏔 Chest pain or discomfort with exercise
쏔 Excessive, unexpected fatigue during or
after exercise
쏔 Use of drugs, such as cocaine, inhalants,
“recreational” drugs, excessive energy drinks or
performance-enhancing supplements
What is CIF doing to help protect student-athletes?
CIF amended its bylaws to include language that adds SCA training to coach certification and practice and game protocol that empowers coaches to
remove from play a student-athlete who exhibits fainting—the number one warning sign of a potential heart condition. A student-athlete who has been
removed from play after displaying signs or symptoms associated with SCA may not return to play until he or she is evaluated and cleared by a licensed
health care provider. Parents, guardians and caregivers are urged to dialogue with student-athletes about their heart health and everyone associated
with high school sports should be familiar with the cardiac chain of survival so they are prepared in the event of a cardiac emergency.
I have reviewed and understand the symptoms and warning signs of SCA and the new CIF protocol to incorporate SCA prevention strategies into my student’s sports program.
STUDENT-ATHLETE SIGNATURE
PRINT STUDENT-ATHLETE’S NAME
DATE
PARENT/GUARDIAN SIGNATURE
PRINT PARENT/GUARDIAN’S NAME
DATE
For more information about Sudden Cardiac Arrest visit
California Interscholastic Federation
http.www.cifstate.org
Eric Paredes Save A Life Foundation
http:www.epsavealife.org
CardiacWise (20-minute training video)
http.www.sportsafetyinternational.org