Download athletic participation packet - Sparta Township School District

Sparta High School
Athletic Department
“Home of the Spartans”
Patrick Shea
Director of Athletics
ATHLETIC PARTICIPATION PACKET
Dear Parent(s)/Guardian(s),
Congratulations on making the commitment to participate in the Sparta High School Athletic Program. Athletics teaches many
valuable lifelong lessons and requires a high level of dedication, responsibility, and diligence. I hope that all participants have
a positive and rewarding interscholastic athletic experience!
Please pay special attention to all the enclosed information. It is imperative that all paperwork is completed, signed and returned
to the school nurse in a timely manner to ensure approval and eligibility for sports. Below is a checklist of required
information. All information can be downloaded at http://shs.sparta.org/athletics
Athletic Physicals must be current within 365 days. If the physical on file is dated more than 90 days prior to the first day of
practice, ONLY the Health History Update Questionnaire (#7) and forms #7-9 must be completed and verified by the
School Nurse in order for your student athlete to participate.
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7
Documents/Forms
Pre-participation Physical Examination History Form (Completed by Parent/Athlete)
Athlete with Special Needs: Supplemental History Form (Only if applicable)
Physical Examination Form (Completed by Physician Conducting Physical)
Clearance Form (Completed by Physician Conducting Physical)
School Physician’s Notification of Sports Participation (Completed by School Physician)
Athletic/Co-Curricular Consent
Health History Update Questionnaire (For Update Physicals Only)
8
Parent-Student Athlete Signature Form (This form verifies receipt/perusal of the following documents –
Yes
Parent Communication Pamphlet, Concussion Fact Sheet, Sudden Cardiac Death Brochure)
9
NJSIAA Steroid Testing Consent Form
All required forms must be submitted before any athlete will be permitted to play in an interscholastic game.
IMPORTANT: If an athlete WEARS GLASSES/CONTACTS they must bring them to the physical site to receive physical
clearance from their physician. If your athlete has ASTHMA they must complete the Asthma Treatment Plan Form or if
your athlete has a LIFE THREATENING ALLERGY they must complete the Allergy Emergency Action Plan Form.
These forms are available on the JT athletic website or from the school nurse, and must be submitted in order to receive
physical clearance from the school doctor. Any INJURY(S) noted in a Health History Update Questionnaire requires a
clearance from a physician in order to be approved to compete.
I look forward to the upcoming school year and wish all students, coaches, and parents/guardians the best of luck for a
successful and healthy season.
Sincerely,
Patrick Shea
■ Preparticipation Physical Evaluation
HISTORY FORM
(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep a copy of this form in the chart.)
Date of Exam
Name
Sex
Date of birth
Age
Grade
School
Sport(s)
Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies?
… Medicines
… Yes
… No If yes, please identify specific allergy below.
… Pollens
… Food
… Stinging Insects
Explain “Yes” answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS
Yes
No
MEDICAL QUESTIONS
1. Has a doctor ever denied or restricted your participation in sports for
any reason?
26. Do you cough, wheeze, or have difficulty breathing during or
after exercise?
2. Do you have any ongoing medical conditions? If so, please identify
below: … Asthma … Anemia … Diabetes …
Infections
Other:
3. Have you ever spent the night in the hospital?
27. Have you ever used an inhaler or taken asthma medicine?
Yes
28. Is there anyone in your family who has asthma?
29. Were you born without or are you missing a kidney, an eye, a testicle
(males), your spleen, or any other organ?
4. Have you ever had surgery?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU
Yes
No
5. Have you ever passed out or nearly passed out DURING or
AFTER exercise?
31. Have you had infectious mononucleosis (mono) within the last month?
32. Do you have any rashes, pressure sores, or other skin problems?
33. Have you had a herpes or MRSA skin infection?
6. Have you ever had discomfort, pain, tightness, or pressure in your
chest during exercise?
34. Have you ever had a head injury or concussion?
7. Does your heart ever race or skip beats (irregular beats) during exercise?
35. Have you ever had a hit or blow to the head that caused confusion,
prolonged headache, or memory problems?
8. Has a doctor ever told you that
check all that apply:
… High blood pressure
… High cholesterol
… Kawasaki disease
No
you have any heart problems? If so,
36. Do you have a history of seizure disorder?
… A heart murmur
… A heart infection
37. Do you have headaches with exercise?
Other:
38. Have you ever had numbness, tingling, or weakness in your arms or
legs after being hit or falling?
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,
echocardiogram)
39. Have you ever been unable to move your arms or legs after being hit
or falling?
10. Do you get lightheaded or feel more short of breath than expected
during exercise?
40. Have you ever become ill while exercising in the heat?
11. Have you ever had an unexplained seizure?
42. Do you or someone in your family have sickle cell trait or disease?
12. Do you get more tired or short of breath more quickly than your friends
during exercise?
43. Have you had any problems with your eyes or vision?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
41. Do you get frequent muscle cramps when exercising?
44. Have you had any eye injuries?
Yes
No
13. 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)?
45. Do you wear glasses or contact lenses?
46. Do you wear protective eyewear, such as goggles or a face shield?
47. Do you worry about your weight?
48. Are you trying to or has anyone recommended that you gain or
lose weight?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan
syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT
syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic
polymorphic ventricular tachycardia?
49. Are you on a special diet or do you avoid certain types of foods?
50. Have you ever had an eating disorder?
15. Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator?
51. Do you have any concerns that you would like to discuss with a doctor?
FEMALES ONLY
16. Has anyone in your family had unexplained fainting, unexplained
seizures, or near drowning?
52. Have you ever had a menstrual period?
BONE AND JOINT QUESTIONS
Yes
No
17. Have you ever had an injury to a bone, muscle, ligament, or tendon
that caused you to miss a practice or a game?
53. How old were you when you had your first menstrual period?
54. How many periods have you had in the last 12 months?
Explain “yes” answers here
18. Have you ever had any broken or fractured bones or dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT scan,
injections, therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an x-ray for neck
instability or atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do you have a bone, muscle, or joint injury that bothers you?
24. Do any of your joints become painful, swollen, feel warm, or look red?
25. Do you have any history of juvenile arthritis or connective tissue disease?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete
Signature of parent/guardian
Date
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503
New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
9-2681/0410
■ Preparticipation Physical Evaluation
THE ATHLETE WITH SPECIAL NEEDS:
SUPPLEMENTAL HISTORY FORM
Date of Exam
Name
Sex
Date of birth
Age
Grade
School
Sport(s)
1. Type of disability
2. Date of disability
3. Classification (if available)
4. Cause of disability (birth, disease, accident/trauma, other)
5. List the sports you are interested in playing
Yes
No
Yes
No
6. Do you regularly use a brace, assistive device, or prosthetic?
7. Do you use any special brace or assistive device for sports?
8. Do you have any rashes, pressure sores, or any other skin problems?
9. Do you have a hearing loss? Do you use a hearing aid?
10. Do you have a visual impairment?
11. Do you use any special devices for bowel or bladder function?
12. Do you have burning or discomfort when urinating?
13. Have you had autonomic dysreflexia?
14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?
15. Do you have muscle spasticity?
16. Do you have frequent seizures that cannot be controlled by medication?
Explain “yes” answers here
Please indicate if you have ever had any of the following.
Atlantoaxial instability
X-ray evaluation for atlantoaxial instability
Dislocated joints (more than one)
Easy bleeding
Enlarged spleen
Hepatitis
Osteopenia or osteoporosis
Difficulty controlling bowel
Difficulty controlling bladder
Numbness or tingling in arms or hands
Numbness or tingling in legs or feet
Weakness in arms or hands
Weakness in legs or feet
Recent change in coordination
Recent change in ability to walk
Spina bifida
Latex allergy
Explain “yes” answers here
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete
Signature of parent/guardian
Date
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
■ Preparticipation Physical Evaluation
PHYSICAL EXAMINATION FORM
Name
Date of birth
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 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
BP
… Male … Female
Weight
/
(
/
)
Pulse
Vision R 20/
MEDICAL
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
L 20/
NORMAL
Corrected … Y
… N
ABNORMAL FINDINGS
Eyes/ears/nose/throat
• Pupils equal
• Hearing
Lymph nodes
Heart a
• 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
Neurologic c
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
• Duck-walk, single leg hop
a
b
c
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
Consider GU exam if in private setting. Having third party present is recommended.
Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
† Cleared for all sports without restriction
† Cleared for all sports without restriction with recommendations for further evaluation or treatment for
† Not cleared
† Pending further evaluation
† For any sports
† For certain sports
Reason
Recommendations
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Date
Name of physician, advanced practice nurse (APN), physician assistant (PA) (print/type)
Address
Phone
Signature of physician, APN, PA
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503
New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
9-2681/0410
■■■Preparticipation Physical Evaluation
CLEARANCE FORM
Sex M F
Name
Age
Date of birth
Cleared for all sports without restriction
Cleared for all sports without restriction with recommendations for further evaluation or treatment for
Not cleared
Pending further evaluation
For any sports
For certain sports
Reason
Recommendations
EMERGENCY INFORMATION
Allergies
Other information
I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent
clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office
and can be made available to the school at the request of the parents. 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, advanced practice nurse (APN), physician assistant (PA)
Address
Phone
Signature of physician, APN, PA
Completed Cardiac Assessment Professional Development Module
Date
Date
Signature
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
SCHOOL PHYSICIAN’S NOTIFICATION OF SPORTS PARTICIPATION
To the Parent/Guardian of
Grade
Sport
The above named student
1.
May participate with no restrictions
2.
May participate with the following restrictions
CLASSIFICATION OF SPORTS BY CONTACT
CONTACT
Collision/Contact
Field Hockey
Football
Ice Hockey
Lacrosse
Soccer
Wrestling
Limited Contact
Baseball
Basketball
Diving
Fencing
Field
High Jump
Pole Vault
Gymnastics
Skiing
Softball
Volleyball
NON-CONTACT
Strenuous
Field
Discus
Javelin
Shot put
Non Strenuous
Bowling
Golf
Rowing
Running/Cross Country
Swimming
Tennis
Track
3.
Conditions require special consideration before clearance of sports participation
• Atlantoaxial Instability
• Bleeding Disorder
• Hypertension
• Congenital Heart Disease
• Dysrthyhmia
• Mitral Valve Prolapse
• Heart Murmur
• Cerebral Palsy
• Diabetes Mellitus
• Eating Disorders
• Heat Illness History
• One-Kidney Athletes
• Hepatomegaly, Splenomegaly
• Malignancy
• History of repeated concussion
• Organ Transplant Recipient
• Cystic Fibrosis
• Sickle Cell Disease
• One-eyed Athletes or Athletes with vision > 20/40 in
one eye
4.
Other
Notification regarding this student’s participation in athletics is based solely on the medical examination and results
submitted by the examining physician, nurse practitioner, or physician’s assistant from the student’s medical home. The
medical report complies with the requirements of NJAC6A:16-22.
Notification regarding this student’s participation in athletics is based solely on the Athletic Participation Health
History Update submitted and signed by the student’s parent/guardian.
Explanation
School Physician’s Initials/Stamp
Athletic/Co-Curricular Consent
I AGREE TO RELEASE the Sparta Board of Education and their employees for injuries incurred when there was proper supervision and
coaching of the athlete by the coaching staff.
I know of no physical or medical condition that would adversely affect my son’s/daughters ability to participate in athletics.
I am aware that student athletes are insured under partial excess accident insurance program. This coverage is an “excess” policy which
means all claims must be filed first with your own insurance carrier (family insurance and primary coverage). The outstanding balance
will then be filed with the school insurance carrier to be paid accordingly to policy limitations.
Realizing that participation in athletics involves the potential for injury which is inherent in all sports, I acknowledge that even with the
best coaching, use of the most advanced protective equipment and strict observances of rules, injuries are still a possibility. On rare
occasions, these injuries can be so severe as to result in total disability, paralysis or even death.
I understand that in order to participate, the athlete must:

Have on file my medical and consent forms.

Be eligible according to NJSIAA rules. a-Any student 19 years of age prior to September 1 is not eligible. b-Receipt of 15 credits
for the first semester and 30 credits at end of the school year is required.

Academic policy is as follows: 1.8 grade point average and not more than one “U” (unsatisfactory) mark in conduct must be
maintained for each marking period. Failure to meet the academic and conduct requirements for any given marking period will
result in the student being placed on a probationary marking period. If the student does not meet the requirements at the end
of the following marking period, the student will be immediately denied participation in any athletic activity for the ensuing
marking period. Eligibility to participate will be reinstated at the end of the non-participating marking period if academic and
conduct standards are met. Eligibility is determined by grades received in each of the marking periods and not the cumulative
grade point average.

Be responsible for the care and safe return of all school athletic equipment used students will pay for lost equipment.

Agree to obey all regulations pertaining to training rules established by the Athletic Department.

Hazing in any form is strictly forbidden and will be considered as a serious form of inter personal disrespect.

Acknowledge the penalties for use and possession of tobacco, steroids, alcohol or ant controlled or dangerous substance (NJAC
6:29-9.3) during your high school eligibility.
First violation-minimum 1 week suspension from activity or sport as recommended by substance awareness coordinator.
Second violation-30 days from activity or sport as recommended by substance awareness coordinator.
Subsequent Violations-Consequences to be determined by the principal, Substance Awareness coordinator and Athletic Director.
Counseling and/or evaluation must be implemented before returning to activity or sport.
Date:______________ SIGNATURE OF PARENT OR GUARDIAN _____________________________________________
Date: _____________ SIGNATURE OF STUDENT_________________________________________________________
State of New Jersey
DEPARTMENT OF EDUCATION
HEALTH HISTORY UPDATE QUESTIONNAIRE
Name of School
To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose
physical examination was completed more than 90 days prior to the first day of official practice shall provide a
health history update questionnaire completed and signed by the student’s parent or guardian.
Student
Age
Date of Last Physical Examination
Grade
Sport
Since the last pre-participation physical examination, has your son/daughter:
1. Been medically advised not to participate in a sport?
Yes
No
If yes, describe in detail
2. Sustained a concussion, been unconscious or lost memory from a blow to the head? Yes
If yes, explain in detail
3. Broken a bone or sprained/strained/dislocated any muscle or joints?
No
Yes
No
4. Fainted or “blacked out?”
If yes, was this during or immediately after exercise?
Yes
No
5. Experienced chest pains, shortness of breath or “racing heart?”
If yes, explain
Yes
No
6. Has there been a recent history of fatigue and unusual tiredness?
Yes
No
7. Been hospitalized or had to go to the emergency room?
If yes, explain in detail
Yes
No
If yes, describe in detail
8. Since the last physical examination, has there been a sudden death in the family or has any member of the family
under age 50 had a heart attack or “heart trouble?”
Yes
9. Started or stopped taking any over-the-counter or prescribed medications?
If yes, name of medication(s)
Date:
Yes
No
Signature of parent/guardian
PLEASE RETURN COMPLETED FORM TO THE SCHOOL NURSE’S OFFICE
E14-00284
Sparta High School
Athletic Department
“Home of the Spartans”
Patrick Shea
Director of Athletics
PARENT - STUDENT ATHLETE
SIGNATURE FORM
On our District web site you will find copies of the Concussion Fact Sheet, SHS Parent Communication
Pamphlet, and the Sudden Cardiac Death in Young Athletes brochure as well as the NJSIAA Steroid Testing
Procedures. The following directions guide you to these documents:
Log on to – www.sparta.org
Click on – High School
Click on – Athletics
Click on – Athletic Participation Physical Packet
Click on – Individual documents
Your signatures below will confirm that you and your student athlete have copied, read, understand and agree
with all the information, terms, regulations and conditions contained in the following documents:
Concussion Fact Sheet
Parent Communication Pamphlet
Sudden Cardiac Death in Young Athletes Brochure
In addition, after reading the NJSIAA Steroid Testing Policy and the list of banned substances on line, you and
your student athlete must sign and submit the Consent to Random Testing form found in your packet.
If you have any questions about any of these procedures or the documents, please call my office at 973-7299498. If you do not have access to a computer or the Internet (or have any problems accessing the information),
again, contact my office and a copy of the documents will be provided for you.
Signature of Student Athlete
Print Student Athlete’s Name
Date
Signature of Parent/Guardian
Print Parent/Guardian’s Name
Date
1161 Route 130, P.O. Box 487, Robbinsville, NJ 08691
609-259-2776
609-259-3047-Fax
NJSIAA
NJSIAA STEROID TESTING POLICY
CONSENT TO RANDOM TESTING
In Executive Order 72, issued December 20, 2005, Governor Richard Codey
directed the New Jersey Department of Education to work in conjunction with the
New Jersey State Interscholastic Athletic Association (NJSIAA} to develop and
implement a program of random testing for steroids, of teams and individuals
qualifying for championship games.
Beginning in the Fall, 2006 sports season, any student-athlete who possesses,
distributes, ingests or otherwise uses any of the banned substances on the attached
page, without written prescription by a fully-licensed physician, as recognized by the
American Medical Association, to treat a medical condition, violates the NJSIAA's
sportsmanship rule, and is subject to NJSIAA penalties; including ineligibility from
competition. The NJSIAA will test certain randomly selected individuals and teams
that qualify for a state championship tournament or state championship competition
for banned substances. The results of all tests shall be considered confidential and
shall only be disclosed to the student, his or her parents and his or her school. No
student may participate in NJSIAA competition unless the student and the student's
parent/guardian consent to random testing.
By signing below, we consent to random testing in accordance with the
NJSIAA steroid testing policy. We understand that, if the student or the student's
team qualifies for a state championship tournament or state championship
competition, the student may be subject to testing for banned substances.
Signature of Student-Athlete
Print Student-Athlete's Name
Date
Signature of Parent/Guardian
Print Parent/Guardian's Name
Date
May1, 2010