Download Physical Forms - Apalachee Baseball

2016-2017BarrowCountySchoolsPHYSICAL,CONSENT&INSURANCEFORM
ALL 4 PAGES MUST BE COMPLETED PRIOR TO STUDENT PARTICIPATION IN ATHLETICS
Name:__________________________________________________________________ DateofExam:___________________________________
EmergencyContactName:_____________________________Relationship:_________________________Phone#:_______________________
Sex:MFAge___Gradefor2016:789101112School:WBHSBCMSRMSAHSHMMSWMS Sport(s) ________________________________
MedicinesandAllergies:Pleaselistalloftheprescriptionandover-the-countermedicinesandsupplements(herbalandnutritional)thatyouarecurrently
taking_______________________________________________________________________________________________________________________ Doyouhaveanyallergies?
□Yes□No
Ifyes,pleaseidentifyspecificallergybelow.
□Medicines _______________ □Pollens__________________ □Food___________________ □StingingInsects__________________________
GENERALQUESTIONS
1.Hasadoctoreverdeniedorrestrictedyourparticipationin
sportsforanyreason?
2.Doyouhaveanyongoingmedicalconditions?Ifso,please
identifybelow:□Asthma□Anemia□Diabetes□Infections
Other:
_______________________________________________
3.Haveyoueverspentthenightinthehospital?
4.Haveyoueverhadsurgery?
HEARTHEALTHQUESTIONSABOUTYOU
5.HaveyoueverpassedoutornearlypassedoutDURINGor
AFTERexercise?
6.Haveyoueverhaddiscomfort,pain,tightness,orpressure
inyourchestduringexercise?
7.Doesyourhearteverraceorskipbeats(irregularbeats)
duringexercise?
8.Hasadoctorevertoldyouthatyouhaveanyheart
problems?Ifso,checkallthatapply:□Highbloodpressure
□Aheartmurmur□Highcholesterol□Aheartinfection
□KawasakidiseaseOther:_____________________
9.Hasadoctoreverorderedatestforyourheart?(For
example,ECG/EKG,echocardiogram)
10.Doyougetlightheadedorfeelmoreshortofbreaththan
expectedduringexercise?
11.Haveyoueverhadanunexplainedseizure?
12.Doyougetmoretiredorshortofbreathmorequickly
thanyourfriendsduringexercise?
HEARTHEALTHQUESTIONSABOUTYOURFAMILY
13.Hasanyfamilymemberorrelativediedofheartproblems
orhadanunexpectedorunexplainedsuddendeathbefore
age50(includingdrowning,unexplainedcaraccident,or
suddeninfantdeathsyndrome)?
14.Doesanyoneinyourfamilyhavehypertrophic
cardiomyopathy,Marfansyndrome,arrhythmogenicright
ventricularcardiomyopathy,longQTsyndrome,shortQT
syndrome,Brugadasyndrome,orcatecholaminergic
polymorphicventriculartachycardia?
15.Doesanyoneinyourfamilyhaveaheartproblem,
pacemaker,orimplanteddefibrillator?
16.Hasanyoneinyourfamilyhadunexplainedfainting,
unexplainedseizures,orneardrowning?
BONEANDJOINTQUESTIONS
17.Haveyoueverhadaninjurytoabone,muscle,ligament,
ortendonthatcausedyoutomissapracticeoragame?
18.Haveyoueverhadanybrokenorfracturedbonesor
dislocatedjoints?
19.Haveyoueverhadaninjurythatrequiredx-rays,MRI,CT
scan,injections,therapy,abrace,acast,orcrutches?
20.Haveyoueverhadastressfracture?
21.Haveyoueverbeentoldthatyouhaveorhaveyouhadan
x-rayforneckinstabilityoratlantoaxialinstability?(Down
syndromeordwarfism)
22.Doyouregularlyuseabrace,orthotics,orotherassistive
device?
23.Doyouhaveabone,muscle,orjointinjurythatbothers
you?
24.Doanyofyourjointsbecomepainful,swollen,feelwarm,
orlookred?
Yes
No
Yes
No
Yes
No
Yes
No
25.Doyouhaveanyhistoryofjuvenilearthritisorconnective
tissuedisease?
MEDICALQUESTIONS
Yes
No
26.Doyoucough,wheeze,orhavedifficultybreathingduringor
afterexercise?
27.Haveyoueverusedaninhalerortakenasthmamedicine?
28.Isthereanyoneinyourfamilywhohasasthma?
29.Wereyoubornwithoutorareyoumissingakidney,aneye,a
testicle(males),yourspleen,oranyotherorgan?
30.Doyouhavegroinpainorapainfulbulgeorherniainthegroin
area?
31.Haveyouhadinfectiousmononucleosis(mono)withinthelast
month?
32.Doyouhaveanyrashes,pressuresores,orotherskin
problems?
33.HaveyouhadaherpesorMRSAskininfection?
34.Haveyoueverhadaheadinjuryorconcussion?
35.Haveyoueverhadahitorblowtotheheadthatcaused
confusion,prolongedheadache,ormemoryproblems?
36.Doyouhaveahistoryofseizuredisorder?
37.Doyouhaveheadacheswithexercise?
38.Haveyoueverhadnumbness,tingling,orweaknessinyour
armsorlegsafterbeinghitorfalling?
39.Haveyoueverbeenunabletomoveyourarmsorlegsafter
beinghitorfalling?
40.Haveyoueverbecomeillwhileexercisingintheheat?
41.Doyougetfrequentmusclecrampswhenexercising?
42.Doyouorsomeoneinyourfamilyhavesicklecelltraitor
disease?
43.Haveyouhadanyproblemswithyoureyesorvision?
44.Haveyouhadanyeyeinjuries?
45.Doyouwearglassesorcontactlenses?
46.Doyouwearprotectiveeyewear,suchasgogglesoraface
shield?
47.Doyouworryaboutyourweight?
48.Areyoutryingtoorhasanyonerecommendedthatyougainor
loseweight?
49.Areyouonaspecialdietordoyouavoidcertaintypesof
foods?
50.Haveyoueverhadaneatingdisorder?
51.Doyouhaveanyconcernsthatyouwouldliketodiscusswitha
doctor?
FEMALESONLY
Yes
No
52.Haveyoueverhadamenstrualperiod?
53.Howoldwereyouwhenyouhadyourfirstmenstrualperiod?
54.Howmanyperiodshaveyouhadinthelast12months?
Explain“YES”answershere
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Iherebystatethat,tothebestofmyknowledge,myanswerstotheabovequestionsarecompleteandcorrect.
__________________________________________________ SignatureofAthlete
_____________________________________________________
SignatureofParent/Guardian
___________________________
Date
PHYSICALEXAMINATIONFORM/CLEARANCEFORM
Name:____________________________________________________________________________ DateofBirth:__________________________________________________________
PHYSICIANREMINDERS
1.Consideradditionalquestionsonmoresensitiveissues
•Doyoufeelstressedoutorunderalotofpressure?
•Doyoueverfeelsad,hopeless,depressed,oranxious?
•Doyoufeelsafeatyourhomeorresidence?
•Haveyouevertriedcigarettes,chewingtobacco,snuff,ordip?
•Duringthepast30days,didyouusechewingtobacco,snuff,ordip?
•Doyoudrinkalcoholoruseanyotherdrugs?
•Haveyouevertakenanabolicsteroidsorusedanyotherperformancesupplement?
•Haveyouevertakenanysupplementstohelpyougainorloseweightorimproveyourperformance?
•Doyouwearaseatbelt,useahelmet,andusecondoms?
2.Considerreviewingquestionsoncardiovascularsymptoms(questions5–14).
EXAMINATION
Height
BP
Weight
/
(
/
□Male
)
Pulse
□Female
VisionR20/
L20/
Corrected
□Y
MEDICAL
Appearance•
Marfanstigmata(kyphoscoliosis,high-archedpalate,pectusexcavatum,arachnodactyly,armspan>height,
hyperlaxity,myopia,MVP,aorticinsufficiency)
Eyes/ears/nose/throat•Pupilsequal•Hearing
NORMAL
Lymphnodes
Hearta•Murmurs(auscultationstanding,supine,+/-Valsalva)•Locationofpointofmaximalimpulse(PMI)
Pulses•Simultaneousfemoralandradialpulses
Lungs
Abdomen
Genitourinary(malesonly)b
Skin•HSV,lesionssuggestiveofMRSA,tineacorporis
Neurologicc
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional•Duck-walk,singleleghop
□N
ABNORMALFINDINGS
A ConsiderECG,echocardiogram,andreferraltocardiologyforabnormalcardiachistoryorexam.
B ConsiderGUexamifinprivatesetting.Havingthirdpartypresentisrecommended.
C Considercognitiveevaluationorbaselineneuropsychiatrictestingifahistoryofsignificantconcussion
□
□
□
Clearedforallsportswithoutrestriction
Clearedforallsportswithoutrestrictionwithrecommendationsforfurtherevaluationortreatmentfor
NotCleared……..□Pendingfurtherevaluation………□Foranysports………….□Forcertainsports
Reason_______________________________________________________________________________
Recommendations______________________________________________________________________
Ihaveexaminedtheabove-namedstudentandcompletedthepre-participationphysicalevaluation.Theathletedoesnotpresentapparentclinicalcontraindicationstopracticeand
participateinthesport(s)asoutlinedabove.Acopyofthephysicalexamisonrecordinmyofficeandcanbemadeavailabletotheschoolattherequestoftheparent.Ifconditionsarise
aftertheathletehasbeenclearedforparticipation,thephysicianmayrescindtheclearanceuntiltheproblemisresolvedandthepotentialconsequencesarecompletelyexplainedtothe
athlete(andparents/guardians).
NameofPhysician(print/type) _______________________________________________________________ Phone________________________________________________________
StreetAddress________________________________________________________ City___________________________________ State ____________ Zip__________________
SignatureofPhysician_______________________________________________________________________
Date of Exam: _____________________________
BarrowCountyPublicSchools
CONSENT, INSURANCE AND ATHLETIC PHYSICAL FORM - MUSTBECOMPLETELYFILLEDIN
PARENTALCONSENTFORATHLETICPARTICIPATION
WARNING:Althoughparticipationinsupervisedinterscholasticathleticsandactivitiesmaybeoneoftheleasthazardousinwhichstudentswillengageinoroutofschool,byitsnature,
participationininterscholasticathleticsincludesariskorinjurywhichmayrangeinseverityfromminortolongtermcatastrophic,includingpermanentparalysisfromtheneckdownor
death.Althoughseriousinjuriesarenotcommoninsupervisedschoolathleticprograms,itispossibleonlytominimize,noteliminatetherisk.
Participants can and have the responsibility to help reduce the chance of injury. Players must obey all safety rules, report all physical problems to their coaches, follow a proper
conditioningprogram,andinspecttheirequipmentdaily.
Bysigningthispermissionform,youacknowledgethatyouhavereadandunderstandthiswarning.Parents or students who do not wish to accept the risks described in this warning
shouldnotsignthispermissionform.
I(we)herebygiveconsentfor_______________________________________________residingat______________________________________________________________________ to:
(1)
(2)
(3)
CompeteinathleticsatApalacheeHighSchooloftheBarrowCountySchoolDistrictinGeorgiaHighSchoolAssociationapprovedsports.
Toaccompanyanyschoolteamofwhichthestudentisamemberonanyofitslocalorout-of-towntrips;
Iherebyverifythattheinformationonbothsidesofthisformiscorrectandunderstandthatanyfalseinformationmayresultinmyson/daughterbeingdeclaredineligible.
Thestudentisdomiciledattheaboveaddresslocatedinthe_______________________________________________________________ HighSchoolDistrict.
HaveyouattendedApalacheeHighSchoolforatleastonefullschoolyear?Yes____
No_____
EMERGENCYCONTACTS--PLEASEPRINTCLEARLY:
NameofFather/Guardian______________________________________ Telephone
Work:_________________________________
Cell _____________________________________
NameofMother/Guardian _____________________________________ Telephone
Work:_________________________________
Cell _____________________________________
EmergencyContact___________________________________________ Telephone
Work:_________________________________
Cell _____________________________________
DateofBirth ________________________
HomeTelephoneNumber_______________________________________________
DateofPhysical______________________
DateEntered9thGrade _________________________________________________ YourGradeLevelThisYear ______________________
Thisacknowledgmentofriskandconsenttoallowparticipationshallremainineffectuntilrevokedinwriting.
INSURANCEINFORMATION–MUSTBECOMPLETED
PleaseINITIALoneofthefollowingstatementsregardinginsurancecoverageforyourson/daughterforthe_______________________________________ schoolyear,thensignbelow.
________ Myson/daughterisadequatelyandcurrentlycoveredbyaccidentinsurancethatwillcoverinjuriessustainedwhileparticipatingininterscholasticathletics(including,but
notlimitedto,varsityandjuniorvarsityfootball).
CompanyProvidingInsurance: _________________________________________________________ Group:_____________________________________________________
NameofInsured: ___________________________________________________________________ Policy#:____________________________________________________
________ IwishtopurchasetheBenefitPlanprovidedbytheBarrowCountySchoolSystem.
(AsignedcopyofthisBenefitPlanshouldbestapledtothisform.)
AUTHORIZATION
Icertifythatthemedicalhistoryonthisformiscompleteandaccurate.Iunderstandthatthiswillserveasthebasisfordeterminingthatmychild,__________________________________,
maycompeteinhighschoolathleticsinBarrowCountySchools.Ialsounderstandthatthismedicalevaluationisonlytodeterminefitnessforathleticsandisnottotaketheplaceofregular
medical examinations. In case of an emergency or accident on the school grounds or during any school activity involving my child, ________________________________, which in the
opinionofschoolauthoritiespresentrequiresimmediatemedicalorsurgicalattention,Iherebygrantpermissiontophysicians,consultingphysicians,athletictrainers,emergencymedical
technicians,andotherhealthcareprovidersselectedbyschoolauthoritiestoprovidemedicalcareandtreatment(includinghospitalizationifdeemedappropriatebyschoolauthoritiesoran
appropriatehealthcareprovider)unlessIampresentandrequestotherwiseoruntilIlaterrequestotherwise.
ATHLETICCODEOFCONDUCT
BarrowCountyPublicSchools’athleticprogramsareagreatsourceofpridetoourcommunities.Involvementinathleticshelpsstudentsdevelopabettersenseofresponsibility,
cooperation;self-discipline,self-confidence,andsportsmanshipthatwillhelpservethemlongaftergraduation.Thelessonsandvalueslearnedbyparticipatingonathleticteamslasta
lifetime.
Allathletesareexpectedtoabidebythehigheststandardsoffairplayandsportsmanshipwhileonthecourtorfield.Wealsohavehighexpectationsregardingbehaviorwhenthestudents
arenotengagedinathleticcompetitions.StudentsparticipatinginGeorgiaHighSchoolAssociationextracurricularathleticactivitiesactasrepresentativesofBarrowCountyPublicSchools.
Allstudentsareexpectedtoconductthemselvesinsuchamannerastomeetthehigheststandardsoftheschoolsystematalltimes.
TheAthleticCodeofConductisdesignedtoestablishhighexpectationsandstandardsforallstudentsparticipatinginGeorgiaHighSchoolsanctionedathleticactivities.TheCodeofConduct
alsoprovidesconsistentconsequenceswhenviolationsoccur.TheconsequenceslistedontheCodeofConductareminimumstandards.Theschoolscansetconsequencesoverandabove
thoselistedontheCodeofConduct.
IhavereadtheBarrowCountyAthleticCodeofConductintheDisciplineHandbookandIunderstandthepotentialconsequencesthatgoalongwithviolatingtheAthleticCodeofConduct.
PLEASESIGNHERE:
Thissignatureconsentstoathleticparticipation,medicalauthorization,verificationofinsurancecoverage,codeofconduct,andpermissiontousetheathletespictureand/orvideoon
ourschoolwebsite,andallotherformsofmediaavailabletoApalacheeHighSchool.
_____________________________________________________________ _____________________________________________________________ _________________________
SignatureofAthlete
SignatureofParent/Guardian
Date
STUDENT/PARENT CONCUSSION AWARENESS FORM
SCHOOL: __________________________
DANGERS OF CONCUSSION
Concussions at all levels of sports have received a great deal of attention and a state law has been
passed to address this issue. Adolescent athletes are particularly vulnerable to the effects of concussion.
Once considered little more than a minor “ding” to the head, it is now understood that a concussion has
the potential to result in death, or changes in brain function (either short-term or long-term). A concussion
is a brain injury that results in a temporary disruption of normal brain function. A concussion occurs when
the brain is violently rocked back and forth or twisted inside the skull as a result of a blow to the head or
body. Continued participation in any sport following a concussion can lead to worsening concussion
symptoms, as well as increased risk for further injury to the brain, and even death.
Player and parental education in this area is crucial – that is the reason for this document. Refer to it
regularly. This form must be signed by a parent or guardian of each student who wishes to participate in
GHSA athletics. One copy needs to be returned to the school, and one retained at home.
COMMON SIGNS AND SYMPTOMS OF CONCUSSION
Headache, dizziness, poor balance, moves clumsily, reduced energy level/tiredness
Nausea or vomiting
Blurred vision, sensitivity to light and sounds
Fogginess of memory, difficulty concentrating, slowed thought processes, confused about surroundings or game
assignments
Unexplained changes in behavior and personality
Loss of consciousness (NOTE: This does not occur in all concussion episodes.)
BY-LAW 2.68: GHSA CONCUSSION POLICY: In accordance with Georgia law and national playing rules
published by the National Federation of State High School Associations, any athlete who exhibits signs, symptoms,
or behaviors consistent with a concussion shall be immediately removed from the practice or contest and shall not
return to play until an appropriate health care professional has determined that no concussion has occurred. (NOTE:
An appropriate health care professional may include licensed physician (MD/DO) or another licensed individual
under the supervision of a licensed physician, such as a nurse practitioner, physician assistant, or certified athletic
trainer who has received training in concussion evaluation and management.
a)Noathleteisallowedtoreturntoagameorapracticeonthesamedaythataconcussion(a)hasbeen
diagnosed,OR(b)cannotberuledout.
b)Anyathletediagnosedwithaconcussionshallbeclearedmedicallybyanappropriatehealthcareprofessional
priortoresumingparticipationinanyfuturepracticeorcontest.Theformulationofagradualreturntoplay
protocolshallbeapartofthemedicalclearance.
c)ItismandatorythateverycoachineachGHSAsportparticipateinafree,onlinecourseonconcussion
managementpreparedbytheNFHSandavailableatwww.nfhslearn.comatleasteverytwoyears–beginningwith
the2013-2014schoolyear.
d)Eachschoolwillberesponsibleformonitoringtheparticipationofitscoachesintheconcussionmanagement
course,andshallkeeparecordofthosewhoparticipate.
I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT.
SIGNED: __________________________________
(Student)
DATE: __________________________
________________________________________
(Parent or Guardian)