Great Oak High School 2013-2014 Wolfpack Athletic/Activities Packet

Page 1 Great Oak High School 2013-2014 Wolfpack Athletic/Activities Packet

Welcome to Great Oak Athletics/Activities

"Coming together is a beginning; keeping together is progress; working together is success."

We strongly believe that our athletic and activities program fosters and enriches the positive climate of Great Oak High School. Athletics and activities at Great Oak are an extension of the instructional program, providing an environment for students to extend their learning and make positive connections to school. GOHS continues to provide comprehensive athletic and activity offerings. Teams will compete in the Southwestern League. We look forward to another exciting year!

Gil Rodriguez Don Skaggs Athletic Director Activities Director Great Oak High School Great Oak High School

Athletic physicals are required each year you participate in a sport.

You must turn in a completed athletic packet, including a physical BEFORE trying out, practicing, or participating in any sport at GOHS.

When completing the packet:

Please read the packet and sign in places indicated.

Take the back page to a doctor for a sports physical. Make sure it is signed by the doctor and stamped with doctor info.

Bring completed packet to the athletic office.

Athletic secretary will hand you a clearance form.

Take clearance form to coach on day of tryout/practice/camp.

Great Oak High School 32555 Deer Hollow Way Temecula, CA 92592 51) 294-6450 x 2004 FAX (951) 294-6453 Page 2

ATTENTION ATHLETES

CALIFORNIA INTERSCHOLASTIC FEDERATION

CIF Southern Section Academics/Integrity/Athletics

CONDENSED ELIGIBILITYRULES

STUDENTS, TO PROTECT YOUR ATHLETIC ELIGIBILITY YOU MUST:

• Be under nineteen years of age prior to June 15 • Have reached the ninth grade • Participate in no more than four seasons of the same sport after enrolling in the ninth grade • Be scholastically eligible (2.0 minimum GPA) • File an Application for Residential Eligibility if you have transferred from another school without a corresponding bona-fide change of residence by your parents/guardians, or you are a foreign student • Since entering the ninth grade, not be in your ninth semester of attendance • Meeting citizenship requirements • Maintain amateur standing • Not have participated in any tryout for a professional team • Maintain in your school files an annual physical examination certifying that you are physically fit to try out and/or participate in athletic activities

YOUR ELIGIBILITY IS SUBJECT TO SPECIAL RULES: (Questions should be directed to your school Coach and/or Athletic Director)

• Competition with an outside team during your high school season in the same sport is prohibited • Participation on the varsity football team is prohibited until you have reached your 15th birthday (14 with a letter from your physician and parent) • If you transfer from one school to another without a bona-fide change of residence by your parents/guardians, your eligibility is subject to special rules which may include non-participation at the varsity level. • Students may participate in All-Star competition, between conclusion of the Southern Section season of sport and September 1.

You are urged to check with the Athletic Director or Coach if you have any questions regarding your eligibility. Competing when you are not eligible could subject your team to forfeiture. Page 3

TEMECULA VALLEY UNIFIED SCHOOL DISTRICT

ATHLETIC/ACTIVITIES CODE OF CONDUCT

Student Responsibilities FIRST OFFENSE: Participation in the GOHS Activities/Athletic Programs (See Upon notification by school authority, the student will miss the next Exhibit A) is a privilege and a responsibility. Students who two events of EVERY sport/activity of which she/he is currently a participate in the GOHS programs understand the privilege and member. Participation during the past twelve (12) months for the agree to uphold the responsibilities below: date of code violation constitutes membership. The two-event The Responsibility to self to maintain high standards of health and sanction will apply during the following twelve (12) month period. safety in order to perform at the maximum level of their potential. The Responsibility to their fellow group/team members to give SECOND OFFENSE: their best effort at all times. Upon notification by school authority, the student will be excluded The Responsibility to their coaches, advisors and directors to from participation in the activity/athletic program for twelve (12) strive for success in every effort they undertake. months from the date of the code violation. The Responsibility to their school, community, whom they represent, to maintain the highest standards of conduct. THIRD OFFENSE: The Responsibility to the youth of the community, who look up to Upon notification by school authority, the student will be excluded them, to be role models of citizenship and behavior. from participation in the activity/athletic program for the In order to meet these responsibilities, participants pledge not to duration of his/her attendance at GOHS. AT ANY TIME, engage in the ILLEGAL USE OF DRUGS, * These penalties are cumulative during a student’s tenure at ALCOHOL, OR TOBACCO OR TO PARTICIPATE IN CRIMINAL GOHS. BEHAVIOR as defined in the California State Education Code and/or Penal Code. CIF ATHLETES CODE OF ETHICS Athletics is an integral part of the school’s total educational Parent Responsibilities program. All school activities, curricular and extracurricular, in the Participants are not under the supervision of school authorities classroom and on the playing field, must be congruent with the twenty-four hours a day. In order to involve parents/guardians in school’ s stated goals and objectives established for the the supervision of their son/daughter, it is asked that they intellectual, physical, social and moral development of its students. (working in partnership with the school) take responsibility for It is within this context that the following Code of Ethics is code enforcement outside of the school’s jurisdiction for their own presented. children. If the parent or guardian reports a violation by the participant, the parent or guardian may request the enforcement As an Athlete, I understand that it is my responsibility to: of the appropriate consequences as outlined in the Activities/Athletic Code. Should school authorities become aware 1. Place academic achievement as a highest priority. of a possible violation of the Activities/Athletic Code, parents or 2. Show respect for teammates, opponents, officials, and guardians will be notified. coaches. 3. Respect the integrity and judgment of game officials. Staff Responsibilities 4. Exhibit fair play, sportsmanship and proper conduct on and School personnel will be responsible for assisting students in off the playing field. meeting their responsibilities under the Code. Coaches and 5. Maintain a high level of safety awareness. advisors play a key role in educating and being role models for the 6. Refrain from the use of profanity, vulgarity, and other students enrolled in their sport or activity. Coaches and advisors offensive language and gestures. are responsible for educating students and enforcing all aspects of 7. Adhere to the established rules and standards of the game to the Activities/Athletic Code. It is essential that a caring and be played. positive approach be used to convey to students their 8. Respect all equipment and use it safely and appropriately. responsibilities and the consequences to students if the Code is 9. Refrain from the use of alcohol, tobacco, illegal and violated. The school administration will be responsible for nonprescription drugs, anabolic steroids or any substance to administering all consequences to students for violation of this increase physical development or performance that is not code. approved by the United States Food and Drug Administration, Surgeon General of the United States, or American Medical Consequences Association. The following are the cumulative* penalties and regulations 10. Know and follow all state, section and school athletic rules and regarding any infractions of the Activities/Athletic Code which will regulations as they pertain to eligibility and sports be applied IN ADDITION TO and AFTER students have complied participation. with the consequences of the regular school discipline program 11. Win with character, lose with dignity. which include suspension and expulsion. Page 4

ATHLETIC/ ACTIVITIES ACADEMIC ELIGIBILITY REQUIREMENTS

In order to be academically eligible, a student MUST meet ALL of the following minimum standards on their previous progress report or semester report card. Students MUST:

1. Be PASSING four classes AND have a GPA of 2.0. Students not meeting the 2.0 may request probation for one eligibility period. 2. No more than one F. 3. No more than one U (in Citizenship or Work Habits). Two U’s from the same teacher will count as one. 4. Students entering GOHS from a non-TVUSD school must be passing four classes on their last grade report and will have until their first GOHS grade report to meet the above standards. 5. All TVUSD incoming freshmen will be required to meet all the above standards. The June report card will be used to determine eligibility for FALL SPORTS. 6. 10 Day Grace Period - A student may leave a sport for any reason during the first 10 days of practice. There shall be NO PENALTY if the athlete informs the coach of such intention to leave that sport and returns all school equipment or gear issued to him or her. Any spirit pack items purchased are non refundable. 7. Release from Team - An athlete may, at any time, request to be released from a team due to special circumstances. The coach may or may not grant this request. If granted, the parent will be notified by mail. 8. Quitting a Team - If an athlete informs the coach that he/she is quitting, after the 10 day grace period, the athlete will miss the first contest of the next sport he/she participate in. The athlete MAY NOT PRACTICE in another sport until the conclusion of the last regularly scheduled contest of the sport quit. The parent will be notified. Any spirit pack items purchased prior to quitting are not refundable. 9. Removal from a Team - If an athlete is removed from a team for violation of any team rules; the athlete will miss the first two contests of the next sport he/she participates in. The athlete MAY NOT practice in another sport until the conclusion of the last regularly scheduled contest of the sport he/she was removed from. The parents will be notified by the coach and may appeal the coach’s decision to the athletic director. 10. Travel Policy - the biggest cost in high school athletics is transportation. Transportation will be arranged in the safest, yet most cost effective manner possible. • Transportation – Options to all contests will be determined prior to each season of sport. • Student Driver - SUMMER PROGRAM ONLY - Due to special circumstances, a student may request his/her coach’s permission to drive to a contest. NO passengers are allowed. Student must have prior guardian approval on the Student Voluntary Transportation Agreement Form. This form must be on file with the coach. • Private vehicle transportation - SUMMER PROGRAM ONLY - Students may ride in a private vehicle driven by a coach or adult volunteer. Student must have prior guardian approval on the Student Voluntary Transportation Agreement Form. This form must be on file with the coach. • School Bus/Van - District bus rules are in effect on all athletic field trips. • Transportation home - Students must return to Great Oak High School in the same vehicle as they arrived. Coaches may release athletes, after a contest, to their guardians only if the athlete provides written permission from the guardian. • Meet there – Students will be asked to meet at the competition location when travel is outside of school hours.

11. At the conclusion of the sports season, all school issued uniforms and equipment must be returned or the athlete will be subject to charges for replacement through the bookkeeper’s office. EXHIBIT A

Violations of the Activity/Athletic Code include, but are not limited to:

Illegal possession, use, or sale of drugs, alcohol, or tobacco.

1. Assault and/or battery 2. Theft 3. Forgery 4. Weapons 5. Other criminal acts as defined by the California State Education Code/Penal Code and determined to be serious in nature by the Great Oak High School Administration. Copies of the California State Education Code can be made available on request. Participants shall not engage in any incidents involving possession, sale, or use or furnishing of firearms, knives, or other weapons, theft, forgery, any violation of Education Code sections 48900 (a-l), 48900.2, 48900.e and/or 48900.4. Any such incidents will result in removal from the activity or athletic team in accordance with the CONSEQUENCES section of this code. Page 5 WARNING TO PARENTS: SERIOUS, CATASTROPHIC AND PERHAPS FATAL INJURY MAY RESULT FROM ATHLETIC PARTICIPATION

By its very nature, competitive athletics may put students in situations in which SERIOUS CATASTROPHIC and perhaps, FATAL ACCIDENTS may occur.

Many forms of athletic competition result in violent physical contact among players, the use of equipment which may result in accidents, strenuous physical exertion, and numerous other exposures to risk of injury.

Students and parents must assess the risks involved in such participation and make their choice to participate, in spite of the risks. No amount of instruction, precaution, or supervision will totally eliminate all risk of injury. Just as driving an automobile involves choice of risk; athletic participation by high school students also may be inherently dangerous. The obligation of parents and students in making this choice to participate cannot be overstated. There have been accidents resulting in death, paraplegia, quadriplegia, and other very serious permanent physical impairment as a result of athletic competition.

By granting permission for your student to participate in athletic competition, you, the parent or guardian, acknowledge that such risk exists.

Students will be instructed in proper techniques to be used in athletic competition and in proper utilization of all equipment worn or used in practice and competition. Students MUST adhere to that instruction and utilization and MUST refrain from improper uses and techniques.

As previously stated, no amount of instruction, precaution, and supervision will totally eliminate all risk of serious catastrophic, or even fatal injury. If any of the foregoing is not completely understood, please contact your school principal for further information.

INSURANCE STATEMENT ***PLEASE READ ENTIRE STATEMENT CAREFULLY***

CALIFORNIA EDUCATION CODE SECTION 32221 REQUIRES THAT EVERY STUDENT OF AN ATHLETIC TEAM HAVE ACCIDENTAL BODILY INJURY INSURANCE, PROVIDING AT LEAST $1500 OF SCHEDULED MEDICAL AND HOSPITAL BENEFITS. IF YOU CANNOT AFFORD THIS MEDICAL COVERAGE FOR YOUR ATHLETE, THE ATHLETIC DEPARTMENT CAN ASSIST IN PROVIDING INFORMATION ON AN ACCIDENT POLICY, WHICH MEETS THE ABOVE REQUIREMENTS. THIS COVERAGE IS NOT A 24 HOUR MEDICAL POLICY. IT ONLY COVERS THE STUDENT WHILE PARTICIPATING IN A SCHOOL-SPONSORED AND SUPERVISED ATHLETIC ACTIVITY. I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION REGARDING TVUSD’S POLICY. I UNDERSTAND THAT MAINTAINING THIS ACCIDENTAL BODILY INJURY INSURANCE POLICY IS MY RESPONSIBILITY AS THE PARENT OR GUARDIAN. IF, AT ANY TIME, DURING THE ATLETHIC SEASON I CAN NO LONGER AFFORD THIS POLICY IT IS MY RESPONSIBILITY TO CONTACT THE ATHLETIC DEPARTMENT.

BY SIGNING THIS DOCUMENT, I ACKNOWLEDGE THAT: 1. I have read the all of the above information and will abide by the provisions. 2 . All information provided is correct. False information will result in student ineligibility and team forfeits. 3. I will keep my insurance, in force, during the time my students tries out, practices or competes in athletics. 4. My student is enrolled or has an appointment to be enrolled in Great Oak High School Page 6

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 • Amnesia • “Pressure in head” • “Don’t feel right” • Nausea or vomiting • Fatigue or low energy • Neck pain • Sadness • Balance problems or dizziness • Nervousness or anxiety • Blurred, double, or fuzzy vision • Irritability • Sensitivity to light or noise • More emotional • Feeling sluggish or slowed down • Confusion • Feeling foggy or groggy • Concentration or memory problems (forgetting • Drowsiness game plays) • Change in sleep patterns • 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 Page 7

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.” and “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 its 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: http://www.cdc.gov/ConcussionInYouthSports/ Page 8

AGE AND RESIDENCE STATEMENT

My son/daughter will not compete on an outside team in the same sport during the high school season of that sport.

STUDENT NAME ______AGE DATE OF BIRTH ____/ _____/ _____ Grade 2013-14_____

Has student attended any OTHER high school? Yes No If yes, name of school

City/State Attended other high school from _/ to /

Did you participate in varsity sports at another high school? Yes No If yes, please specify sport(s):

ATHLETIC/ ACTIVITIES CONTRACT

Code of Conduct and Academic Eligibility Requirements

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 524). I have read and understand the GOHS Wolf Pack Activities/Athletic Code of Conduct and Academic Eligibility Requirements. I understand that by signing this Contract, I agree to accept responsibility for violation of or noncompliance with the rules. 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 200 D, there could be penalties for false or fraudulent information. We also understand that the Temecula Valley Unified School District/Great Oak High School policy regarding the use of illegal drugs will be enforced for any violations of these rules. These cumulative penalties and regulations, regarding any infractions of the Activities/Athletic Code, will be applied IN ADDITION TO and AFTER students have complied with the consequences of the regular school discipline program which include suspension and expulsion. These penalties are cumulative during a student’s tenure at GOHS.

Our signatures below will acknowledge that we understand and have read the following documents:

♦ TVUSD Activities/Athletic Code of Conduct ♦ Athletic/Activities Academic Eligibility Requirements ♦ Athletic/Activities Contract ♦ CIF Code of Ethics ♦ Age and Residence Statement ♦ Warning to Athletes and Parents/Guardians ♦ Insurance Statement ♦ Concussion Information Sheet

STUDENT NAME (PRINT) STUDENT SIGNATURE DATE

PARENT/GUARDIAN NAME (PRINT) PARENT SIGNATURE DATE Page 9 GREAT OAK HIGH SCHOOL ATHLETIC CLEARANCE VERIFICATION FORM

PLEASE fill out BOTH FORMS, pages 9 & 10

PLEASE PRINT - Be sure to complete all information on this form

Student’s Name Grade: 2013-14 LAST FIRST MI

FALL WINTER SPRING Football, Cross Country, Volleyball, Soccer, Wrestling, Basketball, Girls Baseball, Softball, Boys Golf, Track Girls Tennis, Boys Water Polo, Girls Water Polo, Pep Squad , Pep Squad, Boys Tennis, Swimming, Lacrosse Golf, Pep Squad, Dance Team, Dance Team, Step Team Pep Squad, Dance Team, Step Team Step Team (CIRCLE SPORT OF INTEREST) (CIRCLE SPORT OF INTEREST) (CIRCLE SPORT OF INTEREST)

Address: Birthdate / /

Parent/Guardian Name(s): _Cell #:

Mother’s Work Phone: Father’s Work Phone:

In the absence of parent/guardian, please call (in case of illness or accident):

Name: Relationship: Phone:

Name of Family Physician Phone ( )

CONSENT Yes No The student named above has my permission to engage in co-curricular activities, including travel.

TRAINER CONSENT Yes No I give my permission to the Athletic Trainer to administer immediate first-aid, follow-up treatment and rehabilitation when appropriate in his/her professional judgment and/or recommended by the consulting physician.

TREATMENT CONSENT Yes No In the event of accident or emergency, I (we) give permission for the school authorities to take my (our) child to any available doctor or hospital, or request their services. I (we) grant consent to any healthcare providers to provide my (our) child with any necessary medical care as a result of any injury or illness.

***IF YOUR ANSWER IS NO, PLEASE ADVISE THE SCHOOL AS TO WHAT ACTION YOU WOULD LIKE TAKEN

I/we hereby consent that in the event that I/we cannot be reached in an emergency, I/we hereby grant permission to physicians selected by the coaches and staff of the Temecula Valley Unified School District to secure proper treatment including hospitalization, injections, and/or anesthesia and surgery for the person named above. Any restrictions to this are listed below:

Parent/Guardian Signature Date Page 10 GREAT OAK HIGH SCHOOL ATHLETIC CLEARANCE VERIFICATION FORM

PLEASE fill out BOTH FORMS, pages 9 & 10

PLEASE PRINT - Be sure to complete all information on this form

Student’s Name Grade: 2013-14 LAST FIRST MI

Address: Birthdate / /

Parent/Guardian Name(s): _Cell #:

Mother’s Work Phone: Father’s Work Phone:

In the absence of parent/guardian, please call (in case of illness or accident):

Name: Relationship: Phone:

Name of Family Physician Phone ( )

CONSENT Yes No The student named above has my permission to engage in co-curricular activities, including travel.

***IF YOUR ANSWER IS NO, PLEASE ADVISE THE SCHOOL AS TO WHAT ACTION YOU WOULD LIKE TAKEN

Parent/Guardian Signature Date

***Per CIF & TVUSD Rules, this is the only form that can be used for athletic physicals*** Page 11 Pre-participation Physical Evaluation History Form NOTE: This form is to be filled out by the patient and parent prior to seeing the physician DATE OF EXAM:______Name: ______Sex:______Age: ______Date of Birth: ______Address: ______Phone: ______Grade: ______School: ______Sports: ______Personal Physician: ______Phone: ______In case of emergency, contact: Name:______Relationship:______Phone (H):______(W):______Medicines and Allergies: Please list all the prescription and over‐the‐counter medicines and supplements (herbal and nutritional) that you are currently taking. ______Do you have any allergies?  Yes  No If yes, please identify specific allergy below.  Medicines  Pollens  Food  Stinging Insects  Other Explain “Yes” answers below. Circle questions you don’t know the answers to. GENERAL QUESTIONS Y N Do you have a bone, muscle, or joint injury that bothers you? Has a doctor ever denied or restricted your prescription in sports for any Do any of your joints become painful, swollen, feel warm, or look red? reason? Do you have any history of juvenile arthritis or connective tissue disease? Do you have any ongoing medical conditions? If so, please identify: MEDICAL QUESTIONS Y N  Asthma  Anemia  Diabetes  Infections Do you cough, wheeze, or have difficulty breathing during or after Other:______exercise? Have you ever spent the night in the hospital? Have you ever used an inhaler or taken asthma medicine? Have you ever had surgery? Is there anyone in your family who has asthma? HEART HEALTH QUESTIONS ABOUT YOU Y N Were you born without or are you missing a kidney, an eye, a testicle Have you ever passed out or nearly passed out DURING or AFTER (males), your spleen, or any other organ? exercise? Do you have groin pain or a painful bulge or hernia in the groin area? Have you ever had discomfort, pain, tightness, or pressure in your chest Have you had infectious mononucleosis (mono) within the last month? during exercise? Do you have any rashes, pressure sores, or other skin problems? Does your heart ever race or skip beats (irregular beats) during exercise? Have you had a herpes or MRSA skin infection? Has a doctor ever told you that you have any heart problems? If so, check Have you had a head injury or concussion? all that apply: Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?  High blood pressure  A Heart Murmur Do you have a history of seizure disorder?  High Cholesterol  A Heart Infection Do you have headaches with exercise?  Kawasaki Disease Other:______Have you ever had numbness, tingling, or weakness in your arms or legs Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, after being hit or falling? echocardiogram) Have you ever become unable to move your arms or legs after being hit Do you get lightheaded or feel more short of breath than expected during exercise? or falling? Have you ever become ill while exercising in the heat? Have you ever had an unexplained seizure? Do you get frequent muscle cramps when exercising? Do you get tired more quickly than your friends do during exercise? Do you or someone in your family have sickle cell trait or disease? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Y N Have you had any problems with your eyes or vision? Has any family member or relative died of heart problems or had an Have you had any eye injuries? unexpected or unexplained sudden death before age 50 (including Do you wear glasses or contact lenses? drowning, unexplained car accident, or sudden infant death syndrome)? Do you wear protective eyewear, such as goggles or a face shield? Does anyone in your family have hypertrophic cardiomyopathy, Marfan Do you worry about your weight? syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT Are you trying to or has someone recommended that you gain or lose weight? syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? Are you on a special diet or do you avoid certain types of foods?

Does anyone in your family have a heart problem, pacemaker, or Have you ever had an eating disorder? implanted defibrillator? Do you have any concerns that you would like to discuss with a doctor? Has anyone in your family had unexplained fainting, unexplained FEMALES ONLY Y N seizures, or near drowning? Have you ever had a menstrual period? BONE AND JOINT QUESTIONS Y N How old were you when you had your first menstrual period? Have you ever had an injury to a bone, muscle, ligament, or tendon that How many periods have you had in the last 12 months? caused you to miss practice or a game? Have you ever had any broken or fractured bones or dislocated joints? Explain “Yes” Answers Here: Have you ever had an injury that required x‐rays, MRI, CT scan, injections, ______therapy, a brace, a cast, or crutches? ______Have you ever had a stress fracture? ______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) ______Do you regularly use a brace, orthotics, or other assistive device? ______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 for noncommercial purposes with acknowledgment.

PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL EXAMINATION FORM Page 12 Name ______Date of Birth ______

PHYSICIAN REMINDERS Consider additional questions on more sensitive issues  Have you ever tried cigarettes, chewing tobacco, snuff, or dip?  ● Do you ever feel stressed out or under a lot of pressure? ● During the past 30 days, did you use chewing tobacco, snuff, or dip?  Do you ever feel sad, hopeless, depressed, or anxious? ● Do Do you drink alcohol or use any other drugs? you feel safe at your home or residence?  Have you ever taken anabolic steroids or used any other performance supplement? ● Do you wear a seat belt, use a helmet, and use condoms?  Have you ever taken any supplements to help you gain or lose weight or improve your performance? 1. 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 Heart  Murmurs (auscultation standing, supine, +/- Valsalva)  Location of point of maximal impulse (PMI) Pulses  Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only) 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 aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. bConsider 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.  Cleared for all sports without restriction  ______Cleared for all sports without restrictions with recommendations for further evaluation or treatment for ______ ______Not cleared  Pending further evaluation  For any sports  For certain sports ______Reason: ______

Recommendations: ______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: ______Date______Address: ______Phone ______

Signature of Physician: ______MD or DO (ONLY) DR. STAMP FOR VERIFICATION 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.