2018 Unified Cup School Basketball Championship

High schools and colleges that participate in Special Olympics New Jersey’s Unified Champion Schools

program are eligible to take part in the Unified Cup School Championships (formerly Shriver Cups).

These tournaments brings together schools from around New Jersey to offer a state-level competition

to club-based Unified Sports programs.

The 2018 Unified Cup School Basketball Championship is scheduled to be held at Princeton University

on Sunday, April 8.

Schools may send ONE team to the tournament. See Team Composition and Player Eligibility below to

make sure your team meets all the criteria.

Space is limited and teams will be entered into the tournament on a first-come-first-serve basis, so

register as early as possible! The registration deadline is Monday, March 12, 2018 or until all the spots

are full – whichever comes first.

Registration Packet Contents

Please review all of the information provided in this packet carefully. The contents appear in order as

follows:

1. Registration instructions and requirements (3 pages)

2. Unified Cup Basketball Rules and Regulations (1 page)

3. Unified Cup Competition Protocol (2 pages)

4. Unified Schools Participation Packet – NJPPE & SONJ Release forms (10 pages)

Registration Instructions

1. Go to https://www.tfaforms.com/4645446 to access the registration form

2. Select school level

a. Colleges: select your division

3. Enter your school name. This will be your team name.

4. Enter your school colors (ex: blue & gold). We use this information to design your uniform shirts

5. Enter all head coach and assistant coach information

a. Once teams register, all information will be sent directly to the coaches

6. List each player’s first and last name, role on the team (athlete or partner), and t-shirt size

a. Special Olympics New Jersey will provide a uniform shirt for all players as well as a coach

shirt for all coaches

Team Composition

The maximum roster size for the Unified Cup will be 12 players and 3 coaches.

All high school teams competing in the Unified Cup should be following the Unified Sports Player

Development model which combines approximately equal numbers of Special Olympics athletes

(individuals with intellectual disabilities) and partners (individuals without intellectual disabilities) as

teammates on sport teams for training and competition. In Unified Sports Player Development,

teammates are not required to be of similar abilities. Players of higher ability will assist teammates of

lower ability in developing sport-specific skills and tactics and in successfully participating in a team

environment. Unified Sports Player Development teams must follow Unified Sports rules with the

exception of those rules referring to teammates being of similar ability. (see Special Olympics Sports

Rules Article One 14.1.3)

Important notes for High school teams:

Teams that fit within the Competitive Unified Sports model (teammates of similar age and ability level who can play with no modifications) have the opportunity to compete in the NJSIAA Unified Basketball sectional and state final competitions. There will no longer be a division offered for Competitive model high school Unified Basketball teams at the Unified Cup.

Schools may NOT send the SAME team to both NJSIAA Unified basketball competitions as well as the Unified Cup. However, if a high school has enough Unified Basketball participation to field both a Competitive and Player Development team, then that school may send the Competitive team to the NJSIAA events and the Player Development team to the Unified Cup.

Player Eligibility

Unified Basketball teams planning to enter the Unified Cup should adhere to the following player selection criteria. While the Unified Cup is for Player Development teams, this tournament is still a competition and, for the safety of everyone involved, all players must meet minimum standards to participate which are outlined below:

Players must be ambulatory (able to walk/run) and able to play independently

Players must be able to catch, pass, and shoot the basketball independently

Players must have a basic understanding of how to dribble o Some double dribbling is acceptable as long as the player does not gain a competitive

advantage by doing so (up to officials’ discretion) o Some moderate traveling is acceptable as long as the player does not gain a competitive

advantage by doing so (up to officials’ discretion)

Players must have a basic understanding of general basketball game play rules o All fouls and out of bounds calls will be made

High School

All team members must have a current and valid school physical on file in addition to Special Olympics Release forms. See attached Unified Schools Participation Packet

Varsity level basketball players are NOT permitted to be Unified partners

All team members on the Unified Cup roster should have practiced together for a minimum of 6 weeks prior to the tournament

College

All team members must have registered for their college’s Unified Basketball program (online)

All athletes must have a valid Special Olympics New Jersey medical and release forms completed and on file with SONJ at the start of the season

Athletes on the Unified Cup roster should be between the ages of 16 and 39. Older athletes may serve in an assistant coach role for the Unified Cup, if desired

All Unified partners must have completed the Unified partner application forms and taken the online protective behaviors course (each good for 3 years)

Varsity level basketball players are NOT permitted to be Unified partners, however, they may serve as coaches

All team members on the Unified Cup roster should have participated in more than half of the club’s scheduled practice/game dates

Failure to abide by the rules and regulations listed above may result in team disqualification from the Unified Cup Championship.

Coach Eligibility

Any person serving in a coaching role for the Unified Cup must complete the following on or before Monday, April 2, 2018:

Class A Volunteer Form

Protective Behaviors online course

Concussion Training o Must be completed by at least one coach on the team, preferably the head coach

NFHS Coaching Unified Sports course o Must be completed by at least one coach on the team, preferably the head coach o Only needs to be completed once – valid indefinitely

All of the above requirements are free of charge and valid for 3 years from the date of completion, unless otherwise noted.

Scratch Fee

Registering your team for the Unified Cup Championship indicates a commitment to participate in the

tournament. Therefore, any team that drops from the tournament after Sunday, March 18th will be

subject to a $100 scratch fee that will be deducted from your Unified Champion School grant funds.

Unified Cup Basketball questions should be directed to Kalee Iacoangeli, Unified Sports Director at Special Olympics New Jersey. Email: kmi@sonj.org or phone: 609-896-8000 x242

2018 Unified Basketball Rules and Regulations

1. The Unified Cup tournament games will consist of two, 20-minute halves, running clock, with

the exceptions listed below:

a. The clock stops ONLY on foul shots and timeouts.

b. During the last two minutes of the 4th quarter/second half, the clock stops on every

whistle.

2. All teams must maintain a ratio of three (3) Special Olympics athletes to two (2) Unified partners

on the floor at all times.

a. After a game begins and during competition, only the following lineup ratios are

allowed: 3 athletes and 2 partners, 2 athletes and 2 partners, 2 athletes and 1 partner, 1

athlete and 1 partner. Failure to adhere to the required ratio results in a forfeit.

3. If overtime is necessary, the period is five minutes, running time.

a. During the first 4 minutes of overtime, the clock stops ONLY on foul shots and timeouts.

b. During the last minute of overtime, the clock stops on every whistle.

c. Each team receives one additional full timeout during the overtime period.

d. Timing rules listed above are in effect for multiple overtime periods if needed.

e. Time outs earned in previous overtime periods do not carry over in additional overtime

period.

4. Teams are allotted five timeouts per game.

a. Two (2) 30-second time outs

b. Three (3) full (one minute) timeouts.

5. The bonus occurs in each half when a team picks up its 7th team foul.

a. The bonus will ALWAYS result in 2 free throws.

b. Team fouls are reset to zero at the beginning of the second half.

6. Expanded intentional foul definition: The foul shall also be ruled intentional if, while playing the

ball, a player causes excessive contact with an opponent.

7. It is not a violation if a defensive player, who jumped from the front court, secures control of the

ball while both feet are off the floor and he or she returns to the floor with one or both feet in

the back court. 8. One team warning per game for delay of game if player interferes with the ball after a basket is

scored.

a. A technical foul will be called and enforced thereafter.

9. No free throws will be taken for double technical fouls or simultaneous technical fouls by

opponents.

a. Play resumes with an alternating possession throw-in at the division line.

10. No player in a marked lane space shall fake entrance into the lane to cause an opponent to

enter early and commit a violation.

11. During a Free Throw all players must wait until the ball hits the rim before they can step in.

12. In a free-throw situation; there are no substitutions permitted until after the first free throw.

13. IAABO officials are used; therefore SONJ uses IAABO rules to govern basketball games.

Unified Sports Competition Protocol Unified Sports® teams must adhere to the principle of meaningful involvement. This means that during competition, all members (athletes and partners) are presented with numerous opportunities throughout the course of a game to participate and contribute to their team’s performance. This concept decreases the potential for domination by higher-skilled teammates.

The principle of meaningful involvement is the foundation of Unified Sports and helps to ensure a high quality experience. Therefore, it is the expectation for all Unified Sports teams participating at the Unified Cup to demonstrate this fundamental principle during game play.

A formal protocol has been established for the competition, designed to assess all Unified Sports teams to ensure the principle of meaningful involvement is being utilized. The process focuses on educating and communicating to coaches how meaningful involvement is defined and how teams are expected to perform.

The goal is to work with Unified Sports teams to ensure their success in adhering to the standards of meaningful involvement. Qualified individuals knowledgeable in Unified Sports will be on-site to help observe, guide, and monitor and enforce compliance.

On-Site Unified Sports Competition Protocol Points of Emphasis:

• Player dominance and meaningful involvement violations apply to both partners and athletes.

• Game officials on the court do not monitor nor determine meaningful involvement; however, they may be asked for input to assist in a potential violation.

A Unified Sports Evaluation Committee (USEC) member, assigned by SONJ, will be on-site to monitor and evaluate the Unified Sports Competition at the Unified Cup.

The USEC members will work with the Sport Director to oversee a process of

observing all Unified Sports teams to ensure they are incorporating the principle of meaningful involvement.

Sport-specific observation criteria will be used to determine if a team is in violation of the principle of meaningful involvement or if player dominance is occurring.

Teams will be observed regarding meaningful involvement in all games of the competition.

Continues on back

Tournament Play

1. If the USEC member determines that the team is not incorporating the principle of meaningful involvement, he/she consults with the Sport Director. The game is immediately stopped, a meeting with the coach is held, and a verbal warning is given by the USEC member which identifies the specific player who is not adhering to the standards. If more than one team member is in violation, the coach will be held accountable. This applies to each game.

2. If violations continue, the offending player(s) or coach will be issued a written warning. A time out will be called and the USEC member meets with the coach. The Sport Director will be informed of the written warning.

3. If violations continue, the offending player(s) or coach will be suspended for the remainder of that match/game. A time out will be called and the USEC member meets with the coach. The Sport Director will be informed of the suspension.

4. If a team persists in violating the principle of meaningful involvement during the same game or match, they will forfeit the game or match. When a team forfeits a game, the Sport Director and USEC member meet with the coach following the game. He/she is provided with a written warning indicating if any further violations occur in subsequent games, the team will be suspended and will be awarded Participation Ribbons regardless of ranking and/or tournament record.

PARTICIPATION PACKETREQUIRED ITEMS CHECKLIST

Please make a copy of each page to keep for yourself before submission. Please submit the original copy.

Thank you for your interest in Special Olympics New Jersey!

PLEASE NOTE: All required boxes must be checked on thischecklist in order for an athlete to be cleared for participation.

Athlete name Athlete, parent or guardian signature Date

PAGE 1: Release Form

*Required ONLY IF the athlete or the parent/guardian of the athlete checkseither box in item 4 on the Release Form.

PAGE 2: Emergency Medical Care Refusal Form (Athlete Completion) ORPAGE 3: Emergency Medical Care Refusal Form (Parent/Guardian Completion)

Examiner has entered ANY medical information

Date of exam

Athlete cleared for participation

Recommendations, if required Examiner signature/stamp Phone, email, OR license #

Attach Completed NJ PPE Form

PAGE 4: Athlete Medical Form - Health History (Completed by athlete or parent/guardian/caregiver)

Athlete first and last name Address Date of birth Gender

Interscholastic UNIFIED PARTNER checkbox if applicable

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:

Updated 15 May 2017

RELEASE FORM New Jersey

I want to take part in Special Olympics and agree to the following:

1. Able to Participate. I am able to take part in Special Olympics. I know there is a risk of injury.

2. Photo Release. Special Olympics organizations may use my picture, video, name, voice, and words to promoteSpecial Olympics.

3. Overnight Stay. For some events, I may stay in a hotel or someone’s home. If I have questions, I will ask.

4. Emergency Care. If I am unable, or my guardian is unavailable, to make medical decisions in an emergency, Iauthorize Special Olympics to seek medical care on my behalf, unless I check one of these boxes:

I have a religious or other objection to receiving medical treatment. I do not consent to blood transfusions.

(If either box is checked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed.)

5. Health Programs. If I take part in a health program, I consent to health activities, exams, and treatment. Thisshould not replace regular health care. I can say no to treatment or anything else any time.

6. Personal Information. I understand my information may be used and shared by Special Olympics to: Make sure I am eligible and can participate safely; Run trainings and events and share results; Put my information in a computer system; Provide health treatment, make referrals, consult doctors, and remind me about follow-up services; Research, share, and respond to needs of Special Olympics athletes (identifying information removed if shared

publically); and Protect health and safety, respond to government requests, and report information required by law.I can ask to see and change my information.

7. Concussions. I understand the risk of concussions and continuing to play sports with a concussion. I may have toget medical care if I have a suspected concussion. I also may have to wait 7 days or more and get permission from adoctor before I start playing sports again.

ATHLETE NAME: __________________________________________

ATHLETE SIGNATURE (required for athlete over 18 years old with capacity to sign legal documents)

I have read and understand this release. If I have questions, I will ask. By signing, I agree to this form.

Athlete Signature: ____________________________________________ Date: ____________________________

PARENT/GUARDIAN SIGNATURE (required for athlete under 18 years old or lacking capacity to sign legal documents)

I am a parent or guardian of the Athlete. I have read and understand this form and have explained the contents to the Athlete as appropriate. By signing, I agree to this form on my own behalf and on behalf of the Athlete.

Parent/Guardian Signature: _______________________________________ Date: ____________________________

Printed Name: _________________________________________________ Relationship: ______________________

Page 1

Updated 15 May 2017

New Jersey EMERGENCY MEDICAL CARE REFUSAL FORM

Instructions: Only complete this form if you do not consent to emergency medical care on religious or other groundsand have checked a box under the Emergency Care provision on the Release Form.

I, _______________________________________, am a Special Olympics Athlete with capacity to sign documents on my own behalf and agree to the following:

1. No Consent to Emergency Medical Care. I understand that Special Olympics’ standard registration form requires athletes ortheir parents or guardians to consent to emergency medical care for the athlete if needed in an emergency. Based on religiousbeliefs or other reasons I am not consenting to emergency medical care.

YOU MUST CHECK THE BOX AND WRITE YOUR INITIALS NEXT TO ONE STATEMENT TO CONFIRM YOUR INTENT:

I DO NOT CONSENT TO ANY KIND OF MEDICAL TREATMENT, EVEN IN A LIFE-THREATENING EMERGENCY. INITIALS: _____________

I DO NOT CONSENT TO BLOOD TRANSFUSIONS, EVEN IN A LIFE-THREATENING EMERGENCY. I CONSENT TO ALL OTHER KINDS OF EMERGENCY MEDICAL CARE. INITIALS: _____________

2. Printed Instructions. I agree to carry printed instructions that describe my religious or other objections to medical treatmentand how I wish Special Olympics to respond if I get sick or hurt and cannot speak for myself. I agree to carry these printedinstructions with me at all times during my participation in any Special Olympics activity, including during meal times, inovernight accommodations, at training sessions and competitions, and during travel to and from Special Olympics activities.

3. Friend or Family Accompaniment. I understand that I must be accompanied by an adult friend or family member in order forthat person can take personal responsibility for me during a medical emergency where I am unable to speak for myself.

4. Emergency Medical Care If Athlete Is Not Accompanied. I understand that, if I am not carrying the printed instructions orthe accompanying adult is not present and actively taking personal responsibility for me during a medical emergency where Iam unable to speak for myself, Special Olympics may seek emergency medical care for me as recommended by medicalprofessionals responding to the emergency.

5. Liability Release. I release Special Olympics, its employees, and its volunteers from all claims that may arise out of taking orfailing to take measures to provide me with emergency medical care. I am agreeing to this release because I have refused,knowingly and voluntarily, to give Special Olympics permission to take emergency measures, and I am expressly withholdingconsent to emergency medical care on religious or other grounds.

I have read and understand this release. By signing, I agree to this release.

Athlete Signature: __________________________________________________ Date: ________________________________

By signing, I agree to accompany the Athlete during Special Olympics activities and take personal responsibility for the Athlete during an emergency. I understand the extent to which the Athlete does not consent to emergency medical care and agree to act in accordance with the Athlete’s wishes as I understand them.

Signature of Accompanying Adult: ______________________________________ Date: ________________________________

Printed Name: _____________________________________________________ Relationship: __________________________

Page 2

ATHLETE COMPLETION (To be completed by athlete signing on own behalf) If an athlete is not his/her own guardian, please complete Page 3 instead.

Updated 9 August 2016

EMERGENCY MEDICAL CARE REFUSAL FORM New Jersey

Instructions: Only complete this form if you do not consent to emergency medical care on religious or other grounds and have checked a box under the Emergency Care provision on the Release Form.

I am the parent/guardian of ________________________________________________ (the “Athlete”) and agree to the following:

1. No Consent to Emergency Medical Care. I understand that Special Olympics’ standard registration form requiresathletes or their parents or guardians to consent to emergency medical care for the athlete if needed in an emergency.Based on religious beliefs or other reasons I am not consenting to emergency medical care as follows.

YOU MUST CHECK THE BOX AND WRITE YOUR INITIALS NEXT TO ONE STATEMENT TO CONFIRM YOUR INTENT:

I DO NOT CONSENT TO ANY KIND OF MEDICAL TREATMENT, EVEN IN A LIFE-THREATENING EMERGENCY. INITIALS: _____________

I DO NOT CONSENT TO BLOOD TRANSFUSIONS, EVEN IN A LIFE-THREATENING EMERGENCY. I CONSENT TO ALL OTHER KINDS OF EMERGENCY MEDICAL CARE. INITIALS: _____________

2. Accompaniment of Athlete. I understand that I must be present in order to take personal responsibility for the Athleteif any medical treatment is to be refused on the athlete’s behalf in a medical emergency arises. This includes duringmeal times, in overnight accommodations, at training sessions and competitions, and during travel to and from SpecialOlympics activities.

3. Emergency Medical Care If Athlete Is Not Accompanied. I understand that, if I am not present and actively takingpersonal responsibility for the Athlete during a medical emergency, Special Olympics will seek emergency medical carefor the athlete as recommended by medical professionals responding to the emergency.

4. Liability Release. On behalf of myself and the Athlete, I release Special Olympics, its employees, and its volunteersfrom all claims that may arise out of taking or failing to take measures to provide the Athlete with emergency medicalcare. I am agreeing to this release because I have refused, knowingly and voluntarily, to give Special Olympicspermission to take emergency measures, and I am expressly withholding consent to emergency medical care onreligious or other grounds.

I am authorized to enter into this Release on the Athlete’s behalf. I have read and understand this release and have explained the contents to the Athlete as appropriate. By signing, I agree that this Release shall be binding upon me, the Athlete, and our respective heirs and legal representatives.

Signature: ______________________________________________ Date: _____________________________________

Printed Name: ___________________________________________ Relationship: _______________________________

Page 3

PARENT OR GUARDIAN COMPLETION(To be completed by parent or guardian of athlete who is under 18 years

old or otherwise has a legal guardian)

Medical Form for US Programs – updated June 2016 Special Olympics Medical Form |

Athlete Medical Form – HEALTH HISTORY (to be completed by athlete or parent/gu ardian/care giver)

AREA:

LOCAL PROGRAM :ATHLETE INFORMATION PARENT GUARDIAN INFORMATION (if not own guardian)

First Name: Middle Name: Name:

Last Name: Phone: Cell:

Date Birth (mm/dd/yyyy) : Female: Male: E-mail:

Address (Street): Emergency Contact Name: Same as Above:

Address (City, State, Zip): Emergency Contact Phone (cell):

Phone: Cell: Emergency Contact Relationship:

E-mail: Does the athlete have a primary care physician? Yes No If yes, list.

Eye color: Ethnicity: (optional)

Physician Name: Physician Phone:

Athlete Employer, if any: Insurance Policy (Company and Number):

I am my own guardian. Yes No Does the athlete have any objections to emergency medical care? No Yes If yes, contact your local Program to get the Emergency Care Refusal

Form.Does the athlete have (check any that apply):List any sports the athlete wishes to play:

Autism Down syndrome Fragile X Syndrome

Cerebral Palsy Fetal Alcohol Syndrome

Other syndrome, please specify: Has a doctor ever limited the athlete’s participation in sports?

No Yes If yes, please describe: Is the athlete allergic to any of the following (please list):

Latex No Known Allergies

Medications:

Does the athlete use (check any that apply): Insect Bites or Stings:

Brace Colostomy Communication Device Food:

C-PAP Machine Crutches or Walker Dentures List any special dietary needs:

Glasses or Contacts G-Tube or J-Tube Hearing Aid

Implanted Device Inhaler Pacemaker List all past surgeries:

Removable Prosthetics Splint Wheel Chair

Has the athlete had a Tetanus vaccine in the past 7 years? No Yes Does the athlete currently have any chronic or acute infection?

No Yes If yes, please describe: FAMILY HISTORY Has any relative died of a heart problem before age 50? No Yes

Has any family member or relative died while exercising? No Yes

Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)? If yes, select below and describe

Yes, had abnormal EKG Yes, had abnormal Echo List all medical conditions that run in the athlete’s family:

Page 4

Interscholastic UNIFIED PARTNER

CONCUSSON AWARENESS AND SAFETY RECOGNITION POLICY

Objective

It is Special Olympics’ intent to take steps to help ensure the health and safety of all Special Olympics participants. All Special Olympics participants should remember that safety comes first and should take reasonable steps to help minimize risks for concussion or other serious brain injuries.

Defining a Concussion

A concussion is defined by the Centers for Disease Control as a type of traumatic brain injury caused by a bump, blow, or jolt to the head as well as serial, cumulative hits to the head. Concussions can also occur from a blow to the body that causes the head and brain to move quickly back and forth—causing the brain to bounce around or twist within the skull. Although concussions are not usually life-threatening, their effects can be serious and therefore proper attention must be paid to individuals suspected of sustaining a concussion.

Suspected or Confirmed Concussion

Effective immediately, a participant who is suspected of sustaining a concussion in practice, game or competition shall be removed from practice, play or competition at that time. If a qualified medical professional is available on-site to render an evaluation, that person shall have final authority as to whether or not a concussion is suspected. If applicable, the participant’s parent or guardian should be aware that the participant is suspected of sustaining a concussion.

Return to Play

A participant who has been removed from practice, play or competition due to a suspected concussion may not participate in Special Olympics sports activities until either of the following occurs (1) at least seven (7) days have passed since the participant was removed from play and a currently licensed, qualified medical professional provides written clearance for the participant to return to practice, play and competition, or (2) a currently licensed, qualified medical professional determines that the participant did not suffer a concussion and provides written clearance for the participant to return to practice, play immediately. Written clearance in either of the scenarios above shall become a permanent record.

Special Olympics New Jersey

■ 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 __________________________________________________________________________________ Date of birth __________________________

Sex _______ 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? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

GENERAL QUESTIONS Yes No

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 spent the night in the hospital?

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No

5. Have you ever passed out or nearly passed out DURING or

AFTER exercise?

6. Have you ever had discomfort, pain, tightness, or pressure in your

chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during exercise?

8. Has a doctor ever told you that you have any heart problems? If so,

check all that apply:

High blood pressure A heart murmur

High cholesterol A heart infection

Kawasaki disease Other: _____________________

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,

echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected

during exercise?

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your friends

during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY 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)?

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?

15. Does anyone in your family have a heart problem, pacemaker, or

implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained

seizures, or near drowning?

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?

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?

MEDICAL QUESTIONS Yes No

26. Do you cough, wheeze, or have difficulty breathing during or

after exercise?

27. Have you ever used an inhaler or taken asthma medicine?

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?

30. Do you have groin pain or a painful bulge or hernia in the groin area?

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?

34. Have you ever had a head injury or concussion?

35. Have you ever had a hit or blow to the head that caused confusion,

prolonged headache, or memory problems?

36. Do you have a history of seizure disorder?

37. Do you have headaches with exercise?

38. Have you ever had numbness, tingling, or weakness in your arms or

legs after being hit or falling?

39. Have you ever been unable to move your arms or legs after being hit

or falling?

40. Have you ever become ill while exercising in the heat?

41. Do you get frequent muscle cramps when exercising?

42. Do you or someone in your family have sickle cell trait or disease?

43. Have you had any problems with your eyes or vision?

44. Have you had any eye injuries?

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?

49. Are you on a special diet or do you avoid certain types of foods?

50. Have you ever had an eating disorder?

51. Do you have any concerns that you would like to discuss with a doctor?

FEMALES ONLY

52. Have you ever had a menstrual period?

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

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 9-2681/0410

New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

■ Preparticipation Physical Evaluation

THE ATHLETE WITH SPECIAL NEEDS:

SUPPLEMENTAL HISTORY FORM

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ 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

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.

Yes No

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 FORMName __________________________________________________________________________________ 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 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 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

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 restriction 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 condi-

tions 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) (print/type)____________________________________________ Date of exam ________________

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 9-2681/0410

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, a physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained

to the athlete (and parents/guardians).

New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

■■■ �Preparticipation�Physical�Evaluation��CLEARANCE�FORM

Name ___ ____________________________________________________ Sex  M  F 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 _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

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) ____________________________________________________ Date _______________

Address _________________________________________________________________________________________ Phone _________________________

Signature of physician, APN, PA _____________________________________________________________________________________________________

Completed Cardiac Assessment Professional Development Module

Date___________________________ Signature_______________________________________________________________________________________

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Other information _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

©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