checklist for filling out athletic forms...dimethylamphetamine epitrenbolone methyclothiazide...

Name___________________ Grade________ Sport________________

Checklist for filling out Athletic Forms

Page What Must Be Completed Completed

2 Emergency Cards Both Trainer & Coach’s Copies

3 Steroid Testing Policy Athlete & Parent Signature

5 Part I-Student Participation Form

Athlete & Parent Signatures

6 Part II- Player Agreement Athlete & Parent Signature

6 Parental Approval Form Parent Signature

6 Part III- Athletic Eligibility 7-9 Health History

Answer All Questions Parent Signature

10 Physical Evaluation Form You Complete Top Section of

Student & Physician Information

10-12 Physical Evaluation Form Physician Completes

Remainder

13 For Physician & Office Use X 14 Fill in Name of Student

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PARTICIPATION FEE FORM

Please confirm the payment of the participation fee by entering the student(s) name,

sport intended to play, and the confirmation of payment number below. Remember that

it is a one-time payment for the entire school year.

Student Name Sport Order Number

Payment is made on-line by going to www.payforit.net; the 2011-2012 sport participation fee is currently $150.00*. In order to register for the participation fee you will need your power school student ID number. This number can be found by clicking into the “Demographic Update” page in the parent portal of PowerSchool. You will see the following: Name (last, first MI) then the student ID number. * $150 fee is subject to change pending outcome of budget process and formal BOE approval.

http://www.payforit.net/

EMERGENCY CARD ATHLETIC TRAINER’S COPY

SPORT: _____________________GRADE: _______ SCHOOL YEAR: __________DATE OF LAST PHYSICAL______________ SELECT ONLY ONE SPORT PER SEASON NAME: ____________________________________________________________ DATE OF BIRTH: ________________________ ADDRESS: __________________________________________________________ CITY&ZIP: _____________________________ HOME PHONE: ___________________________________________ EMERGENCY PHONE: _____________________________ EMERGENCY INFORMATION- ALL INFO MUST BE COMPLETE PRIOR MEDICAL HISTORY: __________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ FATHER’S EMPLOYER: ______________________________________________________________________________________ BUSINESS PHONE: ________________________________________ CELL PHONE: ____________________________________ MOTHER’S EMPLOYER: _____________________________________________________________________________________ BUSINESS PHONE: ________________________________________ CELL PHONE: ____________________________________

------------- ---------------------------------------- ------------------------------------- ---------------------

EMERGENCY CARD COACHES’ COPY

SPORT:________________________GRADE: ________ SCHOOL YEAR: ___________DATE OF LAST PHYSICAL__________ SELECT ONLY ONE SPORT PER SEASON NAME: ____________________________________________________________ DATE OF BIRTH: ________________________ ADDRESS: __________________________________________________________ CITY&ZIP: _____________________________ HOME PHONE: ____________________________________________ EMERGENCY PHONE:_____________________________ EMERGENCY INFORMATION- ALL INFO MUST BE COMPLETE PRIOR MEDICAL HISTORY: __________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ FATHER’S EMPLOYER: ______________________________________________________________________________________ BUSINESS PHONE: ________________________________________ CELL PHONE: ____________________________________ MOTHER’S EMPLOYER: _____________________________________________________________________________________ BUSINESS PHONE: ________________________________________ CELL PHONE: ___________________________________ BOTH FORMS MUST BE FILLED

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1161 Route 130, P.O. Box 487, Robbinsville, NJ 08691 609-259-2776 609-259-3047-Fax

NJSIAA STEROID TESTING POLICY

CONSENT TO RANDOM TESTING

In Executive Order 72, issued December 20, 2005, Governor Richard Codey directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying for championship games. Beginning in the Fall, 2006 sports season, any student-athlete who possesses, distributes, ingests or otherwise uses any of the banned substances on the attached page, without written prescription by a fully-licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA’s sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition. The NJSIAA will test certain randomly selected individuals and teams that qualify for a state championship tournament or state championship competition for banned substances. The results of all tests shall be considered confidential and shall only be disclosed to the student, his or her parents and his or her school. No student may participate in NJSIAA competition unless the student and the student’s parent/guardian consent to random testing. By signing below, we consent to random testing in accordance with the NJSIAA steroid testing policy. We understand that, if the student or the student’s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances. ___________________________ Signature of student-Athlete Print Student-Athlete’s Name Date

___________________________ Signature of parent/guardian Print Parent/Guardian’s Name Date June 8, 2006

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1161 Route 130, P.O. Box 487, Robbinsville, NJ 08691 609-259-2776 609-259-3047-Fax

NJSIAA Banned-Drug Classes 2006 - 2007

The term “related compounds” comprises substances that are included in the class by their pharmacological action and/or chemical structure. No substance belonging to the prohibited class may be used, regardless of whether it is specifically listed as an example. Many nutritional/dietary supplements contain NJSIAA banned substances. In addition, the U. S. Food and Drug Administration (FDA) does not strictly regulate the supplement industry; therefore purity and safety of nutritional dietary supplements cannot be guaranteed. Impure supplements may lead to a positive NJSIAA drug test. The use of supplements is at the student-athlete’s own risk. Student-athletes should contact their physician or athletic trainer for further information. The following is a list of banned-drug classes, with examples of banned substances under each class: (a) Stimulants (b) Anabolic Agents (c) Diuretics (d) Peptide Hormones & Analogues: amiphenazole anabolic steroids acetazolamide corticotrophin (ACTH) amphetamine androstenediol bendroflumethiazide human chorionic gonadotrophin (hCG) bemigride androstenedione benzhiazide leutenizing hormone (LH) benzphetamine boldenone bumetanide growth hormone (HGH, somatotrophin) bromantan clostebol chlorothiazide insulin like growth hormone (IGF-1) caffeine1 (guorana) dehydrochlormethyl- chlorthalidone chlorphentermine testosterone ethacrynic acid All the respective releasing factors cocaine dehydroepiandro- flumethiazide of the above-mentioned substances cropropamide sterone (DHEA) furosemide also are banned: crothetamide dihydrotestosterone (DHT) hydrochlorothiazide erythropoietin (EPO) diethylpropion dromostanolone hydroflumenthiazide darbypoetin dimethylamphetamine epitrenbolone methyclothiazide sermorelin doxapram fluoxymesterone metolazone ephedrine gestrinone polythiazide (ephedra, ma huang) mesterolone quinethazone ethamivan methandienone spironolactone ethylamphetamine methenolone triamterene fencamfamine trichlormethiazide meclofenoxate and related compounds methamphetamine methyltestosterone methylenedioxymethamphetamine nandrolone (MDMA, ecstasy) norandrostenediol methylphenidate norandrostenedione nikethamide norethandrolone (e) Definitions of positive depends on the following: pemoline oxandrolone 1 for caffeine – if the concentration in urine exceeds 15 micrograms/ml pentetrazol oxymesterone phendimetrazine oxymetholone 2 for testosterone – if administration of testosterone or use of any other phenmetrazine pregnelone manipulation has the result of increasing the ratio of the total phentermine stanozolol concentration of testosterone to that of epitestosterone in the urine phenylpropanolamine (ppa) testosterone2 of greater than 6:1, unless there is evidence that this ratio is due to a picrotoxine tetrahydrogestrinone physiological or pathological condition. pipradol (THG) prolintane trenbolone strychnine and related compounds synephrine other anabolic agents (citrus aurantium, zhi shi, bitter clenbuterol orange) and related compounds June 8, 2006

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GOVERNOR LIVINGSTON HIGH SCHOOL 175 Watchung Blvd. Berkeley Heights, NJ 07922 908-464-3100 Ext. 2540 Fax: 908-464-7508

Email: [email protected] Website: www.bhpsnj.org/~glathletics

The entire document must be completed accurately and signed before a student becomes a candidate for participation in any interscholastic sport.

PART I - STUDENT PARTICIPATION FORM FOR ATHLETICS FOR THE SCHOOL YEAR 200 - 200

Name: ___________________________________________________Grade: ________Date of Birth: ________________ Address:_____________________________________Town/Zip_____________________ Phone:____________________ Name of Fall Sport: ______________________________Winter: ____________________Spring: ___________________ I agree to follow the rules of training, proper conduct, and responsible behavior. I am aware that the development of character is an important aspect of my social, emotional, and intellectual growth. Therefore, I understand any use of or possession of drugs, tobacco and/or alcohol, at any time during the course of the athletic season, whether in school or out of school, or whether during the week or on weekends will result in penalties. The penalties are as follows: 1st offense: For possession or use of alcohol, narcotics, harmful drugs: five days out of school suspension and

an additional five days exclusion from athletics 2nd offense: Suspension from school for ten days plus an additional twenty days exclusion from athletics 3rd offense: Suspension from school for ten days plus an additional thirty-five days exclusion from athletics. 1st offense: For use of or possession of tobacco products during the season: one week suspension from athletics 2nd offense: Suspension from athletics for two weeks 3rd offense: Suspension from athletics for the remainder of the season I realize it is my responsibility, as a member of a team, to be present for all practices and athletic contests; however, I may be excused from athletic contests that occur on religious holidays. If there is any other conflict, for example, with a band performance, I will notify my coach of the conflict well in advance so a resolution can be made. I will not wear jewelry during practices or games because of the possibility of injury.

I further understand that I will abide by all rules and regulations established by the NJSIAA. I will be responsible for and will return all equipment issued to me or pay for that portion which was lost, stolen, or unduly damaged.

DATE: _________________________ SIGNATURE of ATHLETE: ____________________________________

* Sports physicals are provided by the school physician at the end of June only Yes* ___ I give permission for my child to have a physical exam, including a scoliosis screening at school. No ___ I will have my private physician fill out this form.

DATE: _______Parent’s Name (Print) ______________________________ Parent’s Signature ________________________________

FOR OFFICE USE ONLY HEALTH OFFICE ________APPROVED for sports By Health Office Date of Sport Physical _________ _______________NOT APPROVED for sports by Health Office COMMENTS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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PART II - PLAYER AGREEMENT AND PARENTAL APPROVAL FORM As a member of the GOVERNOR LIVINGSTON HIGH SCHOOL ATHLETIC PROGRAM, I agree to the following rules: 1. I will show good sportsmanship at all games, scrimmages, and practices. 2. I will show respect to umpires, opposing team members, opposing coaches, teammates, and fans. 3. I am expected to attend all practices or games unless I am ill or have been excused by my coach. Illness may require a written parental

note. 4. I will be on time for practices and games. 5. I will do what is best for the team by playing any position the coach asks me to if the need arises. 6. At the end of the season, I will hand in all uniforms and all equipment that has been issued to me. 7. I realize dedication is very important and know that if I am in school on a given day I am expected to also be at practice that day. 8. I understand there are Saturday practices and/or games I must attend and there are also practices and/or games during vacations

that I am expected to attend. Furthermore, should short-term family commitments impede my participation on the team, upon return, I understand that I will be required to work to regain my previous position on the team.

As a member of the ATHLETIC PROGRAM, I agree to follow these rules and realize that failure to adhere to any one of the rules may result in disciplinary action and/or dismissal from the program Signed: _________________________________________________________ Date: ______________________ Parent/Guardian Signature: _________________________________________ Date: _____________________

INTERSCHOLASTIC INSURANCE POLICY/PARENTAL APPROVAL

The Board of Education carries an interscholastic insurance policy that provides medical benefits on an "excess" basis only. For parents who already have medical insurance, this represents secondary coverage that will only be paid after the primary carrier(s) first pay their portion of all medical bills. The purpose of this policy is to pay for some portion of the medical expenses not covered by personal or group insurance that most parents usually carry for their families. As with all insurance policies, this policy has limitations and it does not guarantee coverage for "all" medical expenses not covered by other primary insurance. Only when there is no medical insurance in the family, will this policy pay primary benefits, and even then it will only pay up to the limits of the policy.

I understand that athletic transportation has been reduced due to budgetary restraints. I agree to assume responsibility for transportation of my son/daughter, for athletics or cheerleading activities, to and from home and school on Saturdays, Sundays and holidays, for early morning or night practices and from school to home after competitions of away games or activities. I am fully aware that participation in any co-curricular activity may result in injury. I realize it is impossible to predict all of the various types of injuries that a student might incur participating in athletics. I fully understand that a serious physical injury/ accident is possible.

I completely understand the above implications. We, the undersigned, the parents and/or guardians of _________________ __________________________(Name of athlete) do hereby consent to his/her participation in the Governor Livingston HS Interscholastic Athletic Program for the school year 20___ - 20___. We acknowledge that we have been fully informed of the physical hazards in the participation of any or all athletic activities and the risk of physical injury which may occur to my son/daughter as a result of participation in such athletic activity. I have read the statement concerning the rules of training, proper conduct, and responsible behavior as established in the Athletic Policy and by the coach(es) my son/daughter has agreed to participation under. I understand the rules and penalties involved and will encourage my son/daughter to abide by them. I will make certain that he/she fulfills his/her obligations and responsibilities as stated in Part I. I give permission for the Governor Livingston Sports Medical Staff to assess and treat illnesses and injuries that occur during athletic contests and events. _____ Yes _____ No Date: Parent/Guardian:

PART III: ATHLETIC ELIGIBILITY N.J.S.I.A.A.

ATTENTION PARENTS TO BE ELIGIBLE:

1. To be eligible for athletic competition during the first semester (September 1 to January 31) of the 10th grade or higher, or the second year of attendance in the secondary school or beyond, a pupil must have passed 25% of the credits required by the State of New Jersey for Graduation, during the immediately preceding academic year. 2. To be eligible for athletic competition which begins during the second semester (February 1 to June 30) during the ninth grade or higher, the pupil must have passed the equivalent of 12 3/4% of the credits required by the State of New Jersey for graduation at the close of the preceding semester (January 31). Full year courses shall be equated as one-half of the total credits to be gained for the full year to determine credits passed during the immediately preceding semester. 3. The above paragraphs 1 and 2 shall not apply to incoming students from grammar school (grade 8). 4.Notwithstanding the provisions of paragraph 1 and 2 above, a pupil who is eligible at the beginning of a sports season shall be allowed

to finish that season. This is my ________semester in Governor Livingston HS, and my _____semester since first entering the ninth grade. Last semester I attended _______________________School in _________________City, ______State.

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New Jersey Department of Education ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM

Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA

Part A: HEALTH HISTORY QUESTIONNAIRE

Today’s Date:_____________________ Date of Last Sports Physical: __________________________

Student’s Name: __________________________________ Sex: M F (circle one) Age: ____ Grade: ________ Date of Birth: ____/___/_______ School: _____________________________ District: _______________________

Sport(s): _____________________________________________________________________ Home Phone: (_____) ___________

Provider Name (Medical Home): _______________________________ Phone: _______________________ Fax: ____________

EMERGENCY CONTACT INFORMATION

Name of parent/guardian: _________________________________ Relationship to student: ______________________________ Phone (work): _____________________ Phone (home):______________________________ Phone (cell): ______________

Additional emergency contact: ____________________________ Relationship to student: ______________________________ Phone (work): _____________________ Phone (home):______________________________ Phone (cell): ______________ Directions: Please answer the following questions about the student’s medical history by CIRCLING the correct response. Explain all “yes” responses on the lines below the questions. Please respond to all questions.

1. Have you ever had, or do you currently have: a. Restriction from sports for a health related problem? Y / N / Don’t Know b. An injury or illness since your last exam? Y / N / Don’t Know c. A chronic or ongoing illness (such as diabetes or asthma)? Y / N / Don’t Know

(1.) An inhaler or other prescription medicine to control asthma? Y / N / Don’t Know d. Any prescribed or over the counter medications that you take on a regular basis? Y / N / Don’t Know e. Surgery, hospitalization or any emergency room visit(s)? Y / N / Don’t Know f. Any allergies to medications? Y / N / Don’t Know g. Any allergies to bee stings, pollen, latex or foods? Y / N / Don’t Know

(1.) If yes, check type of reaction:

□ Rash □ Hives □ Breathing or other anaphylactic reaction (2.) Take any medication/Epipen taken for allergy symptoms? (List below.) Y / N / Don’t Know

h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Don’t Know i. A blood relative who died before age 50? Y / N / Don’t Know

Explain all “yes” answers here (include relevant dates): List all medications here:

Medication Name Dosage Frequency NJDOE/APPEF Revised 3/10 Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

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2. Have you ever had, or do you currently have, any of the following head-related conditions:

a. Concussion or head injury (including “bell rung” or a “ding”)? Y / N / Don’t Know b. Memory loss? Y / N / Don’t Know c. Knocked out? Y / N / Don’t Know c. A seizure? Y / N / Don’t Know d. Frequent or severe headaches (With or without exercise)? Y / N / Don’t Know e. Fuzzy or blurry vision Y / N / Don’t Know f. Sensitivity to light/noise Y / N / Don’t Know

Explain all “yes” answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

3. Have you ever had, or do you currently have, any of the following heart-related conditions: a. Restriction from sports for heart problems? Y / N / Don’t Know b. Chest pain or discomfort? Y / N / Don’t Know c. Heart murmur? Y / N / Don’t Know d. High blood pressure? Y / N / Don’t Know e. Elevated cholesterol level? Y / N / Don’t Know f. Heart infection? Y / N / Don’t Know g. Dizziness or passing out during or after exercise without known cause? Y / N / Don’t Know h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? Y / N / Don’t Know i. Racing or skipped heartbeats? Y / N / Don’t Know j. Unexplained difficulty breathing or fatigue during exercise? Y / N / Don’t Know k. Any family member (blood relative):

(1.) Under age 50 with a heart condition? Y / N / Don’t Know (2.) With Marfan Syndrome? Y / N / Don’t Know (3.) Died of a heart problem before age 50? If yes, at what age? _____________________ Y / N / Don’t Know (4.) Died with no known reason? Y / N / Don’t Know (5.) Died while exercising? If yes, was it during or after? (Circle one.) Y / N / Don’t Know


4. Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions: a. Vision problems? Y / N / Don’t Know

(1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) Y / N / Don’t Know b. Hearing loss or problems? Y / N / Don’t Know

(1.) Wear hearing aides or implants? Y / N / Don’t Know c. Nasal fractures or frequent nose bleeds? Y / N / Don’t Know d. Wear braces, retainer or protective mouth gear? Y / N / Don’t Know e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? Y / N / Don’t Know


5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions: a. Numbness, a “burner”, “stinger” or pinched nerve? Y / N / Don’t Know b. A sprain? Y / N / Don’t Know c. A strain? Y / N / Don’t Know d. Swelling or pain in muscles, tendons, bones or joints? Y / N / Don’t Know e. Dislocated joint(s)? Y / N / Don’t Know f. Upper or lower back pain? Y / N / Don’t Know g. Fracture(s), stress fracture(s), or broken bone(s)? Y / N / Don’t Know h. Do you wear any protective braces or equipment? Y / N / Don’t Know

Explain all (yes) answers here (include relevant dates): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

NJDOE/APPEF Revised 3/10 Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

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6. Have you ever had or do you currently have any of the following general or exercise related conditions:

a. Difficulty breathing? (1.) During exercise? Y / N / Don’t Know (2.) After running one mile? Y / N / Don’t Know (3.) Coughing, wheezing or shortness of breath in weather changes? Y / N / Don’t Know (4.) Exercise-induced asthma? Y / N / Don’t Know

i. Controlled with medication? (specify __________________________) Y / N / Don’t Know ii. Experience dizziness, passing out or fainting? Y / N / Don’t Know

b. Viral infections (e.g. mono, hepatitis, coxsackie virus)? Y / N / Don’t Know c. Become tired more quickly than others? Y / N / Don’t Know d. Any of the following skin conditions:

(1.) Cold sores/herpes, impetigo, MRSA, ringworm, warts? Y / N / Don’t Know (2.) Sun sensitivity? Y / N / Don’t Know

e. Weight gain/loss (of 10 pounds or more)? Y / N / Don’t Know (1.) Do you want to weigh more or less than you do now? Y / N / Don’t Know

f. Ever had feelings of depression? Y / N / Don’t Know g. Heat-related problems (dehydration, dizziness, fatigue, headache)? Y / N / Don’t Know

(1.) Heat exhaustion (cool, clammy, damp skin)? Y / N / Don’t Know (2.) Heat stroke (hot, red, dry skin)? Y / N / Don’t Know (3.) Muscle cramps? Y / N / Don’t Know

h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)? Y / N / Don’t Know Explain all “yes” answers here (include relevant dates): __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

7. Females only: Age of onset of menstruation:______ How many menstrual periods in the last twelve (12) months? ________

How many periods missed in the last twelve (12) months? ________

8. Males only: Have you had any swelling or pain in your testicles or groin? Y / N / Don’t Know

PARENT/GUARDIAN SIGNATURE I certify that the information provided herein is accurate to the best of my knowledge as of the date of my signature.

_______________________________________ _________________ Signature, Parent/Guardian Date of Signature:

THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.


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ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM Part B: Physical Evaluation Form

(Completed by the examining licensed provider MD, DO, APN or PA)

-STUDENT INFORMATION-

Student’s Name: __________________________________ Sport(s): _______________________________________ Sex: M F (circle one) Age: ________ Grade: _____________ Date of Birth: _________________________________________ Address: ___________________________________________________________________________________________________________ City/State/Zip:________________________________________________ Home Phone: _________________________________________ School: _____________________________________________________ District: _____________________________________________ Parent/Guardian’s Full Name: __________________________________________________________________________________________

- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATION-

If conducted by school physician check here □ Name: _______________________________ Phone: __________________________ Fax: _________________

Address: ______________________________ City/State/Zip:_____________________________________________

- FINDINGS OF PHYSICAL EVALUATION -

Height: _________ Weight: _________ Blood Pressure: ______/_______ Pulse: _____bpm.

Vision: R 20/____ L 20/ ____ Corrected: Y / N Contacts: Y / N Glasses: Y / N

INDICATORS NORMAL? ABNORMAL FINDINGS/COMMENTS

General Appearance YES Head/Neck YES Eyes/Sclera/Pupils YES Ears YES

Gross Hearing YES Nose/Mouth/Throat YES Lymph Glands YES Cardiovascular YES

Heart Rate YES Rhythm YES Murmur ABSENT If murmur present Standing makes it: Louder Softer No Change

Squatting makes it: Louder Softer No Change Valsalva makes it: Louder Softer No Change

Femoral Pulses YES Lungs: Auscultation/Percussion YES Chest Contour YES Skin YES Abdomen (liver, spleen, masses) YES Assessment of physical maturation or YES Tanner Scale Testicular Exam (Males Only) YES Neck/Back/Spine: YES

Range of Motion YES Scoliosis ABSENT

Upper Extremities: (ROM, Strength, YES Stability) Lower Extremities: (ROM, Strength, YES Stability) Neurological: Balance & Coordination YES Hernia ABSENT Evidence of Marfan Syndrome ABSENT


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Most recent immunizations and dates administered: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Medications currently prescribed, with dose and frequency: Medication Name Dosage Frequency

Additional observations: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ General Diagnosis: ____________________________________________________________________________________________ ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

General Recommendations: ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.


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CLEARANCES: This section is completed by the examining healthcare provider.

After examining the student and reviewing the medical history the student is:

A. Cleared for participation in all sports without restrictions.

B. Not cleared for participation in any sport until evaluation/treatment of:

___________________________________________________________________________________

C. Cleared for limited participation in the following types of sports only. Please see below for sport classifications. CHECK ALL THAT APPLY

___ CONTACT/COLLISION ___ NON-CONTACT/STRENUOUS ___ LIMITED CONTACT ___ NON-CONTACT/NON-STRENUOUS

Limitations due to: ___________________________________________________________________ ________________________________________________

NOTES TO THE EXAMINING PROVIDER Conditions requiring clearance before sports participation include, but are not limited to the following: Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension; Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan’s Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye.

SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT Contact/Collision Limited Contact Non-Contact

Strenuous Non-strenuous Basketball Baseball Discus Bowling

Diving Cheerleading Javelin Golf Field Hockey Fencing Shot put

Football High Jump Marching Band Ice Hockey Pole vault Running/Cross Country Lacrosse Gymnastics Strength Training Soccer Skiing Swimming

Wrestling Softball Tennis Volleyball Track

Effects of physiologic maneuvers on heart sounds

Standing Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole

Squatting Increases murmur of AS, MR, AI Decreases murmur of MCH MVP click delayed

Valsalva Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole

HCM: Hypertrophic Cardio Myopathy AS: Aortic Stenosis AI: Aortic Insufficiency MR: Mitral Regugitation MVP: Mitral Valve Prolapse

Physical Stigmata of Marfan’s Syndrome

Kyphosis High arched palate Pectus excavatum Arachnodactyly Arm span > height 1.05:1 or greater Mitral Valve Prolapse Aortic Insufficiency Myopia Lenticular dislocation


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HISTORY REVIEWED AND STUDENT EXAMINED BY: Physician’s/Provider’s Stamp:

Primary Care Provider School Physician Provider License Type:

MD/DO APN PA

PHYSICIAN’S/PROVIDER’S SIGNATURE: __________________________________________________ Today’s Date: ______________ Date of Exam: ______________

RESERVED FOR SCHOOL DISTRICT USE NOTE: N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating approval or disapproval of the student’s participation in athletics based on this physical evaluation. This evaluation and the notification letter become part of the student’s school health record.

History and Physical Reviewed By: __________________________ ________ Date: _______________ Title of Reviewer (please check one): School Nurse School Physician

Medical Eligibility Notification Sent to Parent/Guardian by School Physician ______________________ Date

Letter of notification is attached.

OR

Parent notification indicates that:

Participation Approved without limitations.

Participation Approved with limitations pending evaluation.

Participation NOT Approved

Reason(s) for Disapproval: ____________________________________________________________


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Berkeley Heights Public Schools Berkeley Heights, NJ

Dear Parent/Guardian: Your son/daughter __________________________________

_____ Is cleared to participate on a school athletic squad or team based on the School Physician’s evaluation of your child.

_____ We have received your child Sports Medical Exam Form from your physician. The form is complete and your child may participate in athletics based solely on the medical. _____Your child’s physical expires on ____________. Submit completed forms on or before the expired date

to ensure that your child can participate in sport without interruption.

_____Participation NOT Approved - Reason(s) for Disapproval:

_____ Administration of Medication form (5330) needs to be filled out on a school

year basis for Asthma & or Epipen.

_____Clearance note from licensed care provider needed.

_____Medical Records indicate your child’s physical is expired.

All forms can be downloaded by visiting http://www.bhpsnj.org/~glweb/. Click on

Health Office or Athletics. Asthma & Epipen Conditional Clearance: If your son/daughter has a diagnosis of Asthma or an allergy, it is

the responsibility of the student and student’s family/guardian to ensure that the students have rescue medication with them at all practices games or meet. Dr. Richard Bezozo School Physician Revised 2010 14

http://www.bhpsnj.org/%7Eglweb/

checklist for filling out athletic forms...dimethylamphetamine epitrenbolone methyclothiazide...

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