-----

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

Forsyth County Physical Form

School Year

Lakeside Middle School

Student Name

Physical Expiration Date _______

) HYSICAL E V A L UATION

HISTORY FORM Note This form is to be filled out by the patient and parent prior to seeing the physician The physician should keep this form in the chart)

Dateof Exam

Name Dateof birth ___________

_ __________ Sport(s)Sex Age Grade School

Medicines and Allergies Please list all ot the prescription and overmiddottiemiddotcounter medicines and supplements (herbal and nutrit ional) that you are currently taking

Do you ha ve any allergies D Yes D No If yes please identifyspecific allergy below D edicmes D Poll ens D Food D Stinging Insects

Explain Yes answers below Circle questions you don t know the answers to

GENERAL QUESTIONS

I Hasarloclor ever denied or rest icted your participation 1n smicroorts lor any reason

2 Do you haveany ongoing medical conditions If so pleaseIdentity below D Aslhma D Anemia D Diabetes D Infections Other

3 Have you ever spent the night 1n the 11osp1a1

4 Have you over had surgery

HEART HEALTH QUESTIONS ABOUT YOU

5 Have youever passed out or nearly passed out DURING or AFTER exercise

6 Have you ever had discomfort pain tightnessor pressure in your chest during exercise

7 Does your heart ever race or skrp beats firregular beats) durrng exercrse

8 Has adoctor ve1 told you that you have any heart problems If so check all illat apply D High blood pressure D Aheart murmur D H1g11cholesterol D Aheart 111rect1on D Ka wasaki drsease Other

9 Has adoctor ever ordered alest tor your heart (For example ECGEKG echocardrogram)

I0 Do you get lightheaded or reel more short of breath than expecled during exercise

11 Haveyou ever had an unexplained serzure

12 Do you gel nore lrreo or short ol breath more quickly than your friends during exercise

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

13 Has any lamly member or relalivedied or heart problems or llad an unexpecte1J or unexpl~ined sudden deathbefore age 50 (lnclucling drowningunexplained car accident or suddeninfant deat11 syndrome)

14 Does anyoneIn your family llave hypertrophic cardlomyopathy Marfan syndrome anhythmogenic rrght ventncula1 cardiomyopathy long OT syndrome short OTsyndrome Brugada syndrome or catecholam1nergic polymorpl1lc ventricular tachycardra

15 Does anyone rn your am1ly have aheart problem acemaker or rmplanted defrbnllator

16 Has anyone rnyour family had unexplained lainlngunexplarned seizur es or near drownrng

BONE ANDJOINT QUESTIONS

17 Have you ever had an rn1ury to abone muscle lrgament or 1encton tllat causedyou lo miss a practice or agame

18 Haveyou ever hact any broken or fractured bones or dislocated joints

19 Have you ever llad an 1111ury ltlot requrred x-rays MRI CT scan rr11ect1ons t11erapya brace acast or crutches

20 Haveyouever 11ad astress frac ture

21 Haveyou ever been told that you have or have you had an x-ray for neck mstability or atlantoaxial rnstabilily(Down syndrome or dwarfism)

22 Do you regularly use a braceorthotics or otner assistive device

23 Do you have a bonemuscle or jornt 1n1ury that bothers you

24 Do any ol your Joints become parnful swollen leel warm or look red

25 Do you haveany history of 1uvenilearthrrtis or connective tissue disease

Yes

Yes

Yes

Yes

No

No

No

No

MEDICAL QUESTIONS Yes No

26 Do you cough wheeze or 11avedifl icully hrea t111 ng du11ng or after exerci se

27 Have you evor used an inhaler or taken asthma medicine

28 Is thereanyone in your family who has asthma

29 Wereyou born without or areyou rnrs Ing a krdney an eye a testicle (males) your spleen or any other organ

30 Doyou have grorn pain or a parnful bulge or hernia rn the gram area

31 Have you had rniectious rnononucleoss (mono) within the last month

32 Do you haveany rashes pressure sores or other skin problems

33 Have you 11ad aherpes or MRSA skin infection

34 Have you ever had ahead injuryor concussion

35 Have you ever had ahit or blow to the head that caused conlusion prolonged neadache or memory problems

36 Doyou have a history ol seizure disorder

37 Do you have headac11es with exercise

38 Have you ever had numbness linglrng or weakness 1n your arms or legs after berng hit or lalhrrg

39 Have you ever Ileen unable to move your arms or legs after berng hit or falling

40 Have you ever become 111 whileexercising 1n the neat

41 Do you get frequent muscle cramps when exerc1srng

42 Do you or someone inyour famrly have sickle cell trait or disease

43 Have you had any problems vir thyour eyes or v1s1on

44 Haveyou had any eye injuries

45 Do you wear glasses or contact tenses

46 Doyou wear microrolective eyewearsuch as goggles or a face s111eld

47 Do you worry about your weigllt

48 Areyou trying lo or has anyone recommended that yougarn or lose weight

49 Ale you on aspecial diet or do you avoid certain types of foods

50 Haveyou ever had an eating disorder

5t Do you have any concerns that you would like to a1scuss with aaooor

FEMALES ONLY

52 Have youever had a menst1ual period

53 How old wereyou when you had your frrst menstrual perrod

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 Oare ____ ___S1gn1wre ot 11 tl1lute Signatureol parenlguardlan ____ _ _ ______________

120 IO AmericHn Academy of Family Physicians Ameican Academy of Pediatrics American College of Sports MedicineAmerican Mecticat Society for Sports MedicineAmerican Orthopaedic Society tor Sports Medicineand American OsteopathicAcademy of Spots Medicine Permission ts granted to reprint tor noncommercial educatlonal purposes with acknowledgment

9middot2681041 0

P I- I ~If-~ 1 I ICAL VALUATION

THE ATHLETE WITH SPECIAL NEEDS SUPPLEMENTAL HISTORY FORM

Date of Exam

arne Dateof birth

Sex Age Grade Sc ool Sport(s)

t Type of disability

2 Date of disability

3 Classification (If available)

~- Cause01disability (birth disease accidenV1rau111a olher)

5 Lisi lhe smicroorts you are 1nleresled 111 playing

Yes No 6 Do you regularly usea brace assstive device or prosthelic

7 Do you use any special braceor ass1stive device for sports

8 Do yo u 11ave any rashes pressure sores or any other skin problems

9 Do you have a hearing loss Doyou use ahearing aid

t0 Do you have avisual impai menP

t 1 Do you use any special devices for bowel 01 bladde1 functi on

12 Do you have burning or di scomfort wh en urinating

13 Have you had autonomic dysreflexia

14 Have you ever been di agnosed w1lh aheat -related 1hypertherm1a) or cold-relaled (hypothermia) illness

15 Do you have musclespastic1ty

16 Do you have frequenl se11ures Iha cannol be controlled by med1cat1on

Explain yes answers here

Please indicate if you have ever had any of the following

Yes No Allantoax1al nstab1hty

X-ray evaluation for at1anioax1al inslability

Dislocated Jo1 n1s (more lhan one)

Easy bleeding

Fnlarged splem1

Hepalilis

Osteopenia 01 osleoporosis

Difficulty controll ing bowel

D1ff1cully conlrolllng bladder

Numbness or tingling 111 arms or 11ands

Numbness or tingt1ng in legs or feel

Weakness in arms or hands

Weakness in logs or feet

Recent change in coordina11on

Recent change in ability lo walk

Spina b1flda

La tex allergy

Explain yes answers here

I hereby stato thal to the best of my knowledgemy answers to the above questions are complete and correct

S1onatueof lhlc10 S1gnal1weol parnnrguardinn ____________________ Date _ _______

([) 2010 American Academy of Fa1111ly P11yslciansAmerican Academy of PediatricsAmerican Collegeof Sports Medicine American Me1Jlc11 Sociuty for Sports Medrci11e American Orthomicro11edic Socrely for Spo11s Medicine anC1 American OsteopathicAcademy of Sports Medicine Pern11sslon is granted to reprint tor noncommercial educational purposes withacknowledgment

FORSYTH COUNTY SCHOOL SYSTEM ATHLETIC PARTICIPATION FORM -- - - ~ -= -=

FORSYTH COUNTY ATHLETICS PERM ISSION FORM I

I

Student - Athlete(Please Print) Name of ParentGuardian(Please Print)

Street Address School Grade CIRCLE ONE I

7 8 9 10 11 12

City State Zip Date of Birth Phone Home shy

Workshy~ ~~--=-- shy ~ =-=~ -- - ~=~ = -- --==

In the event of emergency please give the best person and method to contact in the box provided

I Name Relationship Phone Alt I I Request for Permission We the undersigned student and the students parentguard ian apply for permission to participate in interscholastic athlet ics in the followin~ sport(s)

[ ] Baseball Softball [ ] Cross Country ( ] Lacrosse [ ] Tennis [ ] Gymnastics

I[ ] Basketball ( ] Football [ ] Soccer [ ] Track amp Field [ ] Other

~ ]~ading [ ] Golf [ ] Swimming [ ] Wrestling -~= ---= = - ~ =

I

General Requirements- We have read and discussed the general requirements for athletic eligibility We understand that additional questions or specific circumstances should be directed to our students coach athletic director or principa~ We understand that the FC Athletic Guidelines are available through the county website for review

Risk of Injury- We acknowledge and understand that there is a risk of injury involved in athletic participation We understand that the student-athlete will be under the supeNision and direction of a FCSS athletic coach We agree to follow the rules of the sport and the instruction s of the coach in order to reduce the risk of injury to the student and other

II athletes However we acknowledge and understand that neither the coach nor FCSS can eliminate the risk of injury in I sports Injuries may and do occu r Sports injuries can be severe and in some cases may result in permanent disability or even death We freely knowingly and willfully accept and assume the risk of injury that might occur from participation in athletics

Release- In consideration of FCSS allowing the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arisinq from or out of any injury that the student-athlete mav suffer from participation in athletics

Insurance- FCSS requires parents to provide information pertaining to medical insurance coverage for all student I 1 athletes Parents have the option to purchase school insurance (please see school athletic director) or to maintain I

coverage under parental insurance provider

Check One [ I School Accident Insurance [ J Name of Other Insurance Company Policy No

1middot

I Address Group No

CERTIFICATION AND MEDICAL AUTHORIZATION We certify that all of the information provided by us on th is form is correct We agree to abide by state and local rules If the student-athlete is injured wh ile participating in athletics and FCSS is unable to contact the parent we grant FCSS permission and authority to obta in necessary medical care andor treatment for the students injury Treatment may include but is not limited to first aid CPR medical or surg ical treatment

I recommended b a h sician We acce t the financial res onsibil it for such medical care or treatment I middot We the undersigned student and parent have read this document and understand all of the expectations for I

athletic

Student

artici ation at m school

-=

Date

Date -middot =middotshy - ~===~===~~= ~~d

_ ________________________________ _ __________ ___ ______ _

_______ ___ ____ _

0P gt h rPA I 1i-1( AL =VALUATION

PHYSICAL E X AMINATION FORM Name Date of birth

r1 ltsrc n I mi 1 Cons1dor additional questions on more sensitive ssues

bull Do you feel stressed out or under a lot of pressure bull Do you ever feel sad hopeless depressed or anxious bull Do you feel safe at your home or residence bull Haveyou ever tried cigarettes chewing tobacco snutt or drp bull Du11ng thepast 30 days did you use chewing tobacco snuH or dip bull Do youdrink alcohol or use any other drugs bull Have you ever taken anabolic sterords or used any other performancesupplement bull Have you ever taken any supplements to help you gain or lose weight or improve your performance bull Do you wear aseat belt use ahelmet and use condoms

2 Con rder revewrng questions on cardiovascular symptoms (questions 5-14)

EXA MINATI ON

Height werght o Male D Female

BP I ( I ) Pu lse Vision A 201 L 201 Corrected DY O N

MEDI CAL NOR MAL ABNO RM AL FINDI NGS Appearance bull Marian stigmata (kyphoscoliosis high-arched palale pec tus excavalum arachnodactyly

arm span gt height hyperlaxily my~pi a MVPaortic insutf iciency)

Eyesearslnoselth roal bull Pu pils equal bull Hearing

Lymph nodes H a11 bull ur mur (ausculta on standing supne +- Valsalva) bull Loca tion of point of maximal mpulse (PMI)

Puls s bull smultaneous fem oral and radal pulses

Lungs

Abdom en Genitourinary (mates only)

Skrn bull HSV lesions suggestive ol MRSA tinea orporis

Neurologrc

MUSC ULOS KEL ETA L Neck

Back

Shoulderarm Elbowforearm

WnsVhandlfrngers

Hipthigh

Knee

LeganKle

Foottoes Functional bull Duck-walk single log hon

middotCo11 suJt1 1tCh etllUL t1tJ1oun1 m 1md 1tltbullrr11 10 1utlmloyy tu 11 lmu111 1 I cm tJ1ac 111slory or tl( 11 m Cons1dc1GU C(ll m11 111 nnval e so tMg tlav1ng t1111C1 party present s 1orornmendatL Cons1dfl1 C0tJn1tlvo valua 11on or baschnr nc1ropsychiatnc tP~hnJ If a h1stn1y ol siJ01l1cmt crincuss1on

D Cleared for all sports without rest11ctro 11

D Cleared for all spans wrthou( restrrctron wrth recornmendat1ons lor further evaluation or treatment for

D Not cleared

D Pending fur111er evaluation

D For any sporls

D For certain sports - - ------------- ------------ ----- - --------------shy

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 thospor1(s) as outl ined above A copy of the physical exam is on record in my office and can be made available to tho school at the request of the parents If condishytions arise after the athlete has been cleared for participation the physician may rescind the clearance until the prob lem is resolved and the potential consequences are completely explained to the athlete (and parentsguardians)

Name of ~hy s1c 1an (pnnttype) ______ _ ______________________ Da te _

Address Phone

Signature of physician - - ------ ------ ------------ - --- -------------- --middot MO or DO

copy201 OAmerican Academy of Family PnyslciansAmerican Academy of Pedi11tricsAmerican College of Sports MedicineAmerican Medical Society tor Spotts Medicine American Orthopaedic Society for Sports Medicine and American Osteopalhic Academy of Sports Medicine Permission is granted to reprint lo noncommercial educational purposes with acknowledgment HF0Sll3 q 26811)4 0

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

tF A 11 r rSICAL EVALUATION

CLEARANCE FORM Name ______________________ Sex O M O F Age _______ Date of birth _______

D Cleared for all sports without restriction

D Cleared for all sports without restriction with recommendations for further evaluation or treatment for

D Not cleared

D Pending further eval uation

D For any sports

D For certain ports ________________________________________ _

Reason

Rocornmendations

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 parentsguardians)

Name of physician (prinVtype) _ ________________________________ Date ____ ___

Address ____________________________________ Phone __________

Signature of physician---------------- -------- -----------------middot MD or DO

EMERGENCY INFORMATION

Other inform ation

- --- -middotmiddot----- - shy2010 American Academy of Family Physicians American Academy of Pediatrics Amencan College of Sports MedicineAmerican Medical Society or Sports MedicineAmerican 011Jopaedic Society for Sp01s Medicineand American Osteopathic Academy of Sports Medicine Permission Is granted to reprint for noncommercial educational purposes with acknowledgment

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

BLANKET PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL SPONSORED FIELD TRIPS

Sport _________ School Year School

I hereby request that ________________ (Students Name-PLEASE PRINT) be alshylowed to participate in athletic team band orchestra chorus andor any series of field trips re lated to one parshyticular area of study or activity I understand that transportation may or may not be provided by the Forsyth County School District (District) In the event transportation is not provided by the District transportation w ill be the parents responsibility

All team members will ride to an event in school provided transportation with the team Any athlete who arranges independent transportation to an event without permission from the coach and the Athletic Dishyrector in advance will be ineligible to compete in that event All team members will return to their High School in the Forsyth County provided transportation unless a Travel Release form is completed by a parentguardian (see the head coach) Athletes will only be released to their own parentguardian from a contest A parentguardian must sign out the athlete from the coach at the contest site If a student and hisher parent makes arrangements for private transportation they shall not hold the local school offishycers employees or agents responsible for any injury or loss

Detailed trip information including destination date time of departure time of return purpose and superv ishys ion w ill be g iven to the parentsguardians prior to each trip in the series (Exceptions must be approved by the Schoo l Director of Ath letics and Principal)

lf any emergency medical procedures or treatment are required by the student during the trip I consent to the trip superv isor(s) tak ing arranging for and consenting to the procedures or treatment in hisher or their discreshytion

In consideration of FCSS all owi ng the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arising from or out of any injury that the student-athlete may suffer from particshyipation in athletics

NOTE This form must be signed by student if the student is 18 years of age or older

Name of Student (PLEASE PRINT) Signature of Student Date

Na me of ParentGuardian (PLEASE PRINT) Signature of ParentGuardian Date

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE

) HYSICAL E V A L UATION

HISTORY FORM Note This form is to be filled out by the patient and parent prior to seeing the physician The physician should keep this form in the chart)

Dateof Exam

Name Dateof birth ___________

_ __________ Sport(s)Sex Age Grade School

Medicines and Allergies Please list all ot the prescription and overmiddottiemiddotcounter medicines and supplements (herbal and nutrit ional) that you are currently taking

Do you ha ve any allergies D Yes D No If yes please identifyspecific allergy below D edicmes D Poll ens D Food D Stinging Insects

Explain Yes answers below Circle questions you don t know the answers to

GENERAL QUESTIONS

I Hasarloclor ever denied or rest icted your participation 1n smicroorts lor any reason

2 Do you haveany ongoing medical conditions If so pleaseIdentity below D Aslhma D Anemia D Diabetes D Infections Other

3 Have you ever spent the night 1n the 11osp1a1

4 Have you over had surgery

HEART HEALTH QUESTIONS ABOUT YOU

5 Have youever passed out or nearly passed out DURING or AFTER exercise

6 Have you ever had discomfort pain tightnessor pressure in your chest during exercise

7 Does your heart ever race or skrp beats firregular beats) durrng exercrse

8 Has adoctor ve1 told you that you have any heart problems If so check all illat apply D High blood pressure D Aheart murmur D H1g11cholesterol D Aheart 111rect1on D Ka wasaki drsease Other

9 Has adoctor ever ordered alest tor your heart (For example ECGEKG echocardrogram)

I0 Do you get lightheaded or reel more short of breath than expecled during exercise

11 Haveyou ever had an unexplained serzure

12 Do you gel nore lrreo or short ol breath more quickly than your friends during exercise

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

13 Has any lamly member or relalivedied or heart problems or llad an unexpecte1J or unexpl~ined sudden deathbefore age 50 (lnclucling drowningunexplained car accident or suddeninfant deat11 syndrome)

14 Does anyoneIn your family llave hypertrophic cardlomyopathy Marfan syndrome anhythmogenic rrght ventncula1 cardiomyopathy long OT syndrome short OTsyndrome Brugada syndrome or catecholam1nergic polymorpl1lc ventricular tachycardra

15 Does anyone rn your am1ly have aheart problem acemaker or rmplanted defrbnllator

16 Has anyone rnyour family had unexplained lainlngunexplarned seizur es or near drownrng

BONE ANDJOINT QUESTIONS

17 Have you ever had an rn1ury to abone muscle lrgament or 1encton tllat causedyou lo miss a practice or agame

18 Haveyou ever hact any broken or fractured bones or dislocated joints

19 Have you ever llad an 1111ury ltlot requrred x-rays MRI CT scan rr11ect1ons t11erapya brace acast or crutches

20 Haveyouever 11ad astress frac ture

21 Haveyou ever been told that you have or have you had an x-ray for neck mstability or atlantoaxial rnstabilily(Down syndrome or dwarfism)

22 Do you regularly use a braceorthotics or otner assistive device

23 Do you have a bonemuscle or jornt 1n1ury that bothers you

24 Do any ol your Joints become parnful swollen leel warm or look red

25 Do you haveany history of 1uvenilearthrrtis or connective tissue disease

Yes

Yes

Yes

Yes

No

No

No

No

MEDICAL QUESTIONS Yes No

26 Do you cough wheeze or 11avedifl icully hrea t111 ng du11ng or after exerci se

27 Have you evor used an inhaler or taken asthma medicine

28 Is thereanyone in your family who has asthma

29 Wereyou born without or areyou rnrs Ing a krdney an eye a testicle (males) your spleen or any other organ

30 Doyou have grorn pain or a parnful bulge or hernia rn the gram area

31 Have you had rniectious rnononucleoss (mono) within the last month

32 Do you haveany rashes pressure sores or other skin problems

33 Have you 11ad aherpes or MRSA skin infection

34 Have you ever had ahead injuryor concussion

35 Have you ever had ahit or blow to the head that caused conlusion prolonged neadache or memory problems

36 Doyou have a history ol seizure disorder

37 Do you have headac11es with exercise

38 Have you ever had numbness linglrng or weakness 1n your arms or legs after berng hit or lalhrrg

39 Have you ever Ileen unable to move your arms or legs after berng hit or falling

40 Have you ever become 111 whileexercising 1n the neat

41 Do you get frequent muscle cramps when exerc1srng

42 Do you or someone inyour famrly have sickle cell trait or disease

43 Have you had any problems vir thyour eyes or v1s1on

44 Haveyou had any eye injuries

45 Do you wear glasses or contact tenses

46 Doyou wear microrolective eyewearsuch as goggles or a face s111eld

47 Do you worry about your weigllt

48 Areyou trying lo or has anyone recommended that yougarn or lose weight

49 Ale you on aspecial diet or do you avoid certain types of foods

50 Haveyou ever had an eating disorder

5t Do you have any concerns that you would like to a1scuss with aaooor

FEMALES ONLY

52 Have youever had a menst1ual period

53 How old wereyou when you had your frrst menstrual perrod

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 Oare ____ ___S1gn1wre ot 11 tl1lute Signatureol parenlguardlan ____ _ _ ______________

120 IO AmericHn Academy of Family Physicians Ameican Academy of Pediatrics American College of Sports MedicineAmerican Mecticat Society for Sports MedicineAmerican Orthopaedic Society tor Sports Medicineand American OsteopathicAcademy of Spots Medicine Permission ts granted to reprint tor noncommercial educatlonal purposes with acknowledgment

9middot2681041 0

P I- I ~If-~ 1 I ICAL VALUATION

THE ATHLETE WITH SPECIAL NEEDS SUPPLEMENTAL HISTORY FORM

Date of Exam

arne Dateof birth

Sex Age Grade Sc ool Sport(s)

t Type of disability

2 Date of disability

3 Classification (If available)

~- Cause01disability (birth disease accidenV1rau111a olher)

5 Lisi lhe smicroorts you are 1nleresled 111 playing

Yes No 6 Do you regularly usea brace assstive device or prosthelic

7 Do you use any special braceor ass1stive device for sports

8 Do yo u 11ave any rashes pressure sores or any other skin problems

9 Do you have a hearing loss Doyou use ahearing aid

t0 Do you have avisual impai menP

t 1 Do you use any special devices for bowel 01 bladde1 functi on

12 Do you have burning or di scomfort wh en urinating

13 Have you had autonomic dysreflexia

14 Have you ever been di agnosed w1lh aheat -related 1hypertherm1a) or cold-relaled (hypothermia) illness

15 Do you have musclespastic1ty

16 Do you have frequenl se11ures Iha cannol be controlled by med1cat1on

Explain yes answers here

Please indicate if you have ever had any of the following

Yes No Allantoax1al nstab1hty

X-ray evaluation for at1anioax1al inslability

Dislocated Jo1 n1s (more lhan one)

Easy bleeding

Fnlarged splem1

Hepalilis

Osteopenia 01 osleoporosis

Difficulty controll ing bowel

D1ff1cully conlrolllng bladder

Numbness or tingling 111 arms or 11ands

Numbness or tingt1ng in legs or feel

Weakness in arms or hands

Weakness in logs or feet

Recent change in coordina11on

Recent change in ability lo walk

Spina b1flda

La tex allergy

Explain yes answers here

I hereby stato thal to the best of my knowledgemy answers to the above questions are complete and correct

S1onatueof lhlc10 S1gnal1weol parnnrguardinn ____________________ Date _ _______

([) 2010 American Academy of Fa1111ly P11yslciansAmerican Academy of PediatricsAmerican Collegeof Sports Medicine American Me1Jlc11 Sociuty for Sports Medrci11e American Orthomicro11edic Socrely for Spo11s Medicine anC1 American OsteopathicAcademy of Sports Medicine Pern11sslon is granted to reprint tor noncommercial educational purposes withacknowledgment

FORSYTH COUNTY SCHOOL SYSTEM ATHLETIC PARTICIPATION FORM -- - - ~ -= -=

FORSYTH COUNTY ATHLETICS PERM ISSION FORM I

I

Student - Athlete(Please Print) Name of ParentGuardian(Please Print)

Street Address School Grade CIRCLE ONE I

7 8 9 10 11 12

City State Zip Date of Birth Phone Home shy

Workshy~ ~~--=-- shy ~ =-=~ -- - ~=~ = -- --==

In the event of emergency please give the best person and method to contact in the box provided

I Name Relationship Phone Alt I I Request for Permission We the undersigned student and the students parentguard ian apply for permission to participate in interscholastic athlet ics in the followin~ sport(s)

[ ] Baseball Softball [ ] Cross Country ( ] Lacrosse [ ] Tennis [ ] Gymnastics

I[ ] Basketball ( ] Football [ ] Soccer [ ] Track amp Field [ ] Other

~ ]~ading [ ] Golf [ ] Swimming [ ] Wrestling -~= ---= = - ~ =

I

General Requirements- We have read and discussed the general requirements for athletic eligibility We understand that additional questions or specific circumstances should be directed to our students coach athletic director or principa~ We understand that the FC Athletic Guidelines are available through the county website for review

Risk of Injury- We acknowledge and understand that there is a risk of injury involved in athletic participation We understand that the student-athlete will be under the supeNision and direction of a FCSS athletic coach We agree to follow the rules of the sport and the instruction s of the coach in order to reduce the risk of injury to the student and other

II athletes However we acknowledge and understand that neither the coach nor FCSS can eliminate the risk of injury in I sports Injuries may and do occu r Sports injuries can be severe and in some cases may result in permanent disability or even death We freely knowingly and willfully accept and assume the risk of injury that might occur from participation in athletics

Release- In consideration of FCSS allowing the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arisinq from or out of any injury that the student-athlete mav suffer from participation in athletics

Insurance- FCSS requires parents to provide information pertaining to medical insurance coverage for all student I 1 athletes Parents have the option to purchase school insurance (please see school athletic director) or to maintain I

coverage under parental insurance provider

Check One [ I School Accident Insurance [ J Name of Other Insurance Company Policy No

1middot

I Address Group No

CERTIFICATION AND MEDICAL AUTHORIZATION We certify that all of the information provided by us on th is form is correct We agree to abide by state and local rules If the student-athlete is injured wh ile participating in athletics and FCSS is unable to contact the parent we grant FCSS permission and authority to obta in necessary medical care andor treatment for the students injury Treatment may include but is not limited to first aid CPR medical or surg ical treatment

I recommended b a h sician We acce t the financial res onsibil it for such medical care or treatment I middot We the undersigned student and parent have read this document and understand all of the expectations for I

athletic

Student

artici ation at m school

-=

Date

Date -middot =middotshy - ~===~===~~= ~~d

_ ________________________________ _ __________ ___ ______ _

_______ ___ ____ _

0P gt h rPA I 1i-1( AL =VALUATION

PHYSICAL E X AMINATION FORM Name Date of birth

r1 ltsrc n I mi 1 Cons1dor additional questions on more sensitive ssues

bull Do you feel stressed out or under a lot of pressure bull Do you ever feel sad hopeless depressed or anxious bull Do you feel safe at your home or residence bull Haveyou ever tried cigarettes chewing tobacco snutt or drp bull Du11ng thepast 30 days did you use chewing tobacco snuH or dip bull Do youdrink alcohol or use any other drugs bull Have you ever taken anabolic sterords or used any other performancesupplement bull Have you ever taken any supplements to help you gain or lose weight or improve your performance bull Do you wear aseat belt use ahelmet and use condoms

2 Con rder revewrng questions on cardiovascular symptoms (questions 5-14)

EXA MINATI ON

Height werght o Male D Female

BP I ( I ) Pu lse Vision A 201 L 201 Corrected DY O N

MEDI CAL NOR MAL ABNO RM AL FINDI NGS Appearance bull Marian stigmata (kyphoscoliosis high-arched palale pec tus excavalum arachnodactyly

arm span gt height hyperlaxily my~pi a MVPaortic insutf iciency)

Eyesearslnoselth roal bull Pu pils equal bull Hearing

Lymph nodes H a11 bull ur mur (ausculta on standing supne +- Valsalva) bull Loca tion of point of maximal mpulse (PMI)

Puls s bull smultaneous fem oral and radal pulses

Lungs

Abdom en Genitourinary (mates only)

Skrn bull HSV lesions suggestive ol MRSA tinea orporis

Neurologrc

MUSC ULOS KEL ETA L Neck

Back

Shoulderarm Elbowforearm

WnsVhandlfrngers

Hipthigh

Knee

LeganKle

Foottoes Functional bull Duck-walk single log hon

middotCo11 suJt1 1tCh etllUL t1tJ1oun1 m 1md 1tltbullrr11 10 1utlmloyy tu 11 lmu111 1 I cm tJ1ac 111slory or tl( 11 m Cons1dc1GU C(ll m11 111 nnval e so tMg tlav1ng t1111C1 party present s 1orornmendatL Cons1dfl1 C0tJn1tlvo valua 11on or baschnr nc1ropsychiatnc tP~hnJ If a h1stn1y ol siJ01l1cmt crincuss1on

D Cleared for all sports without rest11ctro 11

D Cleared for all spans wrthou( restrrctron wrth recornmendat1ons lor further evaluation or treatment for

D Not cleared

D Pending fur111er evaluation

D For any sporls

D For certain sports - - ------------- ------------ ----- - --------------shy

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 thospor1(s) as outl ined above A copy of the physical exam is on record in my office and can be made available to tho school at the request of the parents If condishytions arise after the athlete has been cleared for participation the physician may rescind the clearance until the prob lem is resolved and the potential consequences are completely explained to the athlete (and parentsguardians)

Name of ~hy s1c 1an (pnnttype) ______ _ ______________________ Da te _

Address Phone

Signature of physician - - ------ ------ ------------ - --- -------------- --middot MO or DO

copy201 OAmerican Academy of Family PnyslciansAmerican Academy of Pedi11tricsAmerican College of Sports MedicineAmerican Medical Society tor Spotts Medicine American Orthopaedic Society for Sports Medicine and American Osteopalhic Academy of Sports Medicine Permission is granted to reprint lo noncommercial educational purposes with acknowledgment HF0Sll3 q 26811)4 0

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

tF A 11 r rSICAL EVALUATION

CLEARANCE FORM Name ______________________ Sex O M O F Age _______ Date of birth _______

D Cleared for all sports without restriction

D Cleared for all sports without restriction with recommendations for further evaluation or treatment for

D Not cleared

D Pending further eval uation

D For any sports

D For certain ports ________________________________________ _

Reason

Rocornmendations

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 parentsguardians)

Name of physician (prinVtype) _ ________________________________ Date ____ ___

Address ____________________________________ Phone __________

Signature of physician---------------- -------- -----------------middot MD or DO

EMERGENCY INFORMATION

Other inform ation

- --- -middotmiddot----- - shy2010 American Academy of Family Physicians American Academy of Pediatrics Amencan College of Sports MedicineAmerican Medical Society or Sports MedicineAmerican 011Jopaedic Society for Sp01s Medicineand American Osteopathic Academy of Sports Medicine Permission Is granted to reprint for noncommercial educational purposes with acknowledgment

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

BLANKET PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL SPONSORED FIELD TRIPS

Sport _________ School Year School

I hereby request that ________________ (Students Name-PLEASE PRINT) be alshylowed to participate in athletic team band orchestra chorus andor any series of field trips re lated to one parshyticular area of study or activity I understand that transportation may or may not be provided by the Forsyth County School District (District) In the event transportation is not provided by the District transportation w ill be the parents responsibility

All team members will ride to an event in school provided transportation with the team Any athlete who arranges independent transportation to an event without permission from the coach and the Athletic Dishyrector in advance will be ineligible to compete in that event All team members will return to their High School in the Forsyth County provided transportation unless a Travel Release form is completed by a parentguardian (see the head coach) Athletes will only be released to their own parentguardian from a contest A parentguardian must sign out the athlete from the coach at the contest site If a student and hisher parent makes arrangements for private transportation they shall not hold the local school offishycers employees or agents responsible for any injury or loss

Detailed trip information including destination date time of departure time of return purpose and superv ishys ion w ill be g iven to the parentsguardians prior to each trip in the series (Exceptions must be approved by the Schoo l Director of Ath letics and Principal)

lf any emergency medical procedures or treatment are required by the student during the trip I consent to the trip superv isor(s) tak ing arranging for and consenting to the procedures or treatment in hisher or their discreshytion

In consideration of FCSS all owi ng the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arising from or out of any injury that the student-athlete may suffer from particshyipation in athletics

NOTE This form must be signed by student if the student is 18 years of age or older

Name of Student (PLEASE PRINT) Signature of Student Date

Na me of ParentGuardian (PLEASE PRINT) Signature of ParentGuardian Date

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE

P I- I ~If-~ 1 I ICAL VALUATION

THE ATHLETE WITH SPECIAL NEEDS SUPPLEMENTAL HISTORY FORM

Date of Exam

arne Dateof birth

Sex Age Grade Sc ool Sport(s)

t Type of disability

2 Date of disability

3 Classification (If available)

~- Cause01disability (birth disease accidenV1rau111a olher)

5 Lisi lhe smicroorts you are 1nleresled 111 playing

Yes No 6 Do you regularly usea brace assstive device or prosthelic

7 Do you use any special braceor ass1stive device for sports

8 Do yo u 11ave any rashes pressure sores or any other skin problems

9 Do you have a hearing loss Doyou use ahearing aid

t0 Do you have avisual impai menP

t 1 Do you use any special devices for bowel 01 bladde1 functi on

12 Do you have burning or di scomfort wh en urinating

13 Have you had autonomic dysreflexia

14 Have you ever been di agnosed w1lh aheat -related 1hypertherm1a) or cold-relaled (hypothermia) illness

15 Do you have musclespastic1ty

16 Do you have frequenl se11ures Iha cannol be controlled by med1cat1on

Explain yes answers here

Please indicate if you have ever had any of the following

Yes No Allantoax1al nstab1hty

X-ray evaluation for at1anioax1al inslability

Dislocated Jo1 n1s (more lhan one)

Easy bleeding

Fnlarged splem1

Hepalilis

Osteopenia 01 osleoporosis

Difficulty controll ing bowel

D1ff1cully conlrolllng bladder

Numbness or tingling 111 arms or 11ands

Numbness or tingt1ng in legs or feel

Weakness in arms or hands

Weakness in logs or feet

Recent change in coordina11on

Recent change in ability lo walk

Spina b1flda

La tex allergy

Explain yes answers here

I hereby stato thal to the best of my knowledgemy answers to the above questions are complete and correct

S1onatueof lhlc10 S1gnal1weol parnnrguardinn ____________________ Date _ _______

([) 2010 American Academy of Fa1111ly P11yslciansAmerican Academy of PediatricsAmerican Collegeof Sports Medicine American Me1Jlc11 Sociuty for Sports Medrci11e American Orthomicro11edic Socrely for Spo11s Medicine anC1 American OsteopathicAcademy of Sports Medicine Pern11sslon is granted to reprint tor noncommercial educational purposes withacknowledgment

FORSYTH COUNTY SCHOOL SYSTEM ATHLETIC PARTICIPATION FORM -- - - ~ -= -=

FORSYTH COUNTY ATHLETICS PERM ISSION FORM I

I

Student - Athlete(Please Print) Name of ParentGuardian(Please Print)

Street Address School Grade CIRCLE ONE I

7 8 9 10 11 12

City State Zip Date of Birth Phone Home shy

Workshy~ ~~--=-- shy ~ =-=~ -- - ~=~ = -- --==

In the event of emergency please give the best person and method to contact in the box provided

I Name Relationship Phone Alt I I Request for Permission We the undersigned student and the students parentguard ian apply for permission to participate in interscholastic athlet ics in the followin~ sport(s)

[ ] Baseball Softball [ ] Cross Country ( ] Lacrosse [ ] Tennis [ ] Gymnastics

I[ ] Basketball ( ] Football [ ] Soccer [ ] Track amp Field [ ] Other

~ ]~ading [ ] Golf [ ] Swimming [ ] Wrestling -~= ---= = - ~ =

I

General Requirements- We have read and discussed the general requirements for athletic eligibility We understand that additional questions or specific circumstances should be directed to our students coach athletic director or principa~ We understand that the FC Athletic Guidelines are available through the county website for review

Risk of Injury- We acknowledge and understand that there is a risk of injury involved in athletic participation We understand that the student-athlete will be under the supeNision and direction of a FCSS athletic coach We agree to follow the rules of the sport and the instruction s of the coach in order to reduce the risk of injury to the student and other

II athletes However we acknowledge and understand that neither the coach nor FCSS can eliminate the risk of injury in I sports Injuries may and do occu r Sports injuries can be severe and in some cases may result in permanent disability or even death We freely knowingly and willfully accept and assume the risk of injury that might occur from participation in athletics

Release- In consideration of FCSS allowing the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arisinq from or out of any injury that the student-athlete mav suffer from participation in athletics

Insurance- FCSS requires parents to provide information pertaining to medical insurance coverage for all student I 1 athletes Parents have the option to purchase school insurance (please see school athletic director) or to maintain I

coverage under parental insurance provider

Check One [ I School Accident Insurance [ J Name of Other Insurance Company Policy No

1middot

I Address Group No

CERTIFICATION AND MEDICAL AUTHORIZATION We certify that all of the information provided by us on th is form is correct We agree to abide by state and local rules If the student-athlete is injured wh ile participating in athletics and FCSS is unable to contact the parent we grant FCSS permission and authority to obta in necessary medical care andor treatment for the students injury Treatment may include but is not limited to first aid CPR medical or surg ical treatment

I recommended b a h sician We acce t the financial res onsibil it for such medical care or treatment I middot We the undersigned student and parent have read this document and understand all of the expectations for I

athletic

Student

artici ation at m school

-=

Date

Date -middot =middotshy - ~===~===~~= ~~d

_ ________________________________ _ __________ ___ ______ _

_______ ___ ____ _

0P gt h rPA I 1i-1( AL =VALUATION

PHYSICAL E X AMINATION FORM Name Date of birth

r1 ltsrc n I mi 1 Cons1dor additional questions on more sensitive ssues

bull Do you feel stressed out or under a lot of pressure bull Do you ever feel sad hopeless depressed or anxious bull Do you feel safe at your home or residence bull Haveyou ever tried cigarettes chewing tobacco snutt or drp bull Du11ng thepast 30 days did you use chewing tobacco snuH or dip bull Do youdrink alcohol or use any other drugs bull Have you ever taken anabolic sterords or used any other performancesupplement bull Have you ever taken any supplements to help you gain or lose weight or improve your performance bull Do you wear aseat belt use ahelmet and use condoms

2 Con rder revewrng questions on cardiovascular symptoms (questions 5-14)

EXA MINATI ON

Height werght o Male D Female

BP I ( I ) Pu lse Vision A 201 L 201 Corrected DY O N

MEDI CAL NOR MAL ABNO RM AL FINDI NGS Appearance bull Marian stigmata (kyphoscoliosis high-arched palale pec tus excavalum arachnodactyly

arm span gt height hyperlaxily my~pi a MVPaortic insutf iciency)

Eyesearslnoselth roal bull Pu pils equal bull Hearing

Lymph nodes H a11 bull ur mur (ausculta on standing supne +- Valsalva) bull Loca tion of point of maximal mpulse (PMI)

Puls s bull smultaneous fem oral and radal pulses

Lungs

Abdom en Genitourinary (mates only)

Skrn bull HSV lesions suggestive ol MRSA tinea orporis

Neurologrc

MUSC ULOS KEL ETA L Neck

Back

Shoulderarm Elbowforearm

WnsVhandlfrngers

Hipthigh

Knee

LeganKle

Foottoes Functional bull Duck-walk single log hon

middotCo11 suJt1 1tCh etllUL t1tJ1oun1 m 1md 1tltbullrr11 10 1utlmloyy tu 11 lmu111 1 I cm tJ1ac 111slory or tl( 11 m Cons1dc1GU C(ll m11 111 nnval e so tMg tlav1ng t1111C1 party present s 1orornmendatL Cons1dfl1 C0tJn1tlvo valua 11on or baschnr nc1ropsychiatnc tP~hnJ If a h1stn1y ol siJ01l1cmt crincuss1on

D Cleared for all sports without rest11ctro 11

D Cleared for all spans wrthou( restrrctron wrth recornmendat1ons lor further evaluation or treatment for

D Not cleared

D Pending fur111er evaluation

D For any sporls

D For certain sports - - ------------- ------------ ----- - --------------shy

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 thospor1(s) as outl ined above A copy of the physical exam is on record in my office and can be made available to tho school at the request of the parents If condishytions arise after the athlete has been cleared for participation the physician may rescind the clearance until the prob lem is resolved and the potential consequences are completely explained to the athlete (and parentsguardians)

Name of ~hy s1c 1an (pnnttype) ______ _ ______________________ Da te _

Address Phone

Signature of physician - - ------ ------ ------------ - --- -------------- --middot MO or DO

copy201 OAmerican Academy of Family PnyslciansAmerican Academy of Pedi11tricsAmerican College of Sports MedicineAmerican Medical Society tor Spotts Medicine American Orthopaedic Society for Sports Medicine and American Osteopalhic Academy of Sports Medicine Permission is granted to reprint lo noncommercial educational purposes with acknowledgment HF0Sll3 q 26811)4 0

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

tF A 11 r rSICAL EVALUATION

CLEARANCE FORM Name ______________________ Sex O M O F Age _______ Date of birth _______

D Cleared for all sports without restriction

D Cleared for all sports without restriction with recommendations for further evaluation or treatment for

D Not cleared

D Pending further eval uation

D For any sports

D For certain ports ________________________________________ _

Reason

Rocornmendations

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 parentsguardians)

Name of physician (prinVtype) _ ________________________________ Date ____ ___

Address ____________________________________ Phone __________

Signature of physician---------------- -------- -----------------middot MD or DO

EMERGENCY INFORMATION

Other inform ation

- --- -middotmiddot----- - shy2010 American Academy of Family Physicians American Academy of Pediatrics Amencan College of Sports MedicineAmerican Medical Society or Sports MedicineAmerican 011Jopaedic Society for Sp01s Medicineand American Osteopathic Academy of Sports Medicine Permission Is granted to reprint for noncommercial educational purposes with acknowledgment

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

BLANKET PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL SPONSORED FIELD TRIPS

Sport _________ School Year School

I hereby request that ________________ (Students Name-PLEASE PRINT) be alshylowed to participate in athletic team band orchestra chorus andor any series of field trips re lated to one parshyticular area of study or activity I understand that transportation may or may not be provided by the Forsyth County School District (District) In the event transportation is not provided by the District transportation w ill be the parents responsibility

All team members will ride to an event in school provided transportation with the team Any athlete who arranges independent transportation to an event without permission from the coach and the Athletic Dishyrector in advance will be ineligible to compete in that event All team members will return to their High School in the Forsyth County provided transportation unless a Travel Release form is completed by a parentguardian (see the head coach) Athletes will only be released to their own parentguardian from a contest A parentguardian must sign out the athlete from the coach at the contest site If a student and hisher parent makes arrangements for private transportation they shall not hold the local school offishycers employees or agents responsible for any injury or loss

Detailed trip information including destination date time of departure time of return purpose and superv ishys ion w ill be g iven to the parentsguardians prior to each trip in the series (Exceptions must be approved by the Schoo l Director of Ath letics and Principal)

lf any emergency medical procedures or treatment are required by the student during the trip I consent to the trip superv isor(s) tak ing arranging for and consenting to the procedures or treatment in hisher or their discreshytion

In consideration of FCSS all owi ng the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arising from or out of any injury that the student-athlete may suffer from particshyipation in athletics

NOTE This form must be signed by student if the student is 18 years of age or older

Name of Student (PLEASE PRINT) Signature of Student Date

Na me of ParentGuardian (PLEASE PRINT) Signature of ParentGuardian Date

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE

FORSYTH COUNTY SCHOOL SYSTEM ATHLETIC PARTICIPATION FORM -- - - ~ -= -=

FORSYTH COUNTY ATHLETICS PERM ISSION FORM I

I

Student - Athlete(Please Print) Name of ParentGuardian(Please Print)

Street Address School Grade CIRCLE ONE I

7 8 9 10 11 12

City State Zip Date of Birth Phone Home shy

Workshy~ ~~--=-- shy ~ =-=~ -- - ~=~ = -- --==

In the event of emergency please give the best person and method to contact in the box provided

I Name Relationship Phone Alt I I Request for Permission We the undersigned student and the students parentguard ian apply for permission to participate in interscholastic athlet ics in the followin~ sport(s)

[ ] Baseball Softball [ ] Cross Country ( ] Lacrosse [ ] Tennis [ ] Gymnastics

I[ ] Basketball ( ] Football [ ] Soccer [ ] Track amp Field [ ] Other

~ ]~ading [ ] Golf [ ] Swimming [ ] Wrestling -~= ---= = - ~ =

I

General Requirements- We have read and discussed the general requirements for athletic eligibility We understand that additional questions or specific circumstances should be directed to our students coach athletic director or principa~ We understand that the FC Athletic Guidelines are available through the county website for review

Risk of Injury- We acknowledge and understand that there is a risk of injury involved in athletic participation We understand that the student-athlete will be under the supeNision and direction of a FCSS athletic coach We agree to follow the rules of the sport and the instruction s of the coach in order to reduce the risk of injury to the student and other

II athletes However we acknowledge and understand that neither the coach nor FCSS can eliminate the risk of injury in I sports Injuries may and do occu r Sports injuries can be severe and in some cases may result in permanent disability or even death We freely knowingly and willfully accept and assume the risk of injury that might occur from participation in athletics

Release- In consideration of FCSS allowing the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arisinq from or out of any injury that the student-athlete mav suffer from participation in athletics

Insurance- FCSS requires parents to provide information pertaining to medical insurance coverage for all student I 1 athletes Parents have the option to purchase school insurance (please see school athletic director) or to maintain I

coverage under parental insurance provider

Check One [ I School Accident Insurance [ J Name of Other Insurance Company Policy No

1middot

I Address Group No

CERTIFICATION AND MEDICAL AUTHORIZATION We certify that all of the information provided by us on th is form is correct We agree to abide by state and local rules If the student-athlete is injured wh ile participating in athletics and FCSS is unable to contact the parent we grant FCSS permission and authority to obta in necessary medical care andor treatment for the students injury Treatment may include but is not limited to first aid CPR medical or surg ical treatment

I recommended b a h sician We acce t the financial res onsibil it for such medical care or treatment I middot We the undersigned student and parent have read this document and understand all of the expectations for I

athletic

Student

artici ation at m school

-=

Date

Date -middot =middotshy - ~===~===~~= ~~d

_ ________________________________ _ __________ ___ ______ _

_______ ___ ____ _

0P gt h rPA I 1i-1( AL =VALUATION

PHYSICAL E X AMINATION FORM Name Date of birth

r1 ltsrc n I mi 1 Cons1dor additional questions on more sensitive ssues

bull Do you feel stressed out or under a lot of pressure bull Do you ever feel sad hopeless depressed or anxious bull Do you feel safe at your home or residence bull Haveyou ever tried cigarettes chewing tobacco snutt or drp bull Du11ng thepast 30 days did you use chewing tobacco snuH or dip bull Do youdrink alcohol or use any other drugs bull Have you ever taken anabolic sterords or used any other performancesupplement bull Have you ever taken any supplements to help you gain or lose weight or improve your performance bull Do you wear aseat belt use ahelmet and use condoms

2 Con rder revewrng questions on cardiovascular symptoms (questions 5-14)

EXA MINATI ON

Height werght o Male D Female

BP I ( I ) Pu lse Vision A 201 L 201 Corrected DY O N

MEDI CAL NOR MAL ABNO RM AL FINDI NGS Appearance bull Marian stigmata (kyphoscoliosis high-arched palale pec tus excavalum arachnodactyly

arm span gt height hyperlaxily my~pi a MVPaortic insutf iciency)

Eyesearslnoselth roal bull Pu pils equal bull Hearing

Lymph nodes H a11 bull ur mur (ausculta on standing supne +- Valsalva) bull Loca tion of point of maximal mpulse (PMI)

Puls s bull smultaneous fem oral and radal pulses

Lungs

Abdom en Genitourinary (mates only)

Skrn bull HSV lesions suggestive ol MRSA tinea orporis

Neurologrc

MUSC ULOS KEL ETA L Neck

Back

Shoulderarm Elbowforearm

WnsVhandlfrngers

Hipthigh

Knee

LeganKle

Foottoes Functional bull Duck-walk single log hon

middotCo11 suJt1 1tCh etllUL t1tJ1oun1 m 1md 1tltbullrr11 10 1utlmloyy tu 11 lmu111 1 I cm tJ1ac 111slory or tl( 11 m Cons1dc1GU C(ll m11 111 nnval e so tMg tlav1ng t1111C1 party present s 1orornmendatL Cons1dfl1 C0tJn1tlvo valua 11on or baschnr nc1ropsychiatnc tP~hnJ If a h1stn1y ol siJ01l1cmt crincuss1on

D Cleared for all sports without rest11ctro 11

D Cleared for all spans wrthou( restrrctron wrth recornmendat1ons lor further evaluation or treatment for

D Not cleared

D Pending fur111er evaluation

D For any sporls

D For certain sports - - ------------- ------------ ----- - --------------shy

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 thospor1(s) as outl ined above A copy of the physical exam is on record in my office and can be made available to tho school at the request of the parents If condishytions arise after the athlete has been cleared for participation the physician may rescind the clearance until the prob lem is resolved and the potential consequences are completely explained to the athlete (and parentsguardians)

Name of ~hy s1c 1an (pnnttype) ______ _ ______________________ Da te _

Address Phone

Signature of physician - - ------ ------ ------------ - --- -------------- --middot MO or DO

copy201 OAmerican Academy of Family PnyslciansAmerican Academy of Pedi11tricsAmerican College of Sports MedicineAmerican Medical Society tor Spotts Medicine American Orthopaedic Society for Sports Medicine and American Osteopalhic Academy of Sports Medicine Permission is granted to reprint lo noncommercial educational purposes with acknowledgment HF0Sll3 q 26811)4 0

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

tF A 11 r rSICAL EVALUATION

CLEARANCE FORM Name ______________________ Sex O M O F Age _______ Date of birth _______

D Cleared for all sports without restriction

D Cleared for all sports without restriction with recommendations for further evaluation or treatment for

D Not cleared

D Pending further eval uation

D For any sports

D For certain ports ________________________________________ _

Reason

Rocornmendations

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 parentsguardians)

Name of physician (prinVtype) _ ________________________________ Date ____ ___

Address ____________________________________ Phone __________

Signature of physician---------------- -------- -----------------middot MD or DO

EMERGENCY INFORMATION

Other inform ation

- --- -middotmiddot----- - shy2010 American Academy of Family Physicians American Academy of Pediatrics Amencan College of Sports MedicineAmerican Medical Society or Sports MedicineAmerican 011Jopaedic Society for Sp01s Medicineand American Osteopathic Academy of Sports Medicine Permission Is granted to reprint for noncommercial educational purposes with acknowledgment

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

BLANKET PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL SPONSORED FIELD TRIPS

Sport _________ School Year School

I hereby request that ________________ (Students Name-PLEASE PRINT) be alshylowed to participate in athletic team band orchestra chorus andor any series of field trips re lated to one parshyticular area of study or activity I understand that transportation may or may not be provided by the Forsyth County School District (District) In the event transportation is not provided by the District transportation w ill be the parents responsibility

All team members will ride to an event in school provided transportation with the team Any athlete who arranges independent transportation to an event without permission from the coach and the Athletic Dishyrector in advance will be ineligible to compete in that event All team members will return to their High School in the Forsyth County provided transportation unless a Travel Release form is completed by a parentguardian (see the head coach) Athletes will only be released to their own parentguardian from a contest A parentguardian must sign out the athlete from the coach at the contest site If a student and hisher parent makes arrangements for private transportation they shall not hold the local school offishycers employees or agents responsible for any injury or loss

Detailed trip information including destination date time of departure time of return purpose and superv ishys ion w ill be g iven to the parentsguardians prior to each trip in the series (Exceptions must be approved by the Schoo l Director of Ath letics and Principal)

lf any emergency medical procedures or treatment are required by the student during the trip I consent to the trip superv isor(s) tak ing arranging for and consenting to the procedures or treatment in hisher or their discreshytion

In consideration of FCSS all owi ng the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arising from or out of any injury that the student-athlete may suffer from particshyipation in athletics

NOTE This form must be signed by student if the student is 18 years of age or older

Name of Student (PLEASE PRINT) Signature of Student Date

Na me of ParentGuardian (PLEASE PRINT) Signature of ParentGuardian Date

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE

_ ________________________________ _ __________ ___ ______ _

_______ ___ ____ _

0P gt h rPA I 1i-1( AL =VALUATION

PHYSICAL E X AMINATION FORM Name Date of birth

r1 ltsrc n I mi 1 Cons1dor additional questions on more sensitive ssues

bull Do you feel stressed out or under a lot of pressure bull Do you ever feel sad hopeless depressed or anxious bull Do you feel safe at your home or residence bull Haveyou ever tried cigarettes chewing tobacco snutt or drp bull Du11ng thepast 30 days did you use chewing tobacco snuH or dip bull Do youdrink alcohol or use any other drugs bull Have you ever taken anabolic sterords or used any other performancesupplement bull Have you ever taken any supplements to help you gain or lose weight or improve your performance bull Do you wear aseat belt use ahelmet and use condoms

2 Con rder revewrng questions on cardiovascular symptoms (questions 5-14)

EXA MINATI ON

Height werght o Male D Female

BP I ( I ) Pu lse Vision A 201 L 201 Corrected DY O N

MEDI CAL NOR MAL ABNO RM AL FINDI NGS Appearance bull Marian stigmata (kyphoscoliosis high-arched palale pec tus excavalum arachnodactyly

arm span gt height hyperlaxily my~pi a MVPaortic insutf iciency)

Eyesearslnoselth roal bull Pu pils equal bull Hearing

Lymph nodes H a11 bull ur mur (ausculta on standing supne +- Valsalva) bull Loca tion of point of maximal mpulse (PMI)

Puls s bull smultaneous fem oral and radal pulses

Lungs

Abdom en Genitourinary (mates only)

Skrn bull HSV lesions suggestive ol MRSA tinea orporis

Neurologrc

MUSC ULOS KEL ETA L Neck

Back

Shoulderarm Elbowforearm

WnsVhandlfrngers

Hipthigh

Knee

LeganKle

Foottoes Functional bull Duck-walk single log hon

middotCo11 suJt1 1tCh etllUL t1tJ1oun1 m 1md 1tltbullrr11 10 1utlmloyy tu 11 lmu111 1 I cm tJ1ac 111slory or tl( 11 m Cons1dc1GU C(ll m11 111 nnval e so tMg tlav1ng t1111C1 party present s 1orornmendatL Cons1dfl1 C0tJn1tlvo valua 11on or baschnr nc1ropsychiatnc tP~hnJ If a h1stn1y ol siJ01l1cmt crincuss1on

D Cleared for all sports without rest11ctro 11

D Cleared for all spans wrthou( restrrctron wrth recornmendat1ons lor further evaluation or treatment for

D Not cleared

D Pending fur111er evaluation

D For any sporls

D For certain sports - - ------------- ------------ ----- - --------------shy

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 thospor1(s) as outl ined above A copy of the physical exam is on record in my office and can be made available to tho school at the request of the parents If condishytions arise after the athlete has been cleared for participation the physician may rescind the clearance until the prob lem is resolved and the potential consequences are completely explained to the athlete (and parentsguardians)

Name of ~hy s1c 1an (pnnttype) ______ _ ______________________ Da te _

Address Phone

Signature of physician - - ------ ------ ------------ - --- -------------- --middot MO or DO

copy201 OAmerican Academy of Family PnyslciansAmerican Academy of Pedi11tricsAmerican College of Sports MedicineAmerican Medical Society tor Spotts Medicine American Orthopaedic Society for Sports Medicine and American Osteopalhic Academy of Sports Medicine Permission is granted to reprint lo noncommercial educational purposes with acknowledgment HF0Sll3 q 26811)4 0

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

tF A 11 r rSICAL EVALUATION

CLEARANCE FORM Name ______________________ Sex O M O F Age _______ Date of birth _______

D Cleared for all sports without restriction

D Cleared for all sports without restriction with recommendations for further evaluation or treatment for

D Not cleared

D Pending further eval uation

D For any sports

D For certain ports ________________________________________ _

Reason

Rocornmendations

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 parentsguardians)

Name of physician (prinVtype) _ ________________________________ Date ____ ___

Address ____________________________________ Phone __________

Signature of physician---------------- -------- -----------------middot MD or DO

EMERGENCY INFORMATION

Other inform ation

- --- -middotmiddot----- - shy2010 American Academy of Family Physicians American Academy of Pediatrics Amencan College of Sports MedicineAmerican Medical Society or Sports MedicineAmerican 011Jopaedic Society for Sp01s Medicineand American Osteopathic Academy of Sports Medicine Permission Is granted to reprint for noncommercial educational purposes with acknowledgment

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

BLANKET PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL SPONSORED FIELD TRIPS

Sport _________ School Year School

I hereby request that ________________ (Students Name-PLEASE PRINT) be alshylowed to participate in athletic team band orchestra chorus andor any series of field trips re lated to one parshyticular area of study or activity I understand that transportation may or may not be provided by the Forsyth County School District (District) In the event transportation is not provided by the District transportation w ill be the parents responsibility

All team members will ride to an event in school provided transportation with the team Any athlete who arranges independent transportation to an event without permission from the coach and the Athletic Dishyrector in advance will be ineligible to compete in that event All team members will return to their High School in the Forsyth County provided transportation unless a Travel Release form is completed by a parentguardian (see the head coach) Athletes will only be released to their own parentguardian from a contest A parentguardian must sign out the athlete from the coach at the contest site If a student and hisher parent makes arrangements for private transportation they shall not hold the local school offishycers employees or agents responsible for any injury or loss

Detailed trip information including destination date time of departure time of return purpose and superv ishys ion w ill be g iven to the parentsguardians prior to each trip in the series (Exceptions must be approved by the Schoo l Director of Ath letics and Principal)

lf any emergency medical procedures or treatment are required by the student during the trip I consent to the trip superv isor(s) tak ing arranging for and consenting to the procedures or treatment in hisher or their discreshytion

In consideration of FCSS all owi ng the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arising from or out of any injury that the student-athlete may suffer from particshyipation in athletics

NOTE This form must be signed by student if the student is 18 years of age or older

Name of Student (PLEASE PRINT) Signature of Student Date

Na me of ParentGuardian (PLEASE PRINT) Signature of ParentGuardian Date

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE

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

tF A 11 r rSICAL EVALUATION

CLEARANCE FORM Name ______________________ Sex O M O F Age _______ Date of birth _______

D Cleared for all sports without restriction

D Cleared for all sports without restriction with recommendations for further evaluation or treatment for

D Not cleared

D Pending further eval uation

D For any sports

D For certain ports ________________________________________ _

Reason

Rocornmendations

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 parentsguardians)

Name of physician (prinVtype) _ ________________________________ Date ____ ___

Address ____________________________________ Phone __________

Signature of physician---------------- -------- -----------------middot MD or DO

EMERGENCY INFORMATION

Other inform ation

- --- -middotmiddot----- - shy2010 American Academy of Family Physicians American Academy of Pediatrics Amencan College of Sports MedicineAmerican Medical Society or Sports MedicineAmerican 011Jopaedic Society for Sp01s Medicineand American Osteopathic Academy of Sports Medicine Permission Is granted to reprint for noncommercial educational purposes with acknowledgment

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

BLANKET PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL SPONSORED FIELD TRIPS

Sport _________ School Year School

I hereby request that ________________ (Students Name-PLEASE PRINT) be alshylowed to participate in athletic team band orchestra chorus andor any series of field trips re lated to one parshyticular area of study or activity I understand that transportation may or may not be provided by the Forsyth County School District (District) In the event transportation is not provided by the District transportation w ill be the parents responsibility

All team members will ride to an event in school provided transportation with the team Any athlete who arranges independent transportation to an event without permission from the coach and the Athletic Dishyrector in advance will be ineligible to compete in that event All team members will return to their High School in the Forsyth County provided transportation unless a Travel Release form is completed by a parentguardian (see the head coach) Athletes will only be released to their own parentguardian from a contest A parentguardian must sign out the athlete from the coach at the contest site If a student and hisher parent makes arrangements for private transportation they shall not hold the local school offishycers employees or agents responsible for any injury or loss

Detailed trip information including destination date time of departure time of return purpose and superv ishys ion w ill be g iven to the parentsguardians prior to each trip in the series (Exceptions must be approved by the Schoo l Director of Ath letics and Principal)

lf any emergency medical procedures or treatment are required by the student during the trip I consent to the trip superv isor(s) tak ing arranging for and consenting to the procedures or treatment in hisher or their discreshytion

In consideration of FCSS all owi ng the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arising from or out of any injury that the student-athlete may suffer from particshyipation in athletics

NOTE This form must be signed by student if the student is 18 years of age or older

Name of Student (PLEASE PRINT) Signature of Student Date

Na me of ParentGuardian (PLEASE PRINT) Signature of ParentGuardian Date

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE

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

BLANKET PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL SPONSORED FIELD TRIPS

Sport _________ School Year School

I hereby request that ________________ (Students Name-PLEASE PRINT) be alshylowed to participate in athletic team band orchestra chorus andor any series of field trips re lated to one parshyticular area of study or activity I understand that transportation may or may not be provided by the Forsyth County School District (District) In the event transportation is not provided by the District transportation w ill be the parents responsibility

All team members will ride to an event in school provided transportation with the team Any athlete who arranges independent transportation to an event without permission from the coach and the Athletic Dishyrector in advance will be ineligible to compete in that event All team members will return to their High School in the Forsyth County provided transportation unless a Travel Release form is completed by a parentguardian (see the head coach) Athletes will only be released to their own parentguardian from a contest A parentguardian must sign out the athlete from the coach at the contest site If a student and hisher parent makes arrangements for private transportation they shall not hold the local school offishycers employees or agents responsible for any injury or loss

Detailed trip information including destination date time of departure time of return purpose and superv ishys ion w ill be g iven to the parentsguardians prior to each trip in the series (Exceptions must be approved by the Schoo l Director of Ath letics and Principal)

lf any emergency medical procedures or treatment are required by the student during the trip I consent to the trip superv isor(s) tak ing arranging for and consenting to the procedures or treatment in hisher or their discreshytion

In consideration of FCSS all owi ng the student-athlete to participate in athletics we agree to release and hold FCSS its athletic coaches and other employees free harmless and indemnified from and against any and all claims suits or causes of action arising from or out of any injury that the student-athlete may suffer from particshyipation in athletics

NOTE This form must be signed by student if the student is 18 years of age or older

Name of Student (PLEASE PRINT) Signature of Student Date

Na me of ParentGuardian (PLEASE PRINT) Signature of ParentGuardian Date

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE

STUDENTPARENT CONCUSSION AWARENESS FORM

SCHOOL

DANGERS OF CONCUSSION Concussions at all levels of sports have received a great deal of attention and a state law has been passed to address this issue Adolescent athletes are particularly vulnerable to the effects of concussion Once considered little more than a minor ding to the head it is now understood that a concuss ion has the potential to result in death or changes in brain function (either short-term or longshyterm) A concussion is a brain injury that results in a temporary disruption of normal brain function A concussion occurs when the brain is violently rocked back and forth or twisted inside the skull as a resu lt of a blow to the head or body Continued participation in any sport following a concussion can lead to worsening concussion symptoms as well as increased risk for further injury to the brain and even death

Player and parental education in this area is crucial - that is the reason for this document Refer to it regularly This form must be signed by a parent or guardian of each student who wishes to participate in GHSA athletics One copy needs to be returned to the school and one retained at home

COMMON SIGNS AND SYMPTOMS OF CONCUSSION bull Headache dizziness poor balance moves clumsily reduced energy leveltiredness

bull Nausea or vomiting

bull Blurred vision sensitivity to light and sounds

bull Fogginess of memory difficulty concentrating slowed thought processes confused about surroundings or game assignments

bull Unexplained changes in behavior and personality

bull Loss of consciousness (NOTE This does not occur in all concussion episodes)

BY-LAW 268 GHSA CONCUSSION POLICY In accordance with Georgia law and national playing rules publi hed by the ational Federation of State High School Associations any athlete who exhibit signs ymptoms or behaviors consistent with a concu sion shall be immediately removed from the practice or contest

and shall not return to play until an appropriate health care professional has determined that no concussion has occurred (NOTE An appropriate health care professional may include licensed physician (MDDO) or another licen ed individual under the supervision of a licensed physician such as a nurse practitioner physician assistant or certified ath letic trainer who has received training in concussion evaluation and management

a) No athlete is allowed to return to a game or a practice on the same day that a concussion (a) has been diagnosed OR (b) cannot be ruled out

b) Any athlete diagnosed with a concussion shall be cleared medically by an appropriate health care professiona l prior to resuming participation in any future practice or contest The formulation of a gradual return to play protocol shall be a part of the medical clearance

c) It is mandatory that every coach in each GHSA sport participate in a free online course on concussion management prepared by the NFHS and available at wwwnfhslearn com at least every two years shybeginning with the 2013-2014 school year

d) Each school will be responsible for monitoring the participation of its coaches in the concussion management course and shall keep a record of those who participate

I HAVE READ THIS FORM AND I UNDERSTAND THE FACTS PRESENTED IN IT

SIGNED (Student) (Parent or Guardian)

DATE