HMS Cheerleading 2020-2021 CHEER TRYOUTS/CLINIC REGISTRATION

FORM

PARTICIPANT’S NAME_____________________________________ AGE/GRADE_____________ ADDRESS_______________________________________________DOB______________ CITY_____________________STATE_______________ZIP_______________ PARENT/LEGAL GUARDIAN’S NAME____________________________________________ HOME PHONE___________________ CELL PHONE________________ WORK_______________ EMAIL ADDRESS__________________________CHEERLEADER’S CELL PHONE_______________ PLEASE INDICATE WHAT SIZE S:SMALL, M:MEDIUM, L:LARGE FOR YOUR CHEERLEADER IN THE FOLLOWING ITEMS: (ONLY NEW CHEERLEADERS) T-SHIRT(ADULT/CHILD): S M L XL XXL XXXL SKORT: XS S M L XL SPORTS(COMPRESSION)LEGGINGS: S M L XL SPANDEX/BLOOMERS: XS S M L XL SOFEE COTTON SHORTS: S M L XL

IN CASE OF EMERGENCY

CONTACT #1 CONTACT #2 NAME__________________ NAME__________________ PHONE_________________ PHONE_________________ RELATION_______________ RELATION_______________ PARTICIPANT’S MEDICAL AND ALLERGY CONDITIONS *MEDICATIONS CANNOT BE GIVEN TO ANY CHILD

INTERNAL USE

PAYMENT TYPE____________________________ AMOUNT PAID_________________________

Schedule of Benefits

Eligibility

Class 1: All interscholastic sports and football, plus dance and cheerleaders.

Covered Activities

Participating in a sports team during a scheduled game, an official tournament game, or in a practice session.

Plan Maximum $15,000 per injury maximum

Deductible $0 per covered Accident

Coinsurance 100% Usual & Customary Charge

Maximum Benefit Period 52 weeks from the date of the covered accident

First Medical Treatment

180 days of the date of the covered accident that Caused injury

Accidental Death and Dismemberment (AD&D) $20,000

Maximum for Dental Treatment (injury only) $300 per tooth per covered Accident

Physical and Occupational Therapy

Maximum per treatment

$50 for up to 1O visits, limited to one treatment

Per day

Updated 11-20-19

t 1,1ll,i, l1( •

2020-2021 HMS Cheerleaders Financial Obligations

**. This is a break down of the entire cost to be a cheerleader. We are going to be

fundraising for as much of this money as we can possibly earn. My goal is for each parent to only pay $300.00 at most out of pocket, but hopefully less.

1. Cheer Uniform- $233.00

2. Cheer Camp ( 3 outfits and 3 meals a day included)- $363.00 (take off $20.00 if you have last year’s Cheer t-shirt.)

3. Warm-Up- $89.95

4. Pom-Poms- $45.50

5. Cheer Bag- $19.18

6. Bloomers- $13.99

7. Asics (Cheer Shoes)- $50.00

8. Knox County Sports Insurance- $60.00 **These are only estimations. I am trying to find the cheapest price I possibly can.

Revised February 21 2020 Revisions are indicated in bold italics

KNOX COUNTY SCHOOLS

Criteria for Cheerleaders and Dance Teams 2020-2021 - Selection and Participation

The following requirements are a matter of Knox County Board of Education records and must be adhered to exactly as written. Parents and Students must abide by these requirements for selecting Cheerleaders and Dance Teams. Please read and review carefully. Section 1 Students may participate only at the school where he/she is enrolled and in regular

attendance or must have a KCS transfer form on file. (Tryout Included) A student may only tryout at one KCS school per calendar year. Students must attend school 3.5 hours to participate in tryouts or games.

Section 2 Home School Students

A. In order to tryout, student must be enrolled in home school conducted by his or her parent(s) or legal guardian(s). The student must notify the Home School Department by August 1 of the current school year.

B. The student must have a legal residence within the school zone where he/she tryout.

C. By August 15 of the school year, parent or guardian must make application for

participation in cheerleading to principal of the school in which the home school student wishes to tryout and possibly participate.

Section 3 The principal of each middle/secondary school shall select a sponsor(s) to coordinate the

selection and function of each team the school sponsors. Section 4 Eligibility Rules

A. Middle School and High School

1. A student who engages in practice or try outs with a school in which the student is enrolled shall be ineligible to cheer the following season if the student enrolls in another school without a corresponding change in the residence of the student’s parents.

2. Faculty recommendations or approvals are not permissible.

B. Middle School

1. A student shall have three consecutive years to participate from the date he/she is

first enrolled in the sixth grade

2. No student shall be eligible to participate during any school year if he/she becomes Fifteen (15) years of age on or before August 1st .

Page 2 (Revisions are indicated in bold italics)

Criteria for Cheerleaders & Dance Teams 2020-2021 -Selection and Participation 3. A student shall have been promoted academically to the next higher grade.

4. Academic Eligibility

a. Students must have a “C” average the prior nine-week grading period to tryout. b. Students must maintain a “C” average each nine-week grading period to be eligible to participate.

• All subjects are included in determining grade point average • Averages are not to be rounded up. • A grade report form with all participants shall be sent to the Athletic

Specialist office each grading period during season.

C. High School

1. The student must earn five credits the preceding school year if less than 24 credits are required for graduation or six credits the preceding school year if 24 or more credits are required for graduation. All credits must be earned by the first day of the school year. Academic eligibility for a student is based on the requirements of the school the student was attending at the conclusion of the previous school year. Knox County Schools requires 28 credits for graduation.

2. No student shall be eligible to participate during any school year if he/she

becomes nineteen years of age on or before August 1st.

3. A student shall be ineligible to try out if he/she attended a secondary school, or schools, for eight semesters. Attendance of forty school days of any semester shall be regarded as a “semester” under this rule. If a student participates during a period of attendance, any number of days less than forty, he/she shall be charged with a semester of attendance.

4. A student who registers for two or more ninth grade subjects after having

completed one school year in the eighth grade shall be classified as a high school student for participation purposes.

Section 5 Tryout Procedures

A. Students interested in trying out for the cheerleading squad and dance team shall turn in their names to the sponsor prior to a date specified by the sponsor and cleared by the principal. The sponsor shall refer these names to the guidance department for certification of scholastic, attendance, and age eligibility.

Page 3 (Revisions are indicated in bold italics) Criteria for Cheerleaders & Dance Teams 2020-2021 -Selection and Participation

B. Before tryouts, each student shall turn in to the sponsor a signed and dated parent permission form stating that they understand the selection criteria, school policies and that they agree to permit their son/daughter to try out. This form shall be kept on file in the principal’s office for three years from date signed. The sponsor shall keep a copy of this agreement for three years from date signed.

C. Students must have a medical examination by a licensed medical doctor prior to

try-outs. Any known medical condition, which might interfere with active participation, should be recorded on the medical form (ex. Asthma, heart condition, epilepsy, diabetes, etc.) These physicals are good for one full year from the date the physical occurred.

D. Selection of cheerleader and dance teams shall be by selection committee.

E. Using a video: Cheerleader candidates will be allowed to provide video to tryout

in the case of an extreme injury documented with physician’s letter explaining the specific injury and restrictions prior to beginning the tryout. The candidate MUST provide any video footage submitted for tryout that highlights the required skills in order for judges to award points appropriately. The candidate must complete all aspects of the program not restricted by the injury identified in the physician’s letter.

• All video footage must be no more than (1) year old. • The candidate’s name may not appear on the video. • The video must reach the cheer coach or athletic director (24) hours prior

to the tryout.

F. A tryout packet will be provided to all candidates. The packet will include clinic information, sample scoresheet, and pertinent information for tryout.

G. Due to federal and state privacy laws protecting student records, a student or

parent shall not view the evaluation forms of other participants. Section 6 Selection criteria by selection committee

A. The selection committee shall be composed of a minimum of three and a maximum of five members that have no connection with the immediate school or students trying out. These members, selected by the school’s sponsor, shall each have a minimum of two years’ experience as a college cheerleader/pom pon squad member, dance team member, cheerleading sponsor/pom pon squad sponsor/dance team sponsor or instructor in a national cheerleader/pom pon squad/dance team association camp. Schools that have a minority enrollment equal to or greater than the system average must have a minimum of one minority judge.

B. The selection committee shall score each student independently of each other. The

candidates will be judged on criteria developed by the Knox County School System.

Page 4 (Revisions are indicated in bold italics) Criteria for Cheerleaders & Dance Teams 2020-2021 -Selection and Participation

C. Scoring and tallying shall be supervised by a school administrator. All scores and

tallies are to be kept on file in the principal’s office for three years from the date signed. Scores and tallies are confidential and may be released only at the direction of the Superintendent or his/her designee.

D. Tryouts are closed. The only people allowed in tryouts will be; Judges,

participants, cheer coaches, school administrators, and score tabulators. Section 7 A maximum of sixteen members are allowed on the court or mat during the game except at

halftime. Keep safety in mind, less than sixteen (16) is recommended for gyms with limited space.

Section 8 Selected members shall serve only one academic year unless they are reselected for future

participation. Section 9 A progressive discipline policy is to be established at each school by the sponsor and

approved by the principal detailing squad/team requirements, discipline and a progressive methodology regarding disciplinary actions. The policy shall include the process for removing a participant from the squad/team. Parents are to be given a copy of these rules and discipline policy before tryouts begin.

Section 10 Transportation to games, practices and camps shall be the responsibility of the students’

parents, unless furnished by the individual school, and under the supervision of the principal’s designee.

Section 11 Team/squad members are REQUIRED to participate in the Knox County Schools’ athletic

insurance program. Section 12 All fund raising and expenditures shall be supervised by the sponsor and approved by the

principal/school board. Section 13 Uniforms A. High School

All cheerleader uniforms and paraphernalia are property of the Knox County Schools. The cost of cheerleading and uniforms will be treated as any other non-revenue sport in each school. Parents will be responsible for the cost of their child’s personal items only (cheerleading camps, shoes, socks, jacket, etc.). Parents will not be responsible for any fees or uniform cost unless items are lost or damaged through irresponsible use or care. Only selected cheerleaders are to participate in fund raising for cheerleading purposes. School principals are to insure that personal item costs will not become cost prohibitive for any student.

B. Middle School

School principals shall insure that the cost of being a cheerleader does not keep any qualified student from being eligible.

MIDDLE SCHOOL CHEERLEADER JUDGING FORM

Candidate’s Number_________________ Judge # __________________ Scoring: 1 (low) to 5 (high) I. Individual Cheer a. Entrance – Enthusiasm – Spirit - Gymnastics 0 1 2 3 4 5 b. Appearance and Smile 0 1 2 3 4 5 c. Incorporation of Jump 0 1 2 3 4 5 d. Projection - Voice Clarity 0 1 2 3 4 5 e. Poise and Confidence 0 1 2 3 4 5 f. Sharpness 0 1 2 3 4 5 g. Gymnastics 0 1 2 3 4 5 SUBTOTAL II. Jumps a. Required 0 1 2 3 4 5 b. Required 0 1 2 3 4 5 c. Optional 0 1 2 3 4 5 SUBTOTAL III. Dance a. Synchronization 0 1 2 3 4 5 b. Motions 0 1 2 3 4 5 c. Knowledge of Routine 0 1 2 3 4 5 d. Eye Contact – Facial Expression 0 1 2 3 4 5 e. Incorporation of Jump 0 1 2 3 4 5 f. Overall Performance of Dance 0 1 2 3 4 5 SUBTOTAL ____________ IV. Group Chant a. Projection 0 1 2 3 4 5 b. Poise and Confidence 0 1 2 3 4 5 c. Sharpness 0 1 2 3 4 5 d. Synchronization 0 1 2 3 4 5 e. Group Awareness 0 1 2 3 4 5 SUBTOTAL _____________ TOTAL _____________ Judge’s Signature on File Judge’s Number Date

REVISED 2-21-2020

HIGH SCHOOL CHEERLEADER JUDGING FORM

Student’s Number____________ Judge # ____________

I. Entrance a. Jumps and Gymnastics 0-10 b. Spirit and Enthusiasm 0-10

II. Jumps a. Required 0-10 b. Required 0-10 c. Optional 0-15

III. Chant a. Projection 0-10 b. Poise and Confidence 0-10 c. Sharpness / Motion 0-20 d. Synchronization 0-10 IV. Dance (female) a. Synchronization 0-10

b. Sharpness / Motions 0-20 c. Knowledge of Routine 0-10 d. Eye Contact – Facial Expression 0-10

e. Incorporation of Jump 0-10 f. Overall Performance of Dance 0-10

V. Cheer

a. Appearance 0-10 b. Eye Contact / Expression / Confidence 0-10 c. Projection / Voice Clarity 0-10 d. Sharpness / Motions 0-20 e. Jump 0-10 f. Incorporation 0-15

VI. Stunts (male) a. 0-35 b. 0-35 TOTAL _____________ Judge’s Signature on File

Judge’s Number

Date REVISED 2-21-2020

7-5-16

Insurance Coverage Statement

• I understand that the athletic insurance carried by the school system is a secondary coverage policy meaning it pays only after the parents’ primary coverage pays.

• I understand that the responsibility to file the proper forms for payment is the parent’s responsibility.

• I understand that medical expenses ARE MY RESPONSIBILITY in connection with my child playing voluntary sports.

• I understand that I accept financial responsibility for any injury not covered by my hospitalization insurance or KCS sport accident insurance.

____________________________________ ___________________________

Parent/Legal Guardian Signature Date

CONCUSSION INFORMATION AND SIGNATURE FORM

FOR STUDENT-ATHLETES & PARENTS/LEGAL GUARDIANS (Adapted from CDC “Heads Up Concussion in Youth Sports”)

Public Chapter 148, effective January 1, 2014, requires that school and community organizations sponsoring youth athletic activities establish guidelines to inform and educate coaches, youth athletes and other adults involved in youth athletics about the nature, risk and symptoms of concussion/head injury.

Read and keep this page. Sign and return the signature page.

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a “ding,” “getting your bell rung” or what seems to be a mild bump or blow to the head can be serious. Did You Know? • Most concussions occur without loss of consciousness. • Athletes who have, at any point in their lives, had a concussion have an increased risk for

another concussion. • Young children and teens are more likely to get a concussion and take longer to recover than

adults. WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION? Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If an athlete reports one or more symptoms of concussion listed below after a bump, blow or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care provider* says s/he is symptom-free and it’s OK to return to play. SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES Appears dazed or stunned Headache or “pressure” in head Is confused about assignment or position Nausea or vomiting Forgets an instruction Balance problems or dizziness Is unsure of game, score or opponent Double or blurry vision Moves clumsily Sensitivity to light Answers questions slowly Sensitivity to noise Loses consciousness, even briefly Feeling sluggish, hazy, foggy or groggy Shows mood, behavior or personality changes Concentration or memory problems Can’t recall events prior to hit or fall Confusion Can’t recall events after hit or fall Just not “feeling right” or “feeling down” *Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training

CONCUSSION DANGER SIGNS In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention after a bump, blow or jolt to the head or body if s/he exhibits any of the following danger signs: • One pupil larger than the other • Is drowsy or cannot be awakened • A headache that not only does not

diminish, but gets worse • Weakness, numbness or decreased

coordination • Repeated vomiting or nausea • Slurred speech • Convulsions or seizures • Cannot recognize people or places • Becomes increasingly confused,

restless or agitated • Has unusual behavior • Loses consciousness (even a brief

loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT HIS OR HER SYMPTOMS? If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brains. They can even be fatal.

Remember: Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer. WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION? If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care provider* says s/he is symptom-free and it’s OK to return to play. Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration such as studying, working on the computer or playing video games may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional. * Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training.

Student-athlete & Parent/Legal Guardian Concussion Statement Must be signed and returned to school or community youth athletic activity prior to participation in practice or play. Student-Athlete Name: _________________________________________________________ Parent/Legal Guardian Name(s): _________________________________________________ After reading the information sheet, I am aware of the following information: Student-Athlete initials

Parent/Legal Guardian

initials

A concussion is a brain injury which should be reported to my parents, my coach(es) or a medical professional if one is available.

A concussion cannot be “seen.” Some symptoms might be present right away. Other symptoms can show up hours or days after an injury.

I will tell my parents, my coach and/or a medical professional about my injuries and illnesses.

N/A

I will not return to play in a game or practice if a hit to my head or body causes any concussion-related symptoms.

N/A

I will/my child will need written permission from a health care provider* to return to play or practice after a concussion.

Most concussions take days or weeks to get better. A more serious concussion can last for months or longer.

After a bump, blow or jolt to the head or body an athlete should receive immediate medical attention if there are any danger signs such as loss of consciousness, repeated vomiting or a headache that gets worse.

After a concussion, the brain needs time to heal. I understand that I am/my child is much more likely to have another concussion or more serious brain injury if return to play or practice occurs before the concussion symptoms go away.

Sometimes repeat concussion can cause serious and long-lasting problems and even death.

I have read the concussion symptoms on the Concussion Information Sheet.

* Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical neuropsychologist with concussion training ______________________________________________ _______________________ Signature of Student-Athlete Date ______________________________________________ ________________________ Signature of Parent/Legal guardian Date

■ Preparticipation Physical Evaluation HISTORY FORM

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

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies? � Yes � No If yes, please identify specific allergy below. � Medicines � Pollens � Food � Stinging Insects

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

GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports for any reason?

2. Do you have any ongoing medical conditions? If so, please identify below: � Asthma � Anemia � Diabetes � InfectionsOther: _______________________________________________

3. Have you ever spent the night in the hospital?

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No5. Have you ever passed out or nearly passed out DURING or

AFTER exercise?

6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

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

8. Has a doctor ever told you that you have any heart problems? If so, check all that apply: � High blood pressure � A heart murmur� High cholesterol � A heart infection� Kawasaki disease Other: _____________________

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

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

11. Have you ever had an unexplained seizure?

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

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No13. Has any family member or relative died of heart problems or had an

unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

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

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No17. Have you ever had an injury to a bone, muscle, ligament, or tendon

that caused you to miss a practice or a game?

18. Have you ever had any broken or fractured bones or dislocated joints?

19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture?

21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)

22. Do you regularly use a brace, orthotics, or other assistive device?

23. Do you have a bone, muscle, or joint injury that bothers you?

24. Do any of your joints become painful, swollen, feel warm, or look red?

25. Do you have any history of juvenile arthritis or connective tissue disease?

MEDICAL QUESTIONS Yes No26. Do you cough, wheeze, or have difficulty breathing during or

after exercise?

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

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

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

31. Have you had infectious mononucleosis (mono) within the last month?

32. Do you have any rashes, pressure sores, or other skin problems?

33. Have you had a herpes or MRSA skin infection?

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

35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

36. Do you have a history of seizure disorder?

37. Do you have headaches with exercise?

38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

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

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

41. Do you get frequent muscle cramps when exercising?

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

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

44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

46. Do you wear protective eyewear, such as goggles or a face shield?

47. Do you worry about your weight?

48. Are you trying to or has anyone recommended that you gain or lose weight?

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

50. Have you ever had an eating disorder?

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

FEMALES ONLY52. Have you ever had a menstrual period?

53. How old were you when you had your first menstrual period?

54. How many periods have you had in the last 12 months?

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete __________________________________________ Signature of parent/guardian ____________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

■ Preparticipation Physical Evaluation THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

1. Type of disability

2. Date of disability

3. Classification (if available)

4. Cause of disability (birth, disease, accident/trauma, other)

5. List the sports you are interested in playing

Yes No6. Do you regularly use a brace, assistive device, or prosthetic?

7. Do you use any special brace or assistive device for sports?

8. Do you have any rashes, pressure sores, or any other skin problems?

9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?

11. Do you use any special devices for bowel or bladder function?

12. Do you have burning or discomfort when urinating?

13. Have you had autonomic dysreflexia?

14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

15. Do you have muscle spasticity?

16. Do you have frequent seizures that cannot be controlled by medication?

Explain “yes” answers here

Please indicate if you have ever had any of the following.

Yes NoAtlantoaxial instability

X-ray evaluation for atlantoaxial instability

Dislocated joints (more than one)

Easy bleeding

Enlarged spleen

Hepatitis

Osteopenia or osteoporosis

Difficulty controlling bowel

Difficulty controlling bladder

Numbness or tingling in arms or hands

Numbness or tingling in legs or feet

Weakness in arms or hands

Weakness in legs or feet

Recent change in coordination

Recent change in ability to walk

Spina bifida

Latex allergy

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete __________________________________________ Signature of parent/guardian __________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

■ Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM

Name __________________________________________________________________________________ Date of birth __________________________

PHYSICIAN REMINDERS1. Consider additional questions on more sensitive issues

• Do you feel stressed out or under a lot of pressure?• Do you ever feel sad, hopeless, depressed, or anxious?• Do you feel safe at your home or residence?• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?• During the past 30 days, did you use chewing tobacco, snuff, or dip?• Do you drink alcohol or use any other drugs?• Have you ever taken anabolic steroids or used any other performance supplement?• Have you ever taken any supplements to help you gain or lose weight or improve your performance?• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATIONHeight Weight � Male � Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected � Y � NMEDICAL NORMAL ABNORMAL FINDINGSAppearance• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)Eyes/ears/nose/throat• Pupils equal• HearingLymph nodesHeart a

• Murmurs (auscultation standing, supine, +/- Valsalva)• Location of point of maximal impulse (PMI)Pulses• Simultaneous femoral and radial pulsesLungsAbdomenGenitourinary (males only)b

Skin• HSV, lesions suggestive of MRSA, tinea corporisNeurologic c

MUSCULOSKELETALNeckBackShoulder/armElbow/forearmWrist/hand/fingersHip/thighKneeLeg/ankleFoot/toesFunctional• Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.bConsider GU exam if in private setting. Having third party present is recommended. cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

��Cleared for all sports without restriction

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

____________________________________________________________________________________________________________________________________________

��Not cleared

��Pending further evaluation

��For any sports

��For certain sports _____________________________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________________________

Recommendations _________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If condi-tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type) _____________________________________________________________________________________________________ Date ________________

Address ___________________________________________________________________________________________________________ Phone _________________________

Signature of physician _______________________________________________________________________________________________________________________, MD or DO

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

■ Preparticipation Physical Evaluation CLEARANCE FORM

Name ___ ____________________________________________________ Sex ��M ��F Age _________________ Date of birth _________________

��Cleared for all sports without restriction

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

___________________________________________________________________________________________________________________________

��Not cleared

��Pending further evaluation

��For any sports

��For certain sports _____________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________

Recommendations _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

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I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type) ___________________________________________________________________________________ Date ________________

Address _________________________________________________________________________________________ Phone _________________________

Signature of physician _____________________________________________________________________________________________________, MD or DO

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

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Other information _______________________________________________________________________________________________________________

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©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

CONSENT FOR ATHLETIC PARTICIPATION & MEDICAL CARE *Entire Page Completed By Patient

Athlete Information

Last Name______________________________ First Name ________________________ MI _______

Sex: [ ] Male [ ] Female Grade ___________ Age _______ DOB ____/____/_____

Allergies ________________________________________________________________________________

Medications______________________________________________________________________________

Insurance ______________________________________ Policy Number ____________________________

Group Number _________________________________ Insurance Phone Number ____________________

Emergency Contact Information

Home Address ______________________________________(City)____________________(Zip)_________

Home Phone __________________ Mother’s Cell _________________ Father’s Cell _________________

Mother’s Name __________________ Work Phone ______________ Email Address __________________

Father’s Name __________________ Work Phone ______________ Email Address __________________

Another Person to Contact _________________________________________________________________

Phone Number _________________________ Relationship ___________________________

Legal/Parent Consent I/We hereby give consent for (athlete’s name) ________________________________________ to represent (name of school) __________________________________ in athletics realizing that such activity involves potential for injury. I/We acknowledge that even with the best coaching, the most advanced equipment, and strict observation of the rules, injuries are still possible. On rare occasions these injuries are severe andresult in disability, paralysis, and even death. I/We further grant permission to the school and TSSAA, its physicians, athletic trainers, and/or EMT to render aid, treatment, medical, or surgical care deemed reasonably necessary to the health and well being of the student athlete named above during or resulting from participation in athletics. By the execution of this consent, the student athlete named above and his/her parent/guardian(s) do hereby consent to screening, examination, and testing of the student athlete during the course of the pre-participation examination by those performing the evaluation, and to the taking of medical history information and the recording of that history and the findings and comments pertaining to the student athlete on the forms attached hereto by those practitioners performing the examination. As parent or legal Guardian, I/We remain fully responsible for any legal responsibility which may result from anypersonal actions taken by the above named student athlete.

Signature of Athlete Signature of Parent/Guardian Date

CONSENTIMIENTO A PARTICIPAR EN ACTIVIDADES ATLETICAS Y RECIBIR CUIDADO MEDICO SI FUERA NECESASRIO

(Este Consentimiento debe ser completado por el Estudiante-Atleta y sus padres o guardianes.)

Información del Estudiante-Atleta

Apellido Nombre SN

Sexo: [ ] Varón [ ] Hembra Grado__________ Edad_________ Fecha de Nacimiento_____/_____/_____

Alergias

Medicaciones

Seguro Médico Número de la Póliza

Número del Grupo Teléfono del Seguro

Información del Contacto en Caso de Emergencia

Dirección de Casa (Ciudad)

(Código Postal)

Teléfono de Casa Celular de la Madre o Guardian

Celular del Padre o Guardian

Nombre de la Madre o Guardian Teléfono del Trabajo

Nombre del Padre o Guardian Teléfono del Trabajo

Otra Persona Contacto

Número de Teléfono Relación

Consentimiento Legal de los Padres o Guardianes

Yo/Nosotros damos nuestro consentimiento para que (nombre del Estudiante-Atleta)____________________________________ pueda representar (nombre de la escuela)________________________________________ en deportes y que yo/nosotros entendemos que esa actividad lleva la posibilidad de sufrir lesiones. Yo/Nosotros sabemos que aún con el mejor entrenamiento, los mejores artículos deportivos, y la observación estricta de las reglas, es posible sufrir lesiones. En algunas ocasiones, estas lesiones son severas y pueden resueltar en incapacidad, parálisis, y hasta la muerte. Yo/Nosotros damos permiso a la escuela y a TSSAA, sus médicos, entrenadores atléticos, y/o técnicos médicos de emergencias a dar ayuda, tratamiento, cuidado médico o quirúrgico considerados necesarios para la salud y bienestar del Estudiante-Atleta nombrado arriba durante o como resultado de su participación en los deportes. Al firmar este consentimiento, el Estudiante-Atleta nombrado arriba y sus padres/guardianes consienten a que los profesionales de la salud conduzcan un chequeo, examinación, y pruebas del Estudiante-Atleta durante la examinación pre-participacipatoria y a obtener la historia médica. Entendemos que los profesionales de la salud que conduzcan estas pruebas y evaluaciones van a anotar los resultados y observaciones en los formularios y records que acompañan este documento. Como padre o guardian , yo/nosotros entendemos que somos totalmente responsables por cualquier asunto legal que pueda resultar de las acciones personales del Estudiante-Atleta nombrado arriba.

Firma del Estudiante-Atleta Firma del Padre/Guardian Fecha

Athlete/Parent/Guardian Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form What is sudden cardiac arrest? Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens, blood stops flowing to the brain and other vital organs. SCA doesn’t just happen to adults; it takes the lives of students, too. However, the causes of sudden cardiac arrest in students and adults can be different. A youth athlete’s SCA will likely result from an inherited condition, while an adult’s SCA may be caused by either inherited or lifestyle issues. SCA is NOT a heart attack. A heart attack may cause SCA, but they are not the same. A heart attack is caused by a blockage that stops the flow of blood to the heart. SCA is a malfunction in the heart’s electrical system, causing the heart to suddenly stop beating. How common is sudden cardiac arrest in the United States? SCA is the #1 cause of death for adults in this country. There are about 300,000 cardiac arrests outside hospitals each year. About 2,000 patients under 25 die of SCA each year. It is the #1 cause of death for student athletes. Are there warning signs? Although SCA happens unexpectedly, some people may have signs or symptoms, such as:

x fainting or seizures during exercise; x unexplained shortness of breath; x dizziness; x extreme fatigue; x chest pains; or x racing heart.

These symptoms can be unclear in athletes, since people often confuse these warning signs with physical exhaustion. SCA can be prevented if the underlying causes can be diagnosed and treated. What are the risks of practicing or playing after experiencing these symptoms? There are risks associated with continuing to practice or play after experiencing these symptoms. When the heart stops, so does the blood that flows to the brain and other vital organs. Death or permanent brain damage can occur in just a few minutes. Most people who experience SCA die from it. Public Chapter 325 – the Sudden Cardiac Arrest Prevention Act The act is intended to keep youth athletes safe while practicing or playing. The requirements of the act are:

x All youth athletes and their parents or guardians must read and sign this form. It must be returned to the school before participation in any athletic activity. A new form must be signed and returned each school year.

Adapted from PA Department of Health: Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form. 7/2013

x The immediate removal of any youth athlete who passes out or faints while participating

in an athletic activity, or who exhibits any of the following symptoms: (i) Unexplained shortness of breath; (ii) Chest pains; (iii) Dizziness (iv) Racing heart rate; or (v) Extreme fatigue; and

x Establish as policy that a youth athlete who has been removed from play shall not return

to the practice or competition during which the youth athlete experienced symptoms consistent with sudden cardiac arrest

x Before returning to practice or play in an athletic activity, the athlete must be evaluated

by a Tennessee licensed medical doctor or an osteopathic physician. Clearance to full or graduated return to practice or play must be in writing.

I have reviewed and understand the symptoms and warning signs of SCA. Signature of Student-Athlete Print Student-Athlete’s Name Date _____________________________ _________________________ __________ Signature of Parent/Guardian Print Parent/Guardian’s Name Date