ors Activities

Department

Dear Parents:

WHEELING PARK HIGH SCHOOL1976 Park View Road, Wheeling, WV 26003-9311

304-243-0405 FAX 304-243-0449

Enclosedplease find an SSAC participation andphysical form and insurance andemergency information form. Please make sure that these forms are filled out complete-ly and returned. Your child MUST sign the top of Part I of the SSMC form, and theparent/guardian MUST sign Part 11 at the bottom of the front page. The questions onPart 111 must be answered and the parent/guardian is also to sign at the bottom of Part111. Parts IV and V concern the actual physical, and must be signed by the conductingphysician.

In addition, please fill out and return the EMERGENCY INSURANCE ANDCONSENTform. You must have insurance coverage. Please list your insurance carrierand policy number. If you do not have insurance, you may opt to purchase the schoolinsurance at the beginning of August. Please make every effort to list phone numberswhere you may be reached in the event of an emergency. Sign and date this form aswell.

Physicals for the upcoming school year must be completed on or after May 1st ofthis year. Students cannot participate in the three week "Out of Season Practice " with-out a completed physical. If you have questions, please call the Athletic Office ofWheeling Park High School, 243-0405.

We hope that your student's experience with Wheeling Park athletic programs isa positive one. Good luck in the upcoming season!

Wheeling Park High Schoolviti s Department

WEST VIRGINIA SECONDARY SCHOOL ACTIVITIES COMMISSION2875 Staunton Turnpike - Parkersburg, WV 26104 May 2020

ATHLETIC PARTICIPATION/PARENTAL CONSENT/PHYSICIAN'S CERTIFICATE FORM(Form required each school year on or after May 1 st, File in School Administration Office)

ATHLETIC PARTICIPATION 1 PARENTAL CONSENT

PART I

Name

Home Address:

City:

School Year: Grade Entering:

Home Address of Parents:

City:

Phone: Date of Birth: Place of Birth:

Last semester I attended (High School) or (Middle School). We have read the condensed eligibility

rules of the WVSSAC athletics. If accepted as a team member, we agree to make every effort to keep up school work and abide by

the rules and regulations of the school authorities and the WVSSAC.

INDIVIDUAL ELIGIBILITY RULESAttention Athlete! To be eligible to represent your school in any interscholastic contest, you ...

must be a regular bona fide student in good standing of the school. (See exception under Rule 127-2-3)

must qualify under the Residence and Transfer Rule (127-2-7)must have earned at least 2 units of credit the previous semester. Summer School may be included. (127-2-6)

must have attained an overall "C" (2.00) average the previous semester. Summer School may be included. (127-2-6)

must not have reached your 15th (MS), 19th (HS) birthday before August I of the current school year. (127-24)

must be residing with parent(s) as specified by Rule 127-2-7 and 8.unless parents have made a bona fide change of residence during school term.unless an AFS or other Foreign-Exchange student (one year of eligibility only).

unless the residence requirement was met by the 365 calendar days attendance prior to participation.

if living with legal guardian/custodian, may not participate at the varsity level. (127-2-8)

must be an amateur as defined by Rule 127-2-11.

must have submitted to your principal before becoming a member of any school athletic team Participation/Parent ConsenYPhysician Form,

completely filled in and properly signed, attesting that you have been examined and found to be physically fit for athletic competition and

that your parents consent to your participation. (127-3-3)

must not have transferred from one school to another for athletic purposes. (127-2-7)

must not have received, in recognition of your ability as a HS or MS athlete, any award not presented or approved by your school or the

WVSSAC. (127-3-5)must not, while a member of a school team in any sport, become a member of any other organized team or as an individual participant in

an unsanctioned meet or tournament in the same sport during the school sport season (See exception 127-2-10).

must follow Al Star Participation Rule. (127-3-4)

must not have been enrolled in more than (8) semesters in grades 9 to 12. Must not have participated in more than three (3) seasons while

in grades 6-7-8. (Rule 127-2-5).

Eligibility to participate in interscholastic athletics is a privilege you earn by meeting not only the above listed minimum standards but also

ail other standards set by your school and the WVSSAC. If you have any questions regarding your eligibility or are in doubt about the effect any

activity or action might have on your eligibility. check with your principal or athletic director. They are aware of the interpretation and intent of each

rule. Meeting the intent and spirit of WVSSAC standards will prevent athletes, teams, and schools from being penalized.

PART Il - PARENTAL CONSENT

In accordance with the rules of the WVSSAC. I give my consent and approval to the participation of the student named above ror the sport NOT MARKED OUT BELOW:

BASEBALL CROSS GOLF SWIMMING VOLLEYBALL

BASKETBALL COUNTRY SOCCER TENNIS WRESTLING

CHEERLEADING FOOTBALL SOFTBALL TRACK

MEDICAL DISQUALIFICATION OF THE STUDENT-ATHLETE / WITHHOLDING A STUDENT-ATHLETE FROM ACTIVITY

The member school's team physician has the final responsibility to determine when a student-athlete is removed or withheld from participation due toan injury. an illness or pregnancy. In addition, clearance for that individual to return to activity is solely the responsibility ofthe member school's teamphysician or that physician's designated representative.

I understand that participation may include, when necessary. early dismissal from classes and travel to participate in interscholastic athleticcontests. I will not hold the school authorities or West Virginia Secondary School Activities Commission responsible in case of accident or injury as aresult of this participation. I also understand that participation in any of those sports listed above may cause permanent disability or death. Pleasecheck appropriate space: He/She has student accident insurance available through the school( ); has football insurance coverage available throughthe school( is insured to our satisfaction (

I also give my consent and approval for the above named student to receive a physical examination, as required in Pan IV, Physician's Certificate,of this form, by an approved health care provider as recommended by the named student's school administration.

consent to WVSSAC's use of the herein named student's name, likeness. and athletically related information in reports of Inter-School Practicesor Scrimmages and Contests. promotional literature of the Association. and other materials and releases related to interscholastic athletics.

I have read/reviewed the concussion and Sudden Cardiac Arrest information as available throuqh the school and atWVSSAC.orq. (Click Sports Medicine)

Date: Student Signature Parent Signature

PART Ill - STUDENT'S MEDICAL HISTORY(To be completed by parent or guardian prior to examination)

May 2020

Name Birthdate Grade Age

Has the student ever had:

Yes NoYes NoYes No

No

Yes NOYesYes NoYes NO

NoYes No

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Chronic or recurrent illness? (Diabetes. Asthma,Seizures, etc.,)Any hospitalizations?

Any surgery (except tonsils)?Any injuries that prohibited your participation in sports?

Dizziness or frequent headaches?Knee, ankle or neck injuries?Broken bone or dislocation?Heat exhaustiontsun stroke?Fainting or passing out?Have any allergies?

Concussion? If Yes

Yes No 12.Have any problems with heart/blood pressure?

Yes No 13. Has anyone in your family ever fainted during exercise?

Yes No 14. Take any medicine?

Yes No 15.appliances

Yes NoYes Noshot?

PLEASE ö(PLAlN ANY "YES" ANSWERS OR ANY OTHERADDITIONAL CONCERNS.

Yes

Yes

Yes

YesYes

Yes

No

No

No

No

No

No

16.

17.

18.

19.

20.

21.

22.

23.

Wear glasses contact lenses dental

Have any organs missing (eye. kidney, testicle, etc.)?

Has it been longer than 10 years since your last tetanus

Have you ever been told not to participate in any sport?

Do you know of any reason this student should notparticipate in sports?

Have a sudden death history in your family?

Have a family history of heart attack before age 50?

Develop coughing, wheezing, or unusual shortness ofbreath when you exercise?(Females Only) Do you have any problems with yourmenstrual periods.

I also give my consent for the physician in attendance and the appropriate medical staff to give treatment at any athletic event forany injury.

SIGNATURE OF PARENT OR GUARDIAN DATE

PART IV - VITAL SIGNS

Height Weight Pulse Blood Pressure

Visual acuity: Uncorrected • Corrected Pupils equal diameter: Y N

PART V - SCREENING PHYSICAL EXAMThis exam is not meant to replace a full physical examination done by your private physician.

Mouth:

Appliances

Missing/loose teeth

Caries needing treatment

Enlarged lymph nodes

Skin - infectious lesions

Peripheral pulses equal

Respiratory:

Y

Y

Y

Y

Y

Y

N

N

N

N

N

N

Symmetrical breath sounds Y

Wheezes Y

Cardiovascular.

Murmur Y

Irregularities Y

Murmur with Valsalva Y

N

N

N

N

Abdomen:

Masses

Organomegaly

Y N

Y N

Genitourinary (males only);

Inguinal hernia Y N

Bilaterally descended testiclesY

Any "YES" under Cardiovascular requires a referral to family doctor or other appropriate healthcare provider.

Musculoskeletal: (note any abnormalities)

Neck:

Shoulder:

Elbow:

Wrist:

Knee/Hip:

Ankle:

Y N Hamstrings: Y N

Y N Scoliosis: Y N

RECOMMENDATIONS BASED ON ABOVE EVALUATION:

After my evaluation, I give my:

Full Approval;

Full approval; but needs further evaluation by Family Dentist • Eye Doctor • Family Physician Other

Limited approval with the following restrictions:

Denial of approval for the following reasons:

MD/DO/DC/Advanced Registered Nurse Practitioner/Physicians Assistant Date

Please list all names as they appear on birth certificate:

SPORT:

CIRCLE ONE: Varsity Junior Varsity Freshman

CIRCLE ONE: Boys Girls

LAST NAME

FIRST NAME

FATHER'SFIRST NAME

MOTHER'SFIRST NAME

NUMBER OF SEMESTERSENROLLED(Including Current one)

DATE OF BIRTHMonth/ Date I Year

CITY AND STATE OFBIRTH-(as on birth certificate)

DO PARENTS RESIDE INOHIO COUNTY?

IF "NO" -STATE REASON OUT OF COUNTY SPEC PERM 127.2.7.1.5you ATTEND WPHS EXCHANGE STUDENT 127.2.7.1.6

GRADE you ARE IN DURING THE2019-2020 SCHOOL YEAR

SCHOOL YOU ATTENDEDTHE PREVIOUS SEMESTER

WHEELING PARK HIGH SCHOOL

EMERGENCY INSURANCE

INFORMATION AND CONSENT o

Athlete's Name Birthdate Grade

Address

Street or PO City State

Father/ Guardian's Name Home Phone

Address

Street or PO City State

Employer Work Phone

Mother/ Guardian's Name Home Phone

Employer Work Phone

If parents cannot be reached in an emergency, please notify

Relationship

Insurance Carrier

Family Physician

Phone

Policy Number

Phone

Zip

Zip

List any serious medical conditions

List any allergies

I/We hereby grant consent to the attending physician, athletic tainer, or coach, to use their

best judgment in securing medical aid in case I/we cannot be reached. I/ We also grant consent to

the above-named personnel to render any first aid or preventative, rehabilitative, or emergency

treatment deemed reasonably necessary to protect the health and well-being of my/ our student.

WILL NOTIFY THE SCHOOL IN WRITING OF ANY

CHANGE OR CANCELLATION OF MY INSURANC3

Signature of Parent/ Guardian Date

What is a conc(ßion?A concsion is a typ of traumatic brain injury. Concusiors

are eused bya bump or blowto the tAd. Even a 'I dingel'

"*ting your rung," or what seerns to mild burnp

or blowto the tPäd can serious

You m'tsæa nnusion. suns and syrnpbrns of oono.lssion

shu up right aftertt•e injury or rnay notapparor be

or wee}s after the ijupj. If your d*lild

reports anysymptoms of wncsiont orif pu notice tipsyrnptorns yourself, seek rngiiæl at&ntbn right away,

What ale the arui symptoms of acon cts-i on?

If your child aperienced a bump or blow to ttp head

during a garrp or pradiæe lookforarv ofthe following

sigrs of a concusion:

ATHLETE

Hadactp or"pressud t in

Nausga or vomiting

Balanæ probérrs ordizirpssDouble or blurry

vision

• ±nsitivity to light

& ±nsitivity to noise

Fæling sluggish,hazyt foggyt or

or

rnernory probérns

ConflEion

rigWt

or'fæling dowrit

Appas dazed or

stunred

Is confused about

a sign ment orposition

Forgatsaninstructon

Is unstire of garn4scorer or opporent

dun-sily

Answers qi.psdors

slowly

Lops orsdotsres(Aen briafly)Shows mood,behavior, or

personality changz

A FACT SHEET FOR

How can you tE1p your child prevent a

concision or other serious brain injury?

Ensure ttnt they follow their coa&l's rules for 9Éty and

the rulg of the sport.

Enourage ttprn practice good spor$rnarship atall tires.

they ærttp right for

ttplr a ctiviVj P r&cdve equip mt should fit property

and be well rnairGined,IJSring a helmet isa must to reduce the risk ofa serious

brain irduy or skull fracture.

- Howe,tert tplrnetsare not prevent

conctssions, There is no "concision-proof' helmet,

So, em with a tplrnett it is irnporäntfor kids and

teens to avoid to tb2 hgad.

What should you do if you thi nk your chi Ld

has a conctsi on?SEEK MEDICAL ATTENTION RIGHT AWA}. A health

professional will be able to dedde how ærious the

concusion isand when it is safe for your child to retum to

regular activities, induding sporS

KEEP YOUR CHILD OUT OF PIN, Conwsions to

Don't let your child return to play tip day ofte injury

and undla tælth care professiornl says it 0K. Chidren who

return play mo san—while the brain is still hadng—

risk a gæter chanæof tavirg a repeat oncusion,or later anctssiors æn be l»ery serious. They cn

Iprrrnnert affecdngyour child fora dfe€rne,

TELL CHILDS CUCH ABOUT AN? PREVIOUSCONCUSSION, COQ chg should know if your child had aprev'ious cond.lsion. Your Childs oach rrgy not know about

a concusion your child received in anottprsport or activity

unles you the coach.

ff's better {o miss one game than the whole season-

For more information, vi sit unmwfcgnt/Concsions

ssnc ssncSUDDEN CARDIAC ARREST AWARENESS

What is Sudden Cardiac Arrest?• Occurs suddenly and often without warning.

• An electrical malfunction (short-circuit) causes the bottom chambers of the heart (ventricles) to

beat dangerously fast (ventricular tachycardia or fibrillation) and disrupts the pumping ability of the

heart,• The heart cannot pump blood to the brain, lungs and other organs of the body.

• The person loses consciousness (passes out) and has no pulse.

Death occurs within minutes if not treated immediately.

What are the symptoms/warning signs of Sudden Cardiac Arrest?

SCA should be suspected in any athlete who has collapsed and is unresponsive

Fainting, a seizure, or convulsions during physical activity

Dizziness or lightheadedness during physical activity

Unusual fatigue/weaknessChest painShortness of breathNausea/vomitingPalpitations (heart is beating unusually fast or skipping beats)

Family history of sudden cardiac arrest at age

ANY of these symptoms/warning signs may necessitate further evaluation from your physician before

returning to practice or a game.

What causes Sudden Cardiac Arrest?• Conditions present at birth (inherited and non-inherited heart abnormalities)

• A blow to the chest (Commotio Cordis)

• An infection/inflammation of the heart, usually caused by a virus. (Myocarditis)

Recreational/Performance-Enhancing drug use.

e Other cardiac & medical conditions / Unknown causes. (Obesity/ldiopathic)

What are ways to screen for Sudden Cardiac Arrest?

• The American Heart Association recommends a pre-participation history and physical which is

mandatory annually In West Virginia.

• Always answer the heart history questions on the student Health History section of the WVSSAC

Physical Form completely and honestly.

• Additional screening may be necessary at the recommendation of a physician.

What is the treatment for Sudden Ca rdiac Arrest?

• Act immediately; time is critical to increase survival rate

e Activate emergency action plan• call 911• Begin CPR

• Use Automated External Defibrillator (AED)

Where can one find additional information?

Contact your primary health care provider

• American Heart Association (www.heart.org)

Revised 2015

LET AN INJURY

TO AN OPIOID ADDICTION2 MILLION ATHLETES ARE EXPECTED TO SUFFER INJURY THIS YEAR

PAINKILLERS

USERS STARTED WITH PRESCRIPTION OPIOIDS

HIGH SCHO OL ATHLETES ARE

AT RISK OF BECO MING AD DICTED ToPRESCRIPTION DRUGS

+ 28.4% Lisa md.Lcal opioids atlnst once over a

yar perlcd.

+ 11% of high school v.édet.$have an oplold

medication Br nonmdLeal rAsons.

+ Nearly ofstudents who chroni*lly use

prascripdon oploldsalso use hemi-n.

WHAT ARE OPIOIDS?

Opioids are a pv.erful and addictive Vpe ofpracription

pa-Ink.lller that have similar chemical pmpertias and

addiction risks as heroin. While opioldsmay provide

tzaprary rel.l&, do noéLlng the underlying

In) uxy md can have serio us side effects,

drugs may to s tolerance,

uci&ntal me-r&se, and

most common pra*.rlbéd oplold plnkillers in V/æt

VLrginia in:

+ Oxyodone (OxyCondn)

+ Hydrocobne and Vlcodin)

O WEST VIRGINIA

HOW TO PROTECT YOUR CHILD

yo ur he-Idic.are provide ut

management tratment options (ee below).

Fhst-tlrce presorlptloa oploid uses Izve a 64%

hkhe.r lisk deary death thupähnts who

altermtlt„e mdLcdion.

Ifyour child is præcrlbd an oploid pal.nki.l.lez

the dangzs of misusing mdicatlon, including

overlise and meA.Leadon diarlng.

your intake of medication

hdshe is Bllowing doge Instructions.

S&ly dispse ofany um-Isa mdlc.adon through a

præc.ripdon drug drop box or a DEA %ke-.Bac.k

program.

Physical Therapy

Chiropracdc

Massage Therapy

Acupuncture

Over-the-Counter Medication

SSAC

Sports Physical Tips

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Ge.t• :SpoYtS

Medical•History

,

Med EXp(éSS.

vsevtiaUS0flnessvdmong othétfqhily memberssurgeries

• yhetheryoU ive•paSsed but, felt dizåynhqd the-st paih,

or•gtrdinetl bteatBihg during exe/clsemy medications you are On

Phykied 4.•.he.ighti weight; pressure dnd pulée.

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