MATAWAN-ABERDEEN REGIONAL SCHOOL DISTRICT



Matawan Aberdeen Regional School District

Sports Physical and Extracurricular Program

Information/Permission Package 2011-2012

Dear Parent/Guardian:

Your child has expressed an interest in joining an interscholastic team or extracurricular activity at Matawan Regional High School/Matawan Aberdeen Middle School.

Regardless of grade or season, there is paperwork required each season that an athlete intends to participate. Please review all information below and sign at the bottom to acknowledge that you have read this information and have granted your permission.

Academic Eligibility: I understand that The New Jersey State Interscholastic Athletic Association Rules and Regulations regarding eligibility are mandatory and that the NJSIAA Regulations and the MARSD BOE have adopted guidelines for students participating in the high school extracurricular activities.

Extra Curricular Code: I understand that all students participating in an extracurricular activity must abide by the Extra Curricular Code with has been set forth by the MARSD BOE (a copy of which is available to the HS Athletic Office or on the HS Athletic Office webpage for my review).

School Physician Examination: I hereby authorize permission for the school physician to exam my child when multiple students on a team have presented with superficial skin infections for the safety and precautionary measures of the school.

Travel Release Form: I understand that my child must submit a completed Travel Release Form to the Athletic Office as his/her coach prior to any event where they will not be taking school transportation either to/from an event.

Early Release Permission: I understand and hereby grant my permission for my child to leave school early should an event so warrant so that they may participate in the sport/event which they below to. I further understand that they will be taking school transportation and be chaperoned by a coach or teacher.

Completed Paperwork: I understand that a Physical Package must be completed in full in order for a student to participate in a sport or marching band. A Medical History Update Form must be completed for each additional season that my child participates in if his/her physical was completed more than 60 days prior to the start of the season. I understand that all the forms in the package must be completed in full by myself, my child and my child’s physician and that the doctor must sign, date and stamp this physical before this package will be accepted by the Athletic Office. Physical Evaluations by a Physician are valid for 365 days; therefore, my child’s physical will expire on the 366th day and he/she will have 10 days from the expiration day to submit an updated physical in order to continue to participate in their sport.

Sudden Cardiac Death Booklet: I acknowledge that I have obtained a copy of this informational booklet either from my student athlete or from the Athletic Office webpage.

Deadline Dates: I understand that all completed paperwork must be submitted to the Athletic prior to the dates listed below in order for my child to be eligible to participate in that season’s sport.

Fall Sports due by September 16, 2011

Winter Sports due by October 28, 2011

Spring Sports due by February 24, 2012

My signature below acknowledges that I have read all the information above and understand its contents and agree to abide by the Matawan Aberdeen Regional School district’s Extracurricular Code and procedures set in place.

_________________________ __________________________ ______

Parent/Guardian Signature Print Name Date

MATAWAN-ABERDEEN REGIONAL SCHOOL DISTRICT

PERMISSION for INTERSCHOLASTIC SPORTS/EXTRACURRICULAR ACTIVITIES,

PHYSICAL AND ACKNOWLEDGMENT OF READING EXTRACURRICULAR CODE

2011-2012

(PLEASE PRINT CLEARLY)

__________ FALL __________ WINTER __________ SPRING

Grade in September ‘11

____________________________ GRADE: [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ]

SPORT/ACTIVITY (Circle One)

____________________________________________ Circle One: MALE FEMALE

LAST NAME FIRST MIDDLE INITIAL

BIRTH DATE: _______________________ AGE: ________ PLACE OF BIRTH: ______________

(City/State or Country)

9th GRADE ENROLLMENT DATE: _____________________

If attending MIDDLE SCHOOL ENROLLMENT DATE:________________

Did your child transfer from another school (during the past year)? YES - NO

If yes, what school/state did he/she transfer from: _________________________________________

I/We will be responsible for any equipment loaned to my child by the school and will reimburse the school for any loss.

I/We understand that students must have a medical examination prior to participation on any athletic team or color/winter guard or marching band only. I understand and agree that the physical examination will be at my own cost/expense.

In order for your son/daughter to participate in after school activities it will be necessary for you to complete and return the attached questionnaire prior to starting the activity. A student/athlete must receive a full physical in the first sport/activity they participate in during the school year. If they choose to participate in another activity, only the blood pressure will be taken along with the completed paper work which will be reviewed by the school doctor and the athletic director.

Realizing that such activity involves the potential for injury which is inherent in all sports/activities, I/we acknowledge that even with excellent coaching, use of appropriate protective equipment and adherence to rules, injuries are still a possibility. On occasions, these injuries can be so severe as to result in total disability, paralysis or even death. I/we acknowledge that I/we have read and understand this warning and upon medical approval by a licensed physician give permission for my child to participate in sports/activities.

TO PARTICIPATE: (In addition to acknowledging the attached participation questionnaire/certification):

I have never received money for playing with any athletic team or professional group. I am an amateur in good standing. As a candidate for the above school activity, I agree to abide faithfully by the standards set by the school. I understand that my participation in the above stated activity may be revoked at such time said standards are not maintained. I promise to return all materials loaned to me by the Board of Education. I also acknowledge that physical hazards may be encountered. I also acknowledge reading the student handbook and the parent/extracurricular handbook and understand the consequences of academic deficiency and/or disciplinary infractions. I/We have read the Extracurricular Code of the school district. I/We understand its contents and agree to abide by its procedures. Any violation of the Extracurricular Code may result in removal from a program or programs indefinitely.

SCHOOL PHYSICIAN EXAMINATION

I hereby authorize permission for the School Physician to examine my child when multiple students on any team have presented with a possible communicable health issue for the safety and precautionary measures of the school.

I have read the Extracurricular Code and understand that I have access to additional information through the Athletic Office Webpage for clarification on any of the procedures and policies listed above and have discussed and explained same to my child. We understand its contents and agree to abide by the Matawan Aberdeen Regional School District’s Extracurricular Code.

_____________________________________________ DATE: ________________________

PRINT NAME OF PARENT/GUARDIAN

_____________________________________________ PHONE: _______________________CELL #______________________________

ADDRESS

PARENT EMAIL:____________________________________________________

__________________________________________

CITY/STATE/ZIP

______________________________

SIGNATURE: Student

_________________________________________

SIGNATURE: Parent/Guardian

MATAWAN-ABERDEEN REGIONAL SCHOOL DISTRICT

INSURANCE INFORMATION FORM

Dear Parent/Guardian,

The Board of Education has purchased insurance coverage to protect all participants in interscholastic sports/extracurricular activities in case of an accidental injury resulting from such participation. This coverage also applies to equipment managers, band members, cheerleaders, flag wavers, and any other approved participants.

The insurance is excess coverage; i.e., it will pay those expenses not covered (including deductibles) by any other medical insurance you may have. Thus, you must submit all bills to your own insurance first. The school policy will pick up the unpaid balances up to the limits of the policy. Contact the athletic trainer (732-705-5307), if you have any questions regarding injuries or insurance coverage.

Although this coverage is very broad, there are restrictions, limitations, and exclusions in this policy. IN MANY SITUATIONS, MEDICAL BILLS MAY NOT BE COVERED IN FULL. Parents should understand that medical expenses are their own responsibility, not the Board of Education’s.

All injuries should be immediately reported to the coach or faculty advisor and trainer. Claim forms will be provided by the school, but it is the parents’ responsibility to:

1. Submit the claim form with Part II filled out COMPLETELY. (Any omissions will delay the processing of the claim.)

1. Submit all itemized bills. (Monthly statements will not be accepted.)

1. Submit the statement received from your own insurance company showing amounts paid and balances due, or a letter of denial stating the claim is not covered. One of these letters is required for any payments to be made.

1. If you have no other medical insurance, you will receive a letter from the company to sign and have notarized. Return this to the company immediately and the claim will be considered for payment. Failure to return this letter will result in a delay or denial of the claim.

It is your responsibility, and to your benefit, to submit the necessary papers as soon as possible as the claim cannot be considered until all papers are submitted. ONLY ONE CLAIM FORM PER ACCIDENT IS REQUIRED.

All claim forms, bills and letters from other insurance companies are to be forwarded to, and questions regarding the coverage, answered by:

Bollinger ~~ Policy # P725

Attn: Joe Mignon

101 JFK Pkwy

Short Hills, NJ 07078

973-467-0444 Ext 8055

Sincerely,

Joseph Martucci

Joseph Martucci

Athletic Director

732-705-5346

=======================================================================================

I hereby acknowledge that I am aware of the type of coverage, benefits, and exclusions of the insurance program for participants in the extracurricular programs, and my responsibilities regarding the insurance program.

___________________________________ _____________________

Signature of Parent/Guardian Date

New Jersey Department of Education

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM

Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider

Part B: PHYSICAL EVALUATION FORM-

Completed by examining licensed provider with MD, DO, APN or PA

Part A: HEALTH HISTORY QUESTIONNAIRE

Today’s Date:_____________________

Date of Last Sports Physical: _______________

Student’s Name: _________________________________ Sex: M F (circle one) Age: ____ Grade: ________

Date of Birth: ____/___/_______

School: _____________________________ District: MRSD

Sport(s):______________________________________________

Home Phone: (_____) ________________

Doctor’s Name: _______________________________ Phone: _______________________ Fax: ____________

Emergency Contact Information

Name of parent/guardian:______________________________

Relationship to student: ______________________________

Phone (work): _____________________

Phone (home):______________________________

Phone (cell): ______________

Additional emergency contact__________________________

Relationship to student: ______________________________

Phone (work): _____________________

Phone (home):______________________________

Phone (cell): ______________

Directions: Please answer the following questions about the student’s medical history by circling the correct response. Explain all “yes” responses on the lines below the questions. Please respond to all questions.

1. Have you ever had, or do you currently have:

a. Restriction from sports for a health related problem?

Y / N / Don’t Know

b. An injury or illness since your last exam? Y / N / Don’t Know

c. A chronic or ongoing illness (such as diabetes or asthma)? Y / N / Don’t Know

(1.) An inhaler or other prescription medicine to control asthma? Y / N / Don’t Know

d. Any prescribed or over the counter medications that you take on a regular basis? Y / N / Don’t Know

e. Surgery, hospitalization or any emergency room visit(s)? Y / N / Don’t Know

f. Any allergies to medications? Y / N / Don’t Know

g. Any allergies to bee stings, pollen, latex or foods?Y / N / Don’t Know

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

|□ Rash □ Hives □ Breathing or other |

|anaphylactic reaction |

(2.) Take any medication/Epi-pen taken for allergy symptoms? (List below.) Y / N / Don’t Know

h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Don’t Know

i. A blood relative who died before age 50? Y / N / Don’t Know

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

List all medications here:

|Medication Name |Dosage |Frequency |

| | | |

| | | |

| | | |

| | | |

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

a. Concussion or head injury (including “bell rung” or a “ding”)? Y / N / Don’t Know

b. Memory loss? Y / N / Don’t Know

c. Knocked out? Y / N / Don’t Know

c. A seizure? Y / N / Don’t Know

d. Frequent or severe headaches (With or without exercise)? Y / N / Don’t Know

e. Fuzzy or blurry vision Y / N / Don’t Know

f. Sensitivity to light/noise Y / N / Don’t Know

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

___________________________________________________________________________________________________________________________________________________________________________

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

a. Restriction from sports for heart problems? Y/ N Don’t Know

b. Chest pain or discomfort? Y / N / Don’t Know

c. Heart murmur? Y / N / Don’t Know

d. High blood pressure? Y / N / Don’t Know

e. Elevated cholesterol level? Y / N / Don’t Know

f. Heart infection? Y / N / Don’t Know

g. Dizziness or passing out during or after exercise without known cause? Y / N / Don’t Know

h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? Y / N / Don’t Know

i. Racing or skipped heartbeats? Y / N / Don’t Know

j. Unexplained difficulty breathing or fatigue during exercise? Y / N / Don’t Know

k. Any family member (blood relative):

(1.) Under age 50 with a heart condition? Y / N / Don’t Know

(2.) With Marfan Syndrome? Y / N / Don’t Know

(3.) Died of a heart problem before age 50? If yes, at what age? _____________________ Y / N / Don’t Know

(4.) Died with no known reason? Y / N / Don’t Know

(5.) Died while exercising? If yes, was it during or after? (Circle one.) Y / N / Don’t Know

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

___________________________________________________________________________________________________________________________________________________________________________

4. Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions:

a. Vision problems? Y / N / Don’t Know

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

b. Hearing loss or problems? Y / N / Don’t Know

(1.) Wear hearing aides or implants?Y / N / Don’t Know

c. Nasal fractures or frequent nose bleeds? Y / N / Don’t Know

d. Wear braces, retainer or protective mouth gear? Y / N / Don’t Know

e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? Y / N / Don’t Know

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

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions:

a. Numbness, a “burner”, “stinger” or pinched nerve? Y / N / Don’t Know

b. A sprain? Y / N / Don’t Know

c. A strain? Y / N / Don’t Know

d. Swelling or pain in muscles, tendons, bones or joints? Y / N / Don’t Know

e. Dislocated joint(s)? Y / N / Don’t Know

f. Upper or lower back pain? Y / N / Don’t Know

g. Fracture(s), stress fracture(s), or broken bone(s)?Y / N / Don’t Know

h. Do you wear any protective braces or equipment?Y / N / Don’t Know

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

___________________________________________________________________________________________________________________________________________________________________________

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

a. Difficulty breathing?

(1.) During exercise? Y / N / Don’t Know

(2.) After running one mile? Y / N / Don’t Know

(3.) Coughing, wheezing or shortness of breath in weather changes? Y / N / Don’t Know

(4.) Exercise-induced asthma? Y / N / Don’t Know

i. Controlled with medication? (specify _______________________)

Y / N / Don’t Know

ii. Experience dizziness, passing out or fainting? Y / N / Don’t Know

b. Viral infections (e.g. mono, hepatitis, coxsackie virus)? Y / N / Don’t Know

c. Become tired more quickly than others? Y / N / Don’t Know

d. Any of the following skin conditions:

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

(2.) Sun sensitivity? Y / N / Don’t Know

e. Weight gain/loss (of 10 pounds or more)? Y / N / Don’t Know

(1.) Do you want to weigh more or less than you do now? Y / N / Don’t Know f. Ever had feelings of depression? Y / N / Don’t Know

g. Heat-related problems (dehydration, dizziness, fatigue, headache)? Y / N / Don’t Know

1.) Heat exhaustion (cool, clammy, damp skin)? Y / N / Don’t Know

(2.) Heat stroke (hot, red, dry skin)? Y / N / Don’t Know

(3.) Muscle cramps? Y / N / Don’t Know

h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)? Y / N / Don’t Know

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

___________________________________________________________________________________________________________________________________________________________________________

7. Females only:

Age of onset of menstruation:______

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

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

8. Males only:

Have you had any swelling or pain in your testicles or groin? Y / N / Don’t Know

PARENT/GUARDIAN SIGNATURE

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

Signature, Parent/Guardian or Student Age 18

Date of Signature:____________________

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

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM

Part B: Physical Evaluation Form

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

-STUDENT INFORMATION-

Student’s Name: __________________________________ Sport(s): ___________________________________

Sex: M F (circle one) Age: ________ Grade: _____________ Date of Birth: ___________________

Address:__________________________________________________________________________________________

City/State/Zip:________________________________________________ Home Phone: _____________________

School: _____________________________________________________ District: MRSD

Parent/Guardian’s Full Name:___________________________________________________________________________

- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATION-

If conducted by school physician check here □

Name: _______________________________Phone: __________________________ Fax:________________

Address:______________________________City/State/Zip:___________________________________________

- FINDINGS OF PHYSICAL EVALUATION -

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

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

|INDICATORS |NORMAL? |ABNORMAL FINDINGS/COMMENTS |

|General Appearance |YES | |

|Head/Neck |YES | |

|Eyes/Sclera/Pupils |YES | |

|Ears |YES | |

|Gross Hearing |YES | |

|Nose/Mouth/Throat |YES | |

|Lymph Glands |YES | |

|Cardiovascular |YES | |

|Heart Rate |YES | |

|Rhythm |YES | |

|Murmur |ABSENT | |

|If murmur present | |Standing makes it: Louder Softer No Change |

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

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

|Femoral Pulses |YES | |

|Lungs: Auscultation/Percussion |YES | |

|Chest Contour |YES | |

|Skin |YES | |

|Abdomen (liver, spleen, masses) |YES | |

|Assessment of physical maturation or Tanner |YES | |

|Scale | | |

|Testicular Exam (Males Only) |YES | |

|Neck/Back/Spine: |YES | |

|Range of Motion |YES | |

|Scoliosis |ABSENT | |

|Upper Extremities: (ROM, Strength, Stability) |YES | |

|Lower Extremities: (ROM, Strength, Stability) |YES | |

|Neurological: Balance & Coordination |YES | |

|Hernia |ABSENT | |

|Evidence of Marfan Syndrome |ABSENT | |

Most recent immunizations and dates administered:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medications currently prescribed, with dose and frequency:

|Medication Name |Dosage |Frequency |

| | | |

| | | |

| | | |

| | | |

| | | |

Additional observations:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

General Diagnosis: ____________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________

General Recommendations: ______________________________________________________________________________________________________________________________________________________________________________________________________________

NOTES TO THE EXAMINING PROVIDER

Conditions requiring clearance before sports participation include, but are not limited to the following:

Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision

greater than 20/40 in one eye.

|SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT |

|Contact/Collision |Limited Contact |Non-Contact |

| | |Strenuous |Non-strenuous |

|Basketball |Baseball |Discus |Bowling |

|Diving |Cheerleading |Javelin |Golf |

|Field Hockey |Fencing |Shot put | |

|Football |High Jump |Rowing | |

|Ice Hockey |Pole vault |Running/Cross Country | |

|Lacrosse |Gymnastics |Strength Training | |

|Soccer |Skiing |Swimming | |

|Wrestling |Softball |Tennis | |

| |Volleyball |Track | |

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

Effects of physiologic maneuvers on heart sounds: Physical Stigmata of Marfan’s Syndrome

Standing Increases murmur of HCM Kyphosis

Decreases murmur of AS, MR High arched palate

MVP click occurs earlier in systole Pectus excavatum

Arachnodactyly

Squatting Increases murmur of AS, MR, AI Arm span > height 1.05:1 or greater

Decreases murmur of MCH Mitral Valve Prolapse

MVP click delayed Aortic Insufficiency

Myopia

Valsalva Increases murmur of HCM Lenticular dislocation

Decreases murmur of AS, MR

MVP click occurs earlier in systole

HCM = Hypertrophic Cardio Myopathy

AS = Aortic Stenosis

AI = Aortic Insufficiency

MR = Mitral Regugitation

MVP = Mitral Valve Prolapse

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

CLEARANCES: (See notes at bottom for conditions requiring attention and for a list of sports by level of contact)

 A. Student is cleared for participation in all sports without restriction.

 B. Student is withheld clearance for participation in any sport until evaluation / treatment of: ________________________________________________________________________________________________________________________________________________________________________

 C. Student is cleared for participation in limited types of sports which exclude the following types of sports contact: (check all that apply)

___ CONTACT/COLLISION ___ NON-CONTACT/STRENUOUS

___ LIMITED CONTACT ___ NON-CONTACT/NON-STRENUOUS

Due to: __________________________________________________________________________

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

Primary Care Provider 

School Physician Provider 

License Type:

MD/DO 

APN 

PA 

Physician’s/Provider’s Signature: _____________________________________ Today’s Date: ______________

Date of Exam: ______________

RESERVED FOR SCHOOL DISTRICT USE

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

History and Physical Reviewed by:______________________________Date:________

Title of Reviewer (please circle one): School Nurse School Physician

Medical Eligibility Notification sent to parent/guardian by School Physician on ______________________________

Date

Letter of notification is attached ___

OR

Parent notification indicates that:

Participation approved without limitations ____

Participation approved with limitations pending evaluation ____

Participation NOT approved ____

Reason(s) for Disapproval:_________________________________________________

______________________________________________________________________

NJSIAA

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

NJSIAA STERIOD TESTING POLICY

CONSENT TO RANDOM TESTING

In Executive Order 72, issued December 20, 2005, Governor Richard Codey directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying for championship games.

Beginning in the Fall, 2006 sports season, any student-athlete who possesses, distributes, ingests or otherwise uses any of the banned substances on the attached page, without written prescription by a fully-licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA’s sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition. The NJSIAA will test certain randomly selected individuals and teams that qualify for a state championship tournament or state championship competition for banned substances. The results of all tests shall be considered confidential and shall only be disclosed to the student, his or her parents and his or her school. No student may participate in NJSIAA competition unless the student and the student’s parent/guardian consent to random testing.

By signing below, we consent to random testing in accordance with the NJSIAA steroid testing policy. We understand that, if the student or the student’s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances.

_____________________ ____________________ _____

Signature of student-athlete Print student-athlete’s name Date

__________________________ _________________________ ______

Signature of parent/guardian Print parent/guardian’s name Date

NJSIAA Banned-Drug Classes

2007 - 2008

The term “related compounds” comprises substances that are included in the class by their pharmacological action and/or chemical structure. No substance belonging to the prohibited class may be used, regardless of whether it is specifically listed as an example.

Many nutritional/dietary supplements contain NJSIAA banned substances. In addition, the U. S. Food and Drug Administration (FDA) does not strictly regulate the supplement industry; therefore purity and safety of nutritional dietary supplements cannot be guaranteed. Impure supplements may lead to a positive NJSIAA drug test. The use of supplements is at the student-athlete’s own risk. Student-athletes should contact their physician or athletic trainer for further information.

The following is a list of banned-drug classes, with examples of banned substances under each class:

(a) Stimulants (b) Anabolic Agents (c) Diuretics (d) Peptide Hormones & Analogues:

amiphenazole anabolic steroids acetazolamide corticotrophin (ACTH)

amphetamine androstenediol bendroflumethiazide human chorionic gonadotrophin (hCG)

bemigride androstenedione benzhiazide leutenizing hormone (LH)

benzphetamine boldenone bumetanide growth hormone (HGH, somatotrophin)

bromantan clostebol chlorothiazide insulin like growth hormone (IGF-1)

caffeine1 (guorana) dehydrochlormethyl- chlorthalidone

chlorphentermine testosterone ethacrynic acid All the respective releasing factors

cocaine dehydroepiandro- flumethiazide of the above-mentioned substances

cropropamide sterone (DHEA) furosemide also are banned:

crothetamide dihydrotestosterone (DHT) hydrochlorothiazide erythropoietin (EPO)

diethylpropion dromostanolone hydroflumenthiazide darbypoetin

dimethylamphetamine epitrenbolone methyclothiazide sermorelin

doxapram fluoxymesterone metolazone

ephedrine gestrinone polythiazide

(ephedra, ma huang) mesterolone quinethazone

ethamivan methandienone spironolactone

ethylamphetamine methenolone triamterene

fencamfamine trichlormethiazide

meclofenoxate and related compounds

methamphetamine methyltestosterone

methylenedioxymethamphetamine nandrolone

(MDMA, ecstasy) norandrostenediol

methylphenidate norandrostenedione

nikethamide norethandrolone (e) Definitions of positive depends on the following:

pemoline oxandrolone 1 for caffeine – if the concentration in urine exceeds 15 micrograms/ml

pentetrazol oxymesterone

phendimetrazine oxymetholone 2 for testosterone – if administration of testosterone or use of any other

phenmetrazine pregnelone manipulation has the result of increasing the ratio of the total

phentermine stanozolol concentration of testosterone to that of epitestosterone in the urine

phenylpropanolamine (ppa) testosterone2 of greater than 6:1, unless there is evidence that this ratio is due to a

picrotoxine tetrahydrogestrinone physiological or pathological condition.

pipradol (THG)

prolintane trenbolone

strychnine and related compounds

synephrine other anabolic agents

(citrus aurantium, zhi shi, bitter clenbuterol

orange)

and related compounds

NJSIAA PARENT/GUARDIAN

CONCUSSION POLICY ACKNOWLEDGMENT FORM

In order to help protect the student athletes of New Jersey, the NJSIAA has mandated that all

athletes, parents/guardians and coaches follow the NJSIAA Concussion Policy.

A concussion is a brain injury and all brain injuries are serious. They may be caused by a bump, blow,

or jolt to the head, or by a blow to another part of the body with the force transmitted to the head.

They can range from mild to severe and can disrupt the way the brain normally works. Even though

most concussions are mild, all concussions are potentially serious and may result in

complications including prolonged brain damage and death if not recognized and managed

properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a

concussion and most sports concussions occur without loss of consciousness. Signs and symptoms

of concussion may show up right after the injury or can take hours or days to fully appear. If your

child/player reports any symptoms of concussion, or if you notice the symptoms or signs of

concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

1. Headache.

2. Nausea/vomiting.

3. Balance problems or dizziness.

4. Double vision or changes in vision.

5. Sensitivity to light or sound/noise.

6. Feeling of sluggishness or fogginess.

7. Difficulty with concentration, short-term memory, and/or confusion.

8. Irritability or agitation.

9. Depression or anxiety.

10. Sleep disturbance.

Signs observed by teammates, parents and coaches include:

1. Appears dazed, stunned, or disoriented.

2. Forgets plays or demonstrates short-term memory difficulties (e.g. is unsure of the

game, score, or opponent)

3. Exhibits difficulties with balance or coordination.

4. Answers questions slowly or inaccurately.

5. Loses consciousness.

6. Demonstrates behavior or personality changes.

7. Is unable to recall events prior to or after the hit

.

What can happen if my child/player keeps on playing with a concussion or returns too soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately.

Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially

vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a

period of time after that concussion occurs, particularly if the athlete suffers another concussion

before completely recovering from the first one. This can lead to prolonged recovery, or even to

severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is

well known that adolescent or teenage athletes will often under report symptoms of injuries. And

concussions are no different. As a result, education of administrators, coaches, parents and students

is the key for student-athlete’s safety.

If you think your child/player has suffered a concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice

immediately. No athlete may return to activity after an apparent head injury or concussion, regardless

of how mild it seems or how quickly symptoms clear. Close observation of the athlete should continue

for several hours.

An athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be

removed from competition at that time and may not return to play until the athlete is evaluated by a

medical doctor or doctor of Osteopathy, trained in the evaluation and management of concussion and

received written clearance to return to play from that health care provider.

You should also inform you child’s Coach, Athletic Trainer (ATC), and/or Athletic Director, if you think

that your child/player may have a concussion. And when it doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to:





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Signature of Student-Athlete Print Student-Athlete’s Name Date

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Signature of Parent/Guardian Print Parent/Guardian’s Name Date

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