(PARENT ) 1



(PARENT) 1

Name Grade Birthdate

Address Phone Birthplace

NOTICE OF CHANGE

REGARDING

SPORTS PHYSICALS

Due to a change in the New Jersey Administrative Code (NJAC 6A:16:2-2) “each student medical examination shall be conducted at the medical home of the student” (the students physician or nurse practitioner, clinical nurse specialist.) If a student does not have a medical home (doctor), the certified school nurse will offer information to the parent or guardian on current NJ sponsored health insurance programs, if there will be a delay in establishing a medical home, the school physician will perform the student medial examination in a district health office. The student’s parent or guardian will be notified in writing of this proposed examination.

Student name Sport

We have a medical home (physician) but would like the school to perform the physical

_____________ We do not have a medical home (physician) and will need a physical exam from our district.

We will receive a physical from home physician.

Parent’s Signature

STATEMENT OF RISK INVOLVED

We are aware that all athletic activity involves the potential for injury. We acknowledge that even with the best coaching, use of good protective equipment and strict observance of rules; injuries are always possible, and in rare occasions these injuries can be so severe as to result in total disability, paralysis or even death. We acknowledge that we have read and understand this warning.

STATEMENT OF PAST PARTICIPATION

While in grammar school prior to high school, did you ever compete on the High School Level.

Yes No

PARENT/GUARDIAN PERMISSION

I hereby give consent for the above-named student (1) represent his/her school and/or participate in athletic activities or an interscholastic and/or intra-mural basis; (2) to accompany any school team, of which he/she is a member on and of its local or out-of-town trips; (3) to be examined and/or treated by any school trainer and/or medial doctor and/or dentist. I am also advised that students are held responsible for all equipment issued to them, even if lost or stolen. (I acknowledge that in the event a student acquired an exam by a medical doctor of her or her own choice, same shall be on a school form, signed, dated and filed with the Athletic Director.)

9/26/13

(PARENT) 2

ANTI-SUBSTANCE ABUSE AND STUDENT CONDUCT AGREEMENT

I, , hereby agree to conduct myself in an appropriate and acceptable manner according to the laws of the State and Rules and requirements of my school and coaches as a member of Keansburg School System interscholastic team and/or extra-curricular and intra-mural activity. I recognize that I have accepted a challenge to be the best I can be by my participation in this activity. Excellence is a goal. I further recognize that I am a representative of the Keansburg School System. I, therefore, also agree that any “substance abuse” (including, without limitation, use of drugs, alcoholic beverages, smoothing and use of tobacco and/or any substances prohibited by and contrary to law and/or school rules and rules of my Coach) may result in my dismissal from the above activity at the direction of my Coach and/or school administrator.

Student Signature Date

EMERGENCY CARE AND PERMISSION AND CONSENT FOR TREATMENT

I authorize and permit the school and its agents, servants, and employees to assist my child to obtain through a physician and/or hospital, any emergency medical care that may become necessary for my child in the course of such athletic activities and or travel. I realize I am responsible for my child’s heath, safety, and medical treatment. I consent for my child and student in the Keansburg School System to be taken for emergency treatment and I do voluntary consent the rendering of such medical care by Bayshore Community Hospital, Riverview Medical Center, and/or any other hospital and it personnel and in particular, but, without limitation, any such limitation, any such treatment by the physicians and nurses in the Emergency Room, as in their judgment, may be considered necessary in the treatment of the condition for which my child needs emergency medical care. This consent extends to diagnostic tests, including Radiology and Pathology tests, and includes the carrying out of any orders of the personal physician of my child which may have been transmitted to the medial and nursing staff of the Emergency Room. This consent also extends to minor surgical procedures including suturing, which may be necessary to complete he treatment in the Emergency Room. I acknowledge that no guarantees or assurances have been made to me as to the effect of any diagnostic tests or the treatment for the condition for which medical care may be sought for my child.

INSURANCE COVERAGE

Some insurance coverage is provided by the school under what is known as “Partial Excess Plan.” However, some parents of the players and participants must provide payment personally or from their personal insurance coverage for treatment for medical and hospital related expenses. Any charge not covered by such personal plan, or if funds are exhausted, may be paid by the school insurance if the policy so provides. (For you information, the Interscholastic Sports Certificate of Insurance is available for review at the Board of Education Offices.) Please provide the following information concerning your family health and medical insurance.

Students Name is covered by insurance for the 20__-20__ school year under our family carrier or group policy at employment.

Name of Insurance Company Policy Number

(PARENT) 3

MEDIA RELEASE

Keansburg High School Student Athletes may have their name/pictures in printed/video media (e.g. Asbury Park Press, The Independent, MSG Varsity). We will assume that you are granting permission unless we hear from you in writing to the contrary.

IN CASE OF EMERGENCY, PLEASE TRY TO CONTACT THE FOLLOWING:

1. Parent/Guardian Name Home Work Cell

2. Relative or Friend Name Phone

3. Name of Family Doctor Phone

LEGAL CERTIFICATION IN LIEU OF OATH

I herby certify that the foregoing statements made by me are the true to the best of my knowledge and that I am also voluntarily signing the Emergency Care and Permission and Consent for Treatment section. I am aware that if any of the foregoing statements made by me are willfully false. I am subject to punishment.

Student Signature Date

Parent/Guardian Signature Date

NO STUDENT WILL BE PERMITTED TO PRACTICE OR PARTICIPATE IN ANY WAY

UNTIL THE CERTIFICATIONS ARE COMPLETE

(PARENT) 4

KEANSBURG HIGH SCHOOL

PARENTAL CODE OF CONDUCT FOR ATHLETIC EVENTS

Preamble: Interscholastic sports programs play an important role in promoting the physical, social and emotional development of our students. It is therefore essential for parents, coaches and officials to encourage youth athletes to embrace the values of good sportsmanship. Moreover, adults involved in youth sports events should be models of good sportsmanship and should lead by example by demonstrating fairness, respect and self-control.

I therefore pledge to be responsible for my words and actions while attending, coaching, officiating or participating in a youth sports event and shall conform my behavior to the following code of conduct:

1. I will not engage in unsportsmanlike conduct with any coach, parent, player, participant, official or any other attendee.

2. I will not encourage my child, or any other person, to engage in unsportsmanlike conduct with any coach, parent, player, participant, official or any other attendee.

3. I will not engage in any behavior which would endanger the health, safety or wellbeing of any coach, parent, player, participant, official or any other attendee.

4. I will not encourage my child, or any other person, to engage in any behavior which would endanger the health, safety or wellbeing of any coach, parent, player, participant, official or any other attendee.

5. I will not use drugs or alcohol while at a youth sports event and will not attend, coach, officiate or participate in a youth sports event while under the influence of drugs or alcohol.

6. I will not permit my child, or encourage any other person, to use drugs or alcohol at a youth sports event and will not permit my child, or encourage any other person, to attend, coach, officiate or participate in a youth sports event while under the influence of drugs or alcohol.

7. I will not engage in the use of profanity.

8 I will not encourage my child, or any other person, to engage in the use of profanity.

9. I will treat any coach, parent, player, participant, official or any other attendee with respect regardless of race, creed, color, national origin, sex, sexual orientation or ability.

10. I will encourage my child to treat any coach, parent, player, participant, official or any other attendee with respect regardless of race, creed color, national origin, sex, sexual orientation or ability.

11. I will not engage in verbal or physical threats or abuse aimed at any coach, parent, player, participant, official or any other attendee.

12. I will not encourage my child, or any other person, to engage in verbal or physical threats or abuse aimed at any coach, parent, player, participant, official or any other attendee.

13. I will not initiate a fight or scuffle with any coach, parent, player, participant, official or any other attendee.

14. I will not encourage my child, or any other person, to initiate a fight or scuffle with any coach, parent, player, participant, official or any other attendee.

I hereby agree that if I fail to conform my conduct to the foregoing while attending, coaching, officiating or participating in a youth sports event, I will be subject to disciplinary action, including but not limited to the following in any order or combination:

1. Verbal warning issued by a school official.

2. Written warning issued by a school official.

3. Suspension or immediate ejection from an interscholastic sporting event issued by a school official who is authorized to issue such suspension or ejection by the Board of Education.

4. Suspension from multiple interscholastic sporting events issued by a school official who is authorized to issue such suspension by the Board of Education.

5. Season suspension or multiple season suspension issued by the Board of Education.

_____________________________________ __________________________________________ ______________

Parent’s Name Printed Parent’s Signature Date

_____________________________________ ___________________________________________ ______________

Student’s Name Printed Student’s Signature Date

(PARENT) 5

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(PARENT) 6

NJSIAA STEROID TESTING POLICY

CONSENT TO RANDOM TESTING

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

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

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

____________________________ ______________

Signature of Student-Athlete Date

____________________________ ______________

Signature of Parent/Guardian Date

(PARENT) 7

Sports-Related Concussion and Head Injury Fact Sheet and

Parent/Guardian Acknowledgement Form

A concussion is a brain injury that can be caused by a blow to the head or body that disrupts normal functioning of the brain. Concussions are a type of Traumatic Brain Injury (TBI), which can range from mild to severe and can disrupt the way the brain normally functions. Concussions can cause significant and sustained neuropsychological impairment affecting problem solving, planning, memory, attention, concentration, and behavior.

The Centers for Disease Control and Prevention estimates that 300,000 concussions are sustained during sports related activities nationwide, and more than 62,000 concussions are sustained each year in high school contact sports. Second-impact syndrome occurs when a person sustains a second concussion while still experiencing symptoms of a previous concussion. It can lead to severe impairment and even death of the victim.

Legislation (P.L. 2010, Chapter 94) signed on December 7, 2010, mandated measures to be taken in order to ensure the safety of K-12 student-athletes involved in interscholastic sports in New Jersey. It is imperative that athletes, coaches, and parent/guardians are educated about the nature and treatment of sports related concussions and other head injuries. The legislation states that:

• All Coaches, Athletic Trainers, School Nurses, and School/Team Physicians shall complete an Interscholastic Head Injury Safety Training Program by the 2011-2012 school year.

• All school districts, charter, and non-public schools that participate in interscholastic sports will distribute annually this educational fact to all student athletes and obtain a signed acknowledgement from each parent/guardian and student-athlete.

• Each school district, charter, and non-public school shall develop a written policy describing the prevention and treatment of sports-related concussion and other head injuries sustained by interscholastic student-athletes.

• Any student-athlete who participates in an interscholastic sports program and is suspected of sustaining a concussion will be immediately removed from competition or practice. The student-athlete will not be allowed to return to competition or practice until he/she has written clearance from a physician trained in concussion treatment and has completed his/her district’s graduated return-to-play protocol.

Quick Facts

• Most concussions do not involve loss of consciousness

• You can sustain a concussion even if you do not hit your head

• A blow elsewhere on the body can transmit an “impulsive” force to the brain and cause a concussion

Signs of Concussions (Observed by Coach, Athletic Trainer, Parent/Guardian)

• Appears dazed or stunned

• Forgets plays or demonstrates short term memory difficulties (e.g. unsure of game, opponent)

• Exhibits difficulties with balance, coordination, concentration, and attention

• Answers questions slowly or inaccurately

• Demonstrates behavior or personality changes

• Is unable to recall events prior to or after the hit or fall

Symptoms of Concussion (Reported by Student-Athlete)

• Headache

• Nausea/vomiting

• Balance problems or dizziness

• Double vision or changes in vision

• Sensitivity to light/sound

• Feeling of sluggishness or fogginess

• Difficulty with concentration, short term memory, and/or confusion

(PARENT) 8

What Should a Student-Athlete do if they think they have a concussion?

• Don’t hide it. Tell your Athletic Trainer, Coach, School Nurse, or Parent/Guardian.

• Report it. Don’t return to competition or practice with symptoms of a concussion or head injury. The sooner you report it, the sooner you may return-to-play.

• Take time to recover. If you have a concussion your brain needs time to heal. While your brain is healing you are much more likely to sustain a second concussion. Repeat concussions can cause permanent brain injury.

What can happen if a student-athlete continues to play with a concussion or returns to play to soon?

• Continuing to play with the signs and symptoms of a concussion leaves the student-athlete vulnerable to second impact syndrome.

• Second impact syndrome is when a student-athlete sustains a second concussion while still having symptoms from a previous concussion or head injury.

• Second impact syndrome can lead to severe impairment and even death in extreme cases.

Should there be any temporary academic accommodations made for Student-Athletes who have suffered a concussion?

• To recover cognitive rest is just as important as physical rest. Reading, texting, testing-even watching movies can slow down a student-athletes recovery.

• Stay home from school with minimal mental and social stimulation until all symptoms have resolved.

• Students may need to take rest breaks, spend fewer hours at school, be given extra time to complete assignments, as well as being offered other instructional strategies and classroom accommodations.

Student-Athletes who have sustained a concussion should complete a graduated return-to-play before they may resume competition or practice, according to the following protocol:

• Step 1: Completion of a full day of normal cognitive activities (school day, studying for tests, watching practice, interacting with peers) without reemergence of any signs or symptoms. If no return of symptoms, next day advance.

• Step 2: Light Aerobic exercise, which includes walking, swimming, and stationary cycling, keeping the intensity below 70% maximum heart rate. No resistance training. The objective of this step is increased heart rate.

• Step 3: Sport-specific exercise including skating, and/or running: no head impact activities. The objective of this step is to add movement.

• Step 4: Non contact training drills (e.g. passing drills). Student-athlete may initiate resistance training.

• Step 5: Following medical clearance (consultation between school health care personnel and student-athlete’s physician), participation in normal training activities. The objective of this step is to restore confidence and assess functional skills by coaching and medical staff.

• Step 6: Return to play involving normal exertion or game activity.

For further information on Sports-Related Concussions and other Head Injuries, please visit:

concussion/sports/index.html

health-safety

__________________________________ _______________________________ __________

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

__________________________________ _______________________________ __________

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

(PARENT) 9

(PARENT) 10

(PARENT) 11

KEANSBURG SCHOOL DISTRICT EMERGENCY TREATMENT CARD

Student’s Name__________________________________ Sport ___________________

If I cannot be reached to give my consent to emergency treatment, I give my permission for the Keansburg Coaching Staff to authorize emergency treatment for my son/daughter. This consent is given only in situations where a physician or emergency room personnel feel, in good faith, that the injury is potentially disabling or life threatening.

Family Physician’s Name ___________________________________________________

Family Physician’s Phone number ____________________________________________

Hospital preference (home event only) ________________________________________

Parent/ Guardian Name ____________________________________________________

Parent/Guardian Signature _________________________________________________

Home phone number _____________________________________________________

Work phone number ______________________________________________________

Email Address: ___________________________________________________________

Emergency contact if parent can’t be reached __________________________________

Phone number __________________________________

Important medical information:

(PARENT) 12

New Jersey Department of Education

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM

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

Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA

Part A: HEALTH HISTORY QUESTIONNAIRE

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

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

Date of Birth: ____/___/_______ School: _____________________________ District: _______________________

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

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

Emergency Contact Information

Name of parent/guardian: _________________________________ Relationship to student: ______________________________

Phone (work): _____________________ Phone (home):______________________________ Phone (cell): ______________

Additional emergency contact: ____________________________ Relationship to student: ______________________________

Phone (work): _____________________ Phone (home):______________________________ Phone (cell): ______________

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

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

a. Restriction from sports for a health related problem? Y / N / Don’t Know

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

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

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

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

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

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

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

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

|□ Rash □ Hives □ Breathing or other anaphylactic reaction |

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

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

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

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

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List all medications here:

|Medication Name |Dosage |Frequency |

| | | |

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(PARENT) 13

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):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(PARENT) 14

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.

(DOCTOR) 15

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM

Part B: Physical Evaluation Form

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

-STUDENT INFORMATION-

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

Sex: M F (circle one) Age: ________ Grade: _____________ Date of Birth: _________________________________________ Address: ___________________________________________________________________________________________________________

City/State/Zip:________________________________________________ Home Phone: _________________________________________

School: _____________________________________________________ District: _____________________________________________

Parent/Guardian’s Full Name: __________________________________________________________________________________________

- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATION-

If conducted by school physician check here □

Name: _______________________________ Phone: __________________________ Fax: _________________

Address: ______________________________ City/State/Zip:_____________________________________________

- FINDINGS OF PHYSICAL EVALUATION -

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

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

|INDICATORS |NORMAL? |ABNORMAL FINDINGS/COMMENTS |

|General Appearance |YES | |

|Head/Neck |YES | |

|Eyes/Sclera/Pupils |YES | |

|Ears |YES | |

|Gross Hearing |YES | |

|Nose/Mouth/Throat |YES | |

|Lymph Glands |YES | |

|Cardiovascular |YES | |

|Heart Rate |YES | |

|Rhythm |YES | |

|Murmur |ABSENT | |

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

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

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

|Femoral Pulses |YES | |

|Lungs: Auscultation/Percussion |YES | |

|Chest Contour |YES | |

|Skin |YES | |

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

|Assessment of physical maturation or 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 | |

(DOCTOR) 16

Most recent immunizations and dates administered:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medications currently prescribed, with dose and frequency:

|Medication Name |Dosage |Frequency |

| | | |

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| | | |

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Additional observations:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

General Diagnosis: ____________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________

General Recommendations: _______________________________________________________________________________________________________________________________________________________________________________________________________________________

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

(DOCTOR) 17

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



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

| |

A. Cleared for participation in all sports without restrictions.

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

___________________________________________________________________________________

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

___ CONTACT/COLLISION ___ NON-CONTACT/STRENUOUS

___ LIMITED CONTACT ___ NON-CONTACT/NON-STRENUOUS

Limitations due to: ___________________________________________________________________

NOTES TO THE EXAMINING PROVIDER

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

Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan 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

(DOCTOR) 18

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

| |

| |

| |

| |

| |

| |

Primary Care Provider

School Physician Provider

License Type:

MD/DO

APN

PA

PHYSICIAN’S/PROVIDER’S SIGNATURE:______________________________________________

Today’s Date: ______________ Date of Exam: ______________

RESERVED FOR SCHOOL DISTRICT USE

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

History and Physical Reviewed By: ________________________________ Date: _______________

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

Medical Eligibility Notification Sent to Parent/Guardian by School Physician ____________________

Date

Letter of notification is attached.

OR

Parent notification indicates that:

Participation Approved without limitations.

Participation Approved with limitations pending evaluation.

Participation NOT Approved

Reason(s) for Disapproval: _________________________________________________________________________________

_________________________________________________________________________________

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