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Athletic Handbook

For Coaches, Student-Athletes and Parents

2019-2020

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Table of Contents

Subject Pages

ATHLETIC STATEMENT 3

ATHLETIC PHILOSOPHY 3

ATHLETIC PROGRAM PROFILE 4

ELIGIBILITY REQUIRMENTS 4

PLAYER CONTRACTS 5

TRYOUTS 5

QUITTING TEAMS 6

ALCOHOL/DRUG POLICY 6

LOCKER ROOM AND TEAM ROOM POLICY 6

INJURIES 6

FACILITIES 7

ATHLETIC EQUIPMENT 7

INCLEMENT WEATHER 8

VARSITY LETTERS 8-9

LETTERMAN JACKET ELIGIBILITY 10

GENERAL AWARDS 10

PLACING OF AWARDS ON THE LETTER JACKET 10

ATHLETIC CHAIN OF COMMAND 10

PARENT/ SPECTATOR ATHLETIC INTERFERENCE POLICY 11

ATHLETIC TICKET INFORMATION 12

FORMS TO TURN COMPLETE AND TURN IN 13-20

STUDENT DRIVERS TO “AWAY” GAME 15

16-17PHYSICAL AND HEALTH HISTORY FORM

ATHLETIC TRAINER FORMS 19-26

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ATHLETIC STATEMENT

This Athletic Handbook is designed to acquaint all student-athletes, parents and coaches with the philosophies, policies and procedures of Greer Middle College Charter High School Athletic Department. Participation in athletics is a privilege which carries with it varying degrees of honor, responsibility and sacrifice. Because it is a privilege to participate, student-athletes who are involved will be expected to follow the policies and procedures outlined in the Athletic Handbook, as well as those rules established by the coaches in their respective sport(s). Student-athletes should understand that they represent their school and community at all times. They are expected to conduct themselves in a manner that would not bring discredit to their school, community or family. This includes but is not limited to classroom behavior, behavior in the community, and their social media behavior.

ATHLETIC PHILOSOPHY & MISSION

The Athletic Department will be centered on the welfare of the student-athletes. As a school, we will strive to procure the best coaching personnel available and provide the best athletic facilities affordable. We will make every effort to provide student-athletes the opportunity to excel in teamwork, sportsmanship, self-discipline and moral character. As a school, we will make every effort to provide student-athletes with experiences that will help them to develop their own personal philosophy toward commitment, responsibility, team and loyalty.

The administration will strive to provide a sound program of athletics in an effort to contribute to the growth of every student, the school, and the community. We believe the mental, physical and emotional growth of high school students can be greatly enhanced by participation in extra-curricular activities such as athletics. We also believe that athletics can be a catalyst in increasing school morale, and can provide a channel through which students can take pride in themselves and their school. We pledge to adhere to all accepted standards of good sportsmanship and to the rules and bylaws of the South Carolina High School League (SCHSL).

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ATHLETIC PROGRAM PROFILE

The athletic program at Greer Middle College is operated in such a manner as to provide any boy or girl, with athletic skill and ability, the opportunity to participate in interscholastic athletics. Greer Middle College provides opportunities to participate in the following SCHSL sanctioned sports or sport activities: boys cross country, girls cross country, boys soccer, girls soccer, girls volleyball, boys basketball, girls basketball, boys golf, girls golf, boys swimming, girls swimming, boys baseball, boys track and girls track to over 200 students in grades 9-12. Student-athletes are allowed to only participate in one sport per season, unless written consent has been obtained from both head coaches from the teams the student athlete is trying to participate in, as well as the Athletic Director. The athlete must also choose a primary sport in which they will compete in 75% of play.

Greer Middle College is a member of the SCHSL and belong to region I in the AA classification. Other members of this region include: Blacksburg High School, Brashier Middle College, Christ Church Episcopal High School, Greenville Tech Charter, Landrum High School, Southside Christian School, and St. Joseph's Catholic School.

ELIGIBILITY REQUIREMENTS

To participate in the athletic program at Greer Middle College, all student-athletes must comply with the standards set forth in the student handbook as well as the regulations established in the constitution for Class AA and bylaws of the SCHSL. Student-athletes must adhere to policies and guidelines set forth in the athletic handbook as well as adhere to the player contract established by each individual coach. Grades are checked every two weeks from the Athletic Department. Athletes below mastery will face consequences set out by the coach's contract.

Before a student is eligible to participate in practice or pre-season conditioning, he/she must have : Physical and Health History from medical doctor cleared for participation Insurance Waiver form signed and dated by parent/ legal guardian Parent’s Permission & Acknowledgment of risk for son or daughter to participate in athletics form

signed and dated by athlete and parent/ legal guardian

Concussion Test with Athletic Trainer A completed consent for Emergency Medical Treatment Form Athlete/Parent Concussion statement form properly filled out, signed and dated by the athlete and

parent/legal guardian "Acknowledgment of Athletic Handbook" form signed and datedrndbook” form signed and dated

Before a student is eligible to participate in SCHSL season he/she must have:

Paid athletic fee $125.00 and all forms listed above For Fall Sports - A passing average (80 or higher), at least 5 credits passed from the previous year

and at least 3 credits passed from 2nd semester of previous year, and not be a same year transfer studentto GMC from another Greenville County school WITHOUT a change of address OR completedtransfer form signed and dated from athletic director and principal of previous high school

For Spring Sports– a passing average from 1 semester, at least 5 credits passed from first semester, andnot be a same year transfer student to GMC from another Greenville county school WITHOUT achange of address OR completed transfer form signed and dated from athletic director and principalof previous school

Grades will be checked every two weeks to ensure that student athletes are remaining at mastery. IF

a student is below mastery they have two weeks to pull their grade up. Failure to bring to mastery

will result in loss of practice and play time until grade is mastery. Students will give the Athletic

Director, Coach, and teacher of below mastery class a plan of action to demonstrate attention andcontinued work towards obtaining mastery.

Note: Physical exams are valid from April 1, 2019 through May 30, 2020.

PLAYER CONTRACTS After tryouts, if a player has made the team, he/she will be required to sign a player contract. This

contract describes the duties of a player and what is required of him/her as a student-athlete on that team. Each contract covers behavior, academics, and commitments for that athletic year. Player contracts are strictly adhered to by players, coaches, and administrators. Player contracts are submitted by each coach and approved by Athletic Department Administration.

TRYOUTS Tryouts will be held for every team sport. Coaches at GMC are required to cut their teams to a manageable number of athletes but in some cases cuts may not be made due to a low volume of participants in a particular sport. Junior Varsity is available for 9-11th grade student athletes that need extra development. If

numbers allow a JV team will be present for Volleyball, Basketball Baseball, and Soccer.

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QUITTING A TEAM

Any student-athlete who chooses to break his/her player contract and quit a specific team after starting, unless he/she is released in good standing by the head coach and Athletic Director, may not join another team until the sport season for the team he/she quit has ended. That student-athlete may not participate in conditioning, practice, small group workouts etc. NO PARTICIPATION IS ALLOWED UNTIL AFTER THE FINAL CONTEST FOR THE TEAM THE STUDENT-ATHLETE QUIT.

However, student-athletes that are cut from a team my join another athletic team during the same season.

ALCOHOL/DRUG POLICY Any student-athlete caught using alcohol or drugs during school, after school, any school function,

or any athletic event will be dismissed from any current team and/or ineligible for next sport season in relation to date of offense. Each offense will be dealt with individually and consequences may differ based on magnitude of offense. All offenses are referred to administration and the student handbook and consequences are approved by administration.

LOCKER ROOM AND TEAM ROOM POLICY Many of our sport facilities at GMC are rentals. However, if the student-athlete participates in a

sport that is provided with a team room or locker room the student-athlete is expected to assist in keeping the locker room neat and clean. Each student-athlete is responsible for picking up his or her own clothes and towels from the floor. Horseplay, loud or boisterous behavior, or vulgarity will not be permitted in the locker room.

INJURIES Any and all injuries are to be reported to the coaching staff, Athletic Director and Athletic Trainer

within 2 hours of injury in order to obtain correct medical attention and documentation. Student-athletes who are absent for five (5) consecutive days or who are physically unable to practice for five (5) consecutive days must present a statement (release statement) from a licensed physician that they are again physically able to participate in athletics before they will be allowed to participate in practice or contests. These documents must be filed with the Athletic Director. Individual team coaches may require a physician’s statement with less than five (5) absences from school/practice. If an athlete suffers a concussion or has suspicion of concussion, it must be reported to the Athletic Trainer and Athletic Director immediately. An athlete cannot return to play until examined and cleared by an MD or DO and has completed a return to play examination by the Athletic Trainer. This policy is per state law.

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Volleyball, Basketball, Soccer and Baseball will have a certified Athletic Trainer from Prisma Health Care

at all home contests. They will also see a GMC student athlete at GMC during their office hours. Hours

are posted on the Athletic Trainer's door. IF the Athletic Trainer is not present the Coach and the

Athletic Administrator on site will contact the Athletic Trainer immediately for a plan of action.

NOTE: if a student athlete sustains a season ending injury that athlete is not dismissed from the team and

is not required to be at contests. However, the athletic department encourages all injured athletes to

continue to participate in team activities and functions as their injury permits.

FACILITIES Because GMC athletics does not own any facilities currently, a degree of creativity must be used

from time to time to secure practice facilities and game facilities. We try to provide facilities that are safe,

clean, have a short distance from the campus, appropriate for the number of fans we house for each sport,

and adhere to SCHSL rules. However, there are occasions when one or two of these factors are less ideal

than what we at GMC want for our parents, fans, and student-athletes. We ask that you be patient as we

are in the process of adding an activities center and other areas for practice and play at our school. We will

make every effort to provide the best possible option for our coaches, fans, student-athletes and parents.

Each student-athlete and his/her family should be aware of practice facilities and playing facilities along with

their location. Locations for home venues are found on the GMC Athletics Website under the Locations

Tab.

ATHLETIC EQUIPMENT

The Athletic Department has invested heavily in equipment and uniforms for athletes at Greer Middle College. Because of limited revenues, it is imperative that the Athletic Department operates in a fiscally conservative manner. This means that each student-athlete must take total responsibility for school-owned property issued to him/her. If equipment should be damaged while the athlete is involved in practice or competition, repair or replacement will be the responsibility of the school. If any school-owned property is lost or damaged while under the care of the student-athlete, he or she will be responsible for any and all replacement/repair costs. School-owned uniforms, equipment or clothing of any kind are to be worn to athletic contests or practices only unless specifically instructed otherwise by the coach of that sport.

In addition, all school uniforms are to be turned in to the head coach immediately after the conclusion of the season. After two weeks from deadline a student failing to return his/her uniform or replacement costs shall not be able to participate on any other school team until those needs have been

met. Students who fail to turn in uniform or pay for lost or destroyed uniform will not receive their

report card until matter is settled (Seniors’ transcripts are withheld).

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INCLEMENT WEATHER

When seriously inclement weather occurs (snow storm, ice, excessive rain, etc.), the Athletic Director will determine if and when any athletic practices or contests will take place. If GMC is in session and released early (prior to normal dismissal time) due to inclement weather, school activities could be canceled for that day based on available forecasts provided by weather departments for our area. Also, if inclement weather occurs during the school day and school is NOT released early, the Athletic Director along with the Principal, and the opposing Athletic Director and/or Principal will make a decision about that day’s activities before students are released from school. If GMC is not in session due to inclement weather, sporting events for that day will be canceled. Every decision in these matters will be made with the safety of the student-athlete and his/her families as the only priority. There are times where our home field may cancel due to their regulations for play and to protect their fields. All parties will be notified as soon as possible should this be the case.

VARSITY LETTERS

The varsity head coach is responsible for keeping accurate record of playing time and/or quarters of participation for purposes of determining awards. At the end of each season, the head coach for each sport will present a season record summary/inventory as well as a list of awards to the Athletic Director. In order to receive a varsity letter, a student must be in grades 9-12 and meet the following requirements by sport:

Basketball - player must play in 3/4 of contests for the season and to get credit for one contest that player must have played at least a cumulative time of 8 min per game.

*Boys Basketball: if the student makes the varsity team and isn't dismissed during the year then

they will receive a letter at the end of season team banquet

Soccer - player must play in 3/4 of contests for the season and to get credit for one contest the player must have played at least a cumulative time of 20 min.

Volleyball - player must have participated at the Varsity level for the entire season and be in good standing with coach and Athletic Department at conclusion of season.

Baseball - player must play in 3/4 of contests for the season and to get credit for one contest that player must have played in at least 3 innings.

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Swimming - a player must swim in 3/4 of contests for the season or must qualify for region meet and if there is no qualifier for region must qualify for state

Golf - Player must play in more than 70% of matches in a 1-5 position throughout season.

Track - player must place in 3/4 of varsity meets, or qualify for region or state, or meet specified time, height, or distance set forth by the coach for event if he/she does not place in required meets or qualify for region or state meets.

Cross Country - player must participate in 3/4 of the meets for the season and qualify for the regional or state, or meet specified time set forth by the coach for 3.1mi if he/she does not place in required meets or qualify for region or state meets.

Injured Athlete If a student-athlete has a season-ending injury which keeps him/her from meeting normal lettering requirements, the varsity coach may grant the student-athlete a varsity letter if they attended all practices and contests for the remainder of the season following the injury, and (in the coach’s professional opinion) would have met the standards for a varsity letter had the injury not occurred.

Lettering Process

Initial lettermen receive a Letter and a Pin for their sport If lettering in 2 sports, that athlete will receive a pin for each individual sport. After initial letter, the athlete will receive a gold bar for subsequent years. Captains Stars are awarded for all team captains.

Individual & Team Patches Any student-athlete who is recognized with All-State honors (either athletic or academic) will receive a special chenille patch for his/her jacket. Additional chenille patches will be awarded to Region I 2AA individual or team champions as well as state individual or team champions.

Numerals for Jackets

Numerals for jersey numbers may be purchased, by the student-athlete, for jacket.

VARSITY ATHLETIC LETTER JACKET ELIGIBILITY

High school student-athletes who have earned a varsity letter in any sport are eligible to purchase a letter jacket. Eligible student-athletes should purchase the jacket through First Team Sports or Jostens. Information on Letter Jackets can be acquired by the Athletic Director. Student-athletes are responsible for the whole cost of the jacket.

GENERAL AWARDS Coaches are provided with three general team awards for the season and cost of these awards are

the responsibility of the Athletic Department. Any other team awards a coach may present will be either the responsibility of the coach through personal funds, donors, or individual team account (must be approved before purchased).

PLACING OF AWARDS ON THE LETTER JACKET

A. Block Letter “GMC” on left breast

B. Numerals on right sleeve

C. All patches for special recognition on right sleeve (above the bicep) or back of jacket

D. Sport pins and captains stars on letter

E. Gold bars aligned in rows of NO more than 4 on right breast.

ATHLETIC CHAIN OF COMMAND

Greer Middle College’s athletic program is established for the direct and long-lasting development of the student-athlete. Many of the lessons learned as a result of athletic participation are the same ones that will promote successful adult lives. In addition, we believe that every parent that becomes a part of our athletic program deserves the right to be made fully aware of and understand the expectations being placed on his or her child. However, there are decisions made by the coaching staff that are not appropriate to discuss with parents.

It is extremely difficult to accept a child not playing as much or as often as the parent wishes. Coaches are professionals and decisions are made on what they believe to be in the very best interest of the

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team. Nonetheless, some areas of conversation that should never be discussed with a coach by a parent include: playing time, team strategy, play calling, line-ups, substitutions, other team members, other parents and past teams and/or athletes.

If a parent requests a meeting to discuss concerns with a coach, the parent is asked to set up an appointment with the coach no sooner than 24 hours if pertaining to an incident/game. The Athletic Director will attend the meeting with coach and parent with coach leading the meeting. In the event that this meeting does not reach a satisfactory conclusion, the parent should set up an individual appointment with the Athletic Director for a second meeting. If a meeting with the Athletic Director does not offer a satisfactory understanding, the final step in our chain of command is a conference with the Principal.

PARENT/SPECTATOR ATHLETIC INTERFERENCE POLICY

The purpose of the GMC Parent/Spectator Athletic Interference Policy is to prevent parent/spectators from exhibiting offensive or threatening behavior toward anyone at GMC school events. Persons coming onto GMC property or any facility used for its athletics shall be under the jurisdiction of the school system and the site administrator. Individuals who come onto GMC property or contact employees on school campus or in any facility associated with GMC athletics are expected to behave in a civil manner and abide by GMC policy. Actions that are discouraged and may warrant further action include, but are not limited to:

1. Cursing or use of obscenities (including obscene clothing) and gestures.2. Disrupting or threatening to disrupt school or events operations.3. Acting in an unsafe manner that could threaten the health or safety of others.4. Verbal or written statements or gestures indicating intent to harm an individual or property.5. Physical attacks (or threats of) intended to harm an individual or damage property.6. Public intoxication.7. Negativity on social media directed to the Athletic Department and/or athletes.

Established rules and regulations to enforce the Athletic Interference Policy are set forth by this policy as follows: FIRST OFFENSE- Removal from the event immediately. The school administration will review the incident within five (5) school days to determine if further action should be taken which may include being suspended from attending school activities for one (1) calendar year.

SECOND OFFENSE- Same process as FIRST OFFENSE but may result in permanent suspension from school athletic events/ campus.

*Important: In the event a parent/spectator’s behavior is such that it cannot be resolved in this manner, lawenforcement will be notified and the situation will be handled by a court of law.

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ATHLETIC TICKET INFORMATION

All-Sports Passes will be made available at the appropriate times through the Athletic Director. Availability will be announced through the school website and newsletter. 2019-2020 ticket prices are:

High School Single Session:

All-Sports Family Pass: Individual All-Sports Pass:

Single Season Family Pass: Individual Single Season Pass:

$5 $3 students Children under 8 Free

$200 $150

$70 $30

*Important: All passes sold by GMC can ONLY be used at regular season GMC hosted events.GMC sports passes will not grant you entry to away games, tournament games, or SCHSL playoffgames.

* Family passes are directed to immediate household family ONLY.

All Sports- entire 2019-2020 athletic season

Single season- specific season ONLY

The following forms are to be signed to be eligible for athletics at Greer Middle College Charter HighSchool. Parents and athletes, please print pages 13-20 and return to Athletic Director.Failure to submit forms will result in loss of play until ALL forms are completed and returned to the Athletic Director. Please also include a copy of your athlete's birth certificate. This will only need to be given at the start of their time at GMC.

ACKNOWLEDGEMENTOF THE ATHLETIC HANDBOOK This is to verify that I have read, understand, and have agreed to fully comply with the contents of the Greer Middle College Athletic Handbook for the 2018-2019 school year. I also agree that I am to consult with my coach or Athletic Director if I have any questions concerning its contents. I understand that the school may modify any or all of the referenced policies and procedures, in whole or in part, at any time, with or without prior notice; and that in the event the school modifies any of the information contained in this handbook, the changes will become binding on me immediately upon issuance of the new or revised policy or procedure by the school. I acknowledge the $125 sports fee must be paid prior to play in any sport.

X ___________________________________________Student's Signature

X ____________________________________________Parent/Guardian's Signature

Date: ______/______/2019-2020

Insurance Waiver

Name_____________________________ Age:_____ Birthdate:___________ Grade____ Sport(s)______________________ Insurance Waiver and Release

Your Child has indicated an interest in participating in the Greer Middle College Athletic Program. We know that it is your wish as well as ours that every precaution be taken to protect our students from injury. We do our utmost to promote this by proper training and coaching, by the use of protective equipment, by supervising all activities and encouraging goo safety habits.

Despite our efforts, accidents do happen occasionally in athletics as elsewhere. We certainly want to do our part to obtain the best possible protection for our young people, however, the school is not legally liable for medical or hospital expenses resulting from athletic injuries incurred in Interscholastic sports.

We ask that each athlete is adequately insured with you own personal family Insurance. In no case will Greer Middle College be responsible for the cost of medical tests, prescriptions, special medications, or any treatment resulting from illness or injury. Cautionary Risk Statement Participation by a student in athletic activities involves a minimal, to substantial, degree of risk of physical injury. Such physical injury can occur in any type of sports activity, be it “contact” or “non-contact” sports. Furthermore, many injuries are truly accidental in nature and involve no negligence by anyone, including a student-athlete. By volunteering to participate in a school sponsored athletic activity, a student-athlete and his/her parent(s) acknowledge the potential risk for accidental physical injuries, paralysis or death to possibly occur.

This is to acknowledge that my child is adequately covered by our own personal insurance against injuries sustained in interscholastic athletics.

Signature of Parent/GuardianX______________________________Date___________________________

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GREER MIDDLE COLLEGE CHARTER HIGH SCHOOL Athlete/ Parent Concussion Statement

PARENTS AND ATHLETES please initial each box Parent Athlete ______ ______ I understand that it is my responsibility to report all injuries to my athletic trainer (when provided) or family doctor. ______ ______ I have read and understand the CDC concussion fact sheet for parents (posted on GMC Athletics website). ______ ______ I have read and understand the CDC concussion fact sheet for athletes (posted on GMC Athletics website). After reading the Concussion fact sheet, I am aware of the following that: ______ ______ a concussion is a brain injury that I am responsible for reporting to a coach, athletic trainer, or physician. ______ ______ a concussion can affect everyday activities, athletic performance balance, sleep, reaction time and school performance. ______ ______ if I suspect a teammate has a concussion, I am responsible for reporting the injury to my coach or trainer. ______ ______ I will not return to activity on the same day if I have received a blow to the head or body that results in concussion related symptoms. ______ ______ following a concussion, the brain needs time to heal. You are much more likely to have another concussion if you return to play prior to your symptoms resolving. ______ ______ in rare cases, repeat concussions can cause permanent brain damage or even death. ______ ______ I understand the physician clearance and completion of Return-to-Play Protocol must be completed before an athlete returns to full participation.

_______________________________ ________________________________ ____________________ Parent Signature Printed Name Date _______________________________ ________________________________ ____________________ Student Signature Printed Name Date

Consent for Emergency Medical Treatment In the event of an accident requiring immediate medical attention, I hereby grant permission to a physician and/or appropriate Hospital personnel to attend my son/daughter/ward. Students name . Students Grade . DOB . .SSN . Address . City . ST . Zip . Phone (H) . Phone Parent can be reached easiest . Email .Family Doctor. . Medical Insurance Company . Policy # . Current Conditions that may affect participation . Allergies . Does athlete suffer from any of the following conditions (circle all that apply) Heart Condition or disease Diabetes Asthma Kidney injures Parent/Guardian Signature . Relationship . Date .

Parent Permission for son/daughter to drive and/or carpool to AWAY athletic events

Due to GMC students coming from all over Greenville County and certain HOME locations being

30+ minute drive from school, at times it is more convenient, more feasible and just as safe for student-

athletes to drive or carpool to “away” events. By completing this form, you are giving your consent for

your child to drive and/or carpool to certain away athletic events.

Student-Athlete Name: _________________________________________________

My son/daughter has my permission to DRIVE to certain AWAY athletic events:

My son/daughter MAY/MAY NOT (circle one) have teammates carpool with them when they drive.

My son/daughter has my permission to CARPOOL to certain AWAY athletic events with

(Please list any and all names you are allowing them to ride with):

Acknowledgement:

By signing this document, I acknowledge the risk involved and take full responsibility for my

child driving and/or carpooling to athletic events.

Parent Signature __________________________________ Date ______________________

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Medical Normal Abnormal Findings

Appearance: Marfan stigmata (kyphoscoliosis, high–arched palate, pectus excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse (MVP), and aortic insufficiency

Eyes / Ears / Nose / Throat - Pupils equal / Hearing

Lymph Nodes

Heart - Murmurs (auscultation standing, auscultation supine, and +/- Valsalva maneuver

Lungs

Abdomen

Skin

- Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or tinea corporis

Neurologic

Musculoskeletal:

- Neck

- Back

- Shoulders/Arm

- Elbow/Forearm

- Wrist/Hand/Fingers

- Hip/Thighs

- Knees

- Leg/Ankles

- Foot/Toes

- Functional: Double-leg squat test, single leg squat test, and box drop or step drop test

___________________________________________________________ _________________________

Last Name First Name Middle Initial Date of Birth

Examination Height: Weight:

BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected ___ Yes ___ No

Consider: electrocardiography (ECG), echocardiography, and referral to cardiologist for abnormal cardiac history or examination findings or a combination of those.

Preparticipation Physical Evaluation

___ Medically eligible for all sports without restriction.

___ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of: ________________________

___________________________________________________________________________________________________________________

___ Medically eligible for certain sports: _____________________________________________________________________________________

___ Not medically eligible pending further evaluation.

___ Not medically eligible for any sports.

Recommendations: ______________________________________________________________________________________________________

______________________________________________________________________________________________________________________

I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. If conditions arise after the athlete had been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete and parents or guardians.

Name of health care professional (print or type): _____________________________________________ Date: _________________

Address: _________________________________________________________________________Phone: ____________________

Signature of health care professional: ___________________________________________________________ MD, DO, NP, or PA

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy od Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

Name: _________________________________________________________ Date of Birth: _____________________________ Sex: _____

Date of Examination: __________________________ Sport(s): ___________________________________________________________________

List past and current medical conditions: ____________________________________________________________________________________

______________________________________________________________________________________________________________________

Have you ever had surgery? If yes, list all past surgical procedures: ________________________________________________________________

______________________________________________________________________________________________________________________

Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional): _______________

______________________________________________________________________________________________________________________

Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects): ______________________________

______________________________________________________________________________________________________________________

General Questions. Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.

Yes

No

1. Do you have any concerns that you would like to discuss with your provider?

2. Has a provider ever denied or restricted your participation in sports for any reason?

3. Do you have any ongoing medical issues or recent illness?

Heart Heath Questions About You Yes No

4. Have you ever passed out or nearly passed out DURING or AFTER exercise?

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

6. Does your heart ever race, flutter in your chest or skip beats (irregular beats) during exercise?

7. Has a doctor ever told you that you have any heart problems?

8. Has a doctor ever ordered a test for your heart? (for example Electrocardiography (ECG) or echocardiography.

9. Do you get lightheaded or feel shorter of breath than your friends

during exercise?

10. Have you ever had a seizure?

Health Questions About Your Family Yes No

11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including drowning or unexplained car accident)?

12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogen-

ic right ventricular cardiomyopathy (ARVC), long QTsyndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)?

13. Does anyone in your family had a pacemaker or implanted Defibrillator before age 35?

Bone and Joint Questions Yes No

14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint or tendon that caused you to miss a game or practice?

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

Medical Questions Yes No

16. Do you cough, wheeze, or have difficulty breathing during or after exercise?

17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

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

19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?

20. Have you ever had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?

21. Have you ever had numbness, tingling, or weakness in your arms or leg, or been unable to move your arms or legs after being hit or falling?

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

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

24. Have you ever had or do you have any problems with your eyes or vision?

25. Do you worry about your weight?

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

27. Are you on a special Diet or do you avoid certain types of foods?

28. Have you ever had an eating disorder?

Females Only Yes No

29. Have you ever had a menstrual period?

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

31. When was your most recent menstrual period?

32. How many periods have you had in the past 12 months?

Explain a “Yes” answer here: _________________________________________

_________________________________________________________________

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© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy od Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.

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

Signature of athlete: _________________________________________________________________________

Signature of parent or guardian: ________________________________________________________________

Date _______________________

As a parent or legal guardian of the above named student-athlete. I give per-mission for his/her participation in athletic events and the physical evaluation for that participation. I understand that this is simply a screening evaluation and not a substitute for regular health care. I also grant permission for treat-ment deemed necessary for a condition arising during participation of these events, including medical or surgical treatment that is recommended by a medical doctor. I grant permission to nurses, trainers and coaches as well as physicians or those under their direction who are part of athletic injury pre-vention and treatment, to have access to necessary medical information. I know that the risk of injury to my child/ward comes with participation in sports and during travel to and from play and practice. I have had the opportunity to understand the risk of injury during participation in sports through meetings, written information or by some other means. My signature indicates that to the best of my knowledge, my answers to the above questions are complete and correct. I understand that the data acquired during these evaluations may be used for research purposes.

Parent’s Permission& Acknowledgement of Risk for Son or Daughter to Participate in Athletics

Name (please print)

Signature of Athlete Date:

Signature of Parent/Guardian Date:

Steadman Hawkins Sports Medicine

Post-Concussion Return to Play Protocol

Athlete must remain asymptomatic for a minimum of 24 hours prior to beginning.

Stages must be separated by at least 24 hours.

If an athlete becomes symptomatic during activity, he/she can resume activity at theprevious stage after remaining asymptomatic for 24 hours.

All stages of this progression must be monitored by an athletic trainer.

Stage 1. 20 minute stationary bike ride (10-14mph)

Stage 2. Interval bike ride: 30 sec sprint30 sec recovery (18-20mph/10-14) x 10; followed by a bodyweight circuit: Squats/Pushups/Sit-ups x 20sec x 3

Stage 3. 60 yard shuttle run x 10 (40 sec rest); followed by plyometric workout: 10 yd. bounding/10 medicine ball throws/10 vertical jumps x 3; followed by non-contact sport specific drills for approximately 15 minutes

*At this point, balance and neurocognitive assessments may be reevaluated.*Physician clearance is required to progress to Stage 4.

Stage 4. Limited, controlled return to full-contact practice and monitoring for symptoms

Stage 5. Full sport participation in a practice

Stage 6. Return to full participation

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Steadman Hawkins Sports Medicine

Concussion Policy

Concussions, a type of traumatic brain injury, are serious and potential life threatening injuries.

Continued research has revealed the extent of the injury may be felt, not only in the short term, but

years later if not properly identified and treated. In an attempt to maintain the safety and well-being of

our student-athletes, we have a policy to identify and manage student-athletes that may suffer a

concussion. This policy was developed using recommendations established by the National Athletic

Training Association and the 4th International Conference on Concussion in Sport, along with research

from the University of North Carolina at Chapel Hill and the University of Pittsburgh.

Definition

Concussions will be defined as a temporary impairment of mental functions, such as, but not limited to,

memory, balance, and vision, which results from a direct or indirect injury to the brain. Terminology

regarding concussions will no longer include severity (mild, moderate, severe) or the use of slang (“bell

rung”, “seeing stars”, “dinged”). It is important to note that no two concussions are identical and

treatment will be determined on a case by case basis to meet the needs of the patient.

Education and Risk Acknowledgement

1. All student-athletes and parents must read the CDC Concussion Fact Sheet and sign the Student-

athlete/Parent Concussion Statement acknowledging that:

a. they have read and understand the CDC Concussion Fact Sheet.

b. they accept responsibility for reporting all injuries and illnesses of themselves and

others to the school medical staff and/or school personnel, including signs and

symptoms of concussion.

2. All coaches (head coaches and assistant coaches) must sign the Coaches Concussion Statement

acknowledging that:

a. they have taken and passed the NFHS Concussion in Sport Course.

b. will encourage student-athletes to report any suspected injuries and illnesses to the

medical staff and/or school personnel, including signs and symptoms of concussion.

c. have read and understood the concussion policy.

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3. The medical staff must acknowledge that they have read and understand the concussion policy.

4. Head coaches of each respective sport will be required to direct the signing and collection of the

aforementioned documents from their staffs and student-athletes. Head coaches will also be

responsible for making certain that all required student-athletes have completed the required

baseline neurocognitive and balance screening. Student-athletes will not be eligible for

participation until their documentation has been received and baseline screening completed.

Management of Concussions

1. The management of a concussion begins with pre-season baseline screening.

a. Screening will involve a graded symptom checklist (GSC) and sideline assessment tool

(SCAT3) along with computerized neurocognitive (e.g. ImPACT) and balance (e.g. BESS)

assessments.

b. Student-athletes to be tested include: students entering the 9th and 11th grades,

transfer students, and student-athletes who suffered a concussion in the previous year.

c. All testing must be completed before a student-athlete is eligible for participation.

d. The following sports are considered at-risk and require baseline testing: baseball,

basketball (boys and girls), cheerleading, football, lacrosse (boys and girls), soccer (boys

and girls), softball, track and field (field events only), volleyball, and wrestling.

i. Student-athletes who are not baseline tested will have their post-concussion

testing scores compared to currently available normative data.

e. The medical staff will be responsible for conducting and documenting baseline screening

results.

2. Any student-athlete who presents with concussion signs and/or symptoms should be removed

from play immediately.

a. If a team physician or athletic trainer is present, the student-athlete should be referred

to that individual for a thorough concussion evaluation.

b. No student-athlete suspected to have suffered a concussion will return to play on the

same day. Student-athletes will only be permitted to return to activity if a team

physician or athletic trainer determines that no concussion has occurred and return to

play is safe.

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c. If the team physician or athletic trainer is not present, the head coach will be

responsible for removing the student-athlete from activity and notifying the student-

athlete’s parent(s)/guardian and school athletic trainer.

d. All student-athletes must have their parent(s)/guardian notified if a concussion is

suspected.

i. Student-athletes with a suspected concussion are only to be released to the

direct care of their parent(s)/guardian unless emergency transportation is

necessary.

ii. Instructions regarding the home care of a concussion should always be given to

parent(s)/guardians before the student-athlete is released. These instructions

should be given verbally and written with any questions addressed.

3. Following the diagnosis of a concussion, the athletic trainer will coordinate with the treating

physician to determine a concussion management plan. Only MDs or DOs who have training in

the management of concussions can direct the management plan.

a. Cognitive rest is necessary during the early treatment of concussion and should be

included in the concussion management plan.

i. Activities that worsen symptoms (e.g. school work or computer use) should be

withheld until deemed appropriate by the medical staff.

b. Concussion management plans will consist of appropriate post-concussion evaluation,

which may include balance and neurocognitive assessments, and a graduated return to

play progression.

4. The graduated return to play (RTP) progression can begin once the student-athlete has been

symptom free for 24 hours or through the direction of the treating physician.

a. The graduated RTP protocol consists of 5 stages conducted in the presence of an ATC.

b. Signs and symptoms should be assessed before, during, and after each stage is

conducted.

c. Each stage must be separated by at least 24 hours.

d. If a student-athlete becomes symptomatic during the prescribed activity, the test should

be stopped immediately. The student-athlete can begin at the previous stage after

remaining asymptomatic for 24 hours.

e. The graduated RTP progression can be found at the end of the policy.

f. Student-athletes must be cleared by the treating physician to progress to the contact

stages of the graduated RTP protocol.

i. Repeat balance and neurocognitive testing will be considered by the treating

physician before advancement.

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5. Student-athletes diagnosed with a concussion will not be permitted to return to full unrestricted

activity until all of the following conditions have been met:

a. the student-athlete no longer presents with signs and/or symptoms of concussion

b. the student-athlete completes the graduated RTP progression while remaining

asymptomatic

c. the student-athlete obtains a written medical release from a physician (MD or DO)

trained in concussion management

i. the written medical release must be documented on a concussion-specific

return to participation form.

***Please note: Concussion management is a widely studied topic and advancements in treatment

occur frequently. This policy will be updated as needed to stay current with the latest research and

methodology.

Acknowledgements

Harmon, K., et al. "American Medical Society for Sports Medicine position statement: concussion in sport." British Journal of Sports Medicine 47 (2012): 15-26.

McCrory P, et al. "Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012." British Journal of Sports Medicine 47 (2013): 250-258.

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Parent Permission for son/daughter to drive and/or carpool to AWAY athletic events

Due to GMC students coming from all over Greenville County and certain HOME locations being

30+ minute drive from school, at times it is more convenient, more feasible and just as safe for student-

athletes to drive or carpool to “away” events. By completing this form, you are giving your consent for

your child to drive and/or carpool to certain away athletic events.

Student-Athlete Name: _________________________________________________

My son/daughter has my permission to DRIVE to certain AWAY athletic events:

My son/daughter MAY/MAY NOT (circle one) have teammates carpool with them when they drive.

My son/daughter has my permission to CARPOOL to certain AWAY athletic events with

(Please list any and all names you are allowing them to ride with):

Acknowledgement:

By signing this document, I acknowledge the risk involved and take full responsibility for my

child driving and/or carpooling to athletic events.

Parent Signature __________________________________ Date ______________________