Name___________________ Grade_____ Sport________________ Gym Block ______

Checklist for filling out Athletic Forms

Page What Must Be Completed

2 Emergency Cards Both Trainer & Coach’s Copies

3 Steroid Testing Policy Athlete & Parent Signature

5 Part I-Student Participation Form Athlete & Parent Signatures

6 Part II- Player Agreement Athlete & Parent Signature

6 Parental Approval Form Parent Signature

6 Part III- Athletic Eligibility

7-9 Health History Answer All Questions Parent Signature

10 Physical Evaluation Form You Complete Top Section of

Student & Physician Information 10-12 Physical Evaluation Form

Physician Completes Remainder

13 For Physician & Office Use

14 Fill in Name of Student

Completed

X

Please confirm the payment of the participation fee by entering the student(s) name, sport

intended to play, and the confirmation of payment number below. Remember that it is a one-

time payment for the entire school year.

Payment is made on-line by going to www.payforit.net; the 2011-2012 sport participation fee

is currently $150.00*. In order to register for the participation fee you will need your power

school student ID number. This number can be found by clicking into the “Demographic

Update” page in the parent portal of PowerSchool. You will see the following: Name (last, first

MI) then the student ID number.

* $150 fee is subject to change pending outcome of budget process and formal BOE

approval.

SPORT: _____________________GRADE: _______ SCHOOL YEAR: __________DATE OF LAST PHYSICAL______________ SELECT ONLY ONE SPORT PER SEASON

NAME: ____________________________________________________________ DATE OF BIRTH: ________________________

ADDRESS: __________________________________________________________ CITY&ZIP: _____________________________

HOME PHONE: ___________________________________________ EMERGENCY PHONE: _____________________________ EMERGENCY INFORMATION- ALL INFO MUST BE COMPLETE

PRIOR MEDICAL HISTORY: __________________________________________________________________________________

FATHER’S EMPLOYER: ______________________________________________________________________________________

BUSINESS PHONE: ________________________________________ CELL PHONE: ____________________________________

MOTHER’S EMPLOYER: _____________________________________________________________________________________

BUSINESS PHONE: ________________________________________ CELL PHONE: ____________________________________

SPORT:________________________GRADE: ________ SCHOOL YEAR: ___________DATE OF LAST PHYSICAL__________ SELECT ONLY ONE SPORT PER SEASON

NAME: ____________________________________________________________ DATE OF BIRTH: ________________________

ADDRESS: __________________________________________________________ CITY&ZIP: _____________________________

HOME PHONE: ____________________________________________ EMERGENCY PHONE:_____________________________

EMERGENCY INFORMATION- ALL INFO MUST BE COMPLETE

PRIOR MEDICAL HISTORY: __________________________________________________________________________________

FATHER’S EMPLOYER: ______________________________________________________________________________________

BUSINESS PHONE: ________________________________________ CELL PHONE: ____________________________________

MOTHER’S EMPLOYER: _____________________________________________________________________________________

BUSINESS PHONE: ________________________________________ CELL PHONE: ___________________________________

BOTH FORMS MUST BE COMPLETED

1161 Route 130, P.O. Box 487, Robbinsville, NJ 08691 609-259-2776 609-259-3047-Fax

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

__________________________________ Signature of parent/guardian

June 8, 2006

_______________________ _____ Print Student-Athlete’s Name Date

________________________ _____ Print Parent/Guardian’s Name Date

1161 Route 130, P.O. Box 487, Robbinsville, NJ 08691 609-259-2776 609-259-3047-Fax

NJSIAA Banned-Drug Classes2006 - 2007

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 amiphenazole amphetamine bemigride benzphetamine bromantan caffeine1 (guorana)

chlorphentermine cocaine cropropamide crothetamide diethylpropion

dimethylamphetamine

doxapram

ephedrine

(ephedra, ma huang)

ethamivan

ethylamphetamine

fencamfamine

meclofenoxate

methamphetamine

(b) Anabolic Agents (c) Diuretics anabolic steroids acetazolamide androstenediol bendroflumethiazide

androstenedione benzhiazide boldenone bumetanide clostebol chlorothiazide

dehydrochlormethyl chlorthalidone testosterone ethacrynic acid

dehydroepiandro- flumethiazide sterone (DHEA) furosemide dihydrotestosterone (DHT) hydrochlorothiazide dromostanolone hydroflumenthiazide

epitrenbolone methyclothiazide

fluoxymesterone metolazone

gestrinone polythiazide

mesterolone quinethazone

methandienone spironolactone

methenolone triamterene

trichlormethiazide

and related compounds

methyltestosterone

(d) Peptide Hormones & Analogues: corticotrophin (ACTH) human chorionic gonadotrophin (hCG) leutenizing hormone (LH) growth hormone (HGH, somatotrophin) insulin like growth hormone (IGF-1)

All the respective releasing factors of the above-mentioned substances also are banned: erythropoietin (EPO) darbypoetin sermorelin

methylenedioxymethamphetamine nandrolone

(MDMA, ecstasy) norandrostenediol

methylphenidate norandrostenedione

nikethamide norethandrolone

pemoline oxandrolone

pentetrazol oxymesterone

phendimetrazine oxymetholone phenmetrazine pregnelone phentermine stanozolol

phenylpropanolamine (ppa) testosterone2 picrotoxine tetrahydrogestrinone

pipradol (THG)

prolintane trenbolone

strychnine and related compounds

synephrine other anabolic agents

(citrus aurantium, zhi shi, bitter clenbuterol

orange)

(e) Definitions of positive depends on the following: 1 for caffeine - if the concentration in urine exceeds 15 micrograms/ml

2 for testosterone - if administration of testosterone or use of any other

manipulation has the result of increasing the ratio of the total

concentration of testosterone to that of epitestosterone in the urine of

greater than 6:1, unless there is evidence that this ratio is due to a

physiological or pathological condition. 5

GOVERNOR LIVINGSTON HIGH SCHOOL

175 Watchung Blvd. Berkeley Heights, NJ 07922

Phone: 908-464-3100 Ext. 2540 Fax: 908-464-7508

Email: shopkins@bhpsnj.org Website: www.bhpsnj.org/~glathletics

The entire document must be completed accurately and signed before a student becomes a candidate for participation in any interscholastic sport.

PART I -STUDENT PARTICIPATION FORM FOR ATHLETICS

FOR THE SCHOOL YEAR 200 - 200

Name: ___________________________________________________Grade: ________Date of Birth: ________________

Address:_____________________________________Town/Zip_____________________ Phone:____________________

Name of Fall Sport: ______________________________Winter: ____________________Spring: ___________________ I agree to follow the rules of training,

proper conduct, and responsible behavior. I am aware that the development of character is an important aspect of my social, emotional, and intellectual growth.

Therefore, I understand any use of or possession of drugs, tobacco and/or alcohol, at any time during the course of the athletic season, whether in school or out of

school, or whether during the week or on weekends will result in penalties. The penalties are as follows:

1st offense: For possession or use of alcohol, narcotics, harmful drugs: five days out of school suspension and an

additional five days exclusion from athletics

2nd offense: Suspension from school for ten days plus an additional twenty days exclusion from athletics

3rd offense: Suspension from school for ten days plus an additional thirty-five days exclusion from athletics.

1ST Offense: For use of or possession of tobacco products during the season: one week suspension from athletics 2nd

Offense: Suspension from athletics for two weeks

3rd Offense: Suspension from athletics for the remainder of the season

I realize it is my responsibility, as a member of a team, to be present for all practices and athletic contests; however, I may be excused from athletic contests that

occur on religious holidays. If there is any other conflict, for example, with a band performance, I will notify my coach of the conflict well in advance so a

resolution can be made.

I will not wear jewelry during practices or games because of the possibility of injury. I further understand that I will abide by all rules and regulations

established by the NJSIAA. I will be responsible for and will return all equipment issued to me or pay for that portion which was lost, stolen or

unduly damaged.

DATE: _________________________ SIGNATURE of ATHLETE: ___________________________________________________

* Sports physicals are provided by the school physician at the end of June only Yes* ___ I give permission for my child

to have a physical exam, including a scoliosis screening at school. No ___ I will have my private physician fill out this form.

DATE: _______Parent’s Name (Print) ______________________________ Parent’s Signature ________________________________

FOR OFFICE USE ONLY

HEALTH OFFICE _______ APPROVED for sports By Health Office Date of Sport Physical _________

_______ NOT APPROVED for sports by Health Office

COMMENTS:________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

6

PART II - PLAYER AGREEMENT AND PARENTAL APPROVAL FORM As a member of the GOVERNOR LIVINGSTON HIGH SCHOOL ATHLETIC PROGRAM, I agree to the following rules:

1 I will show good sportsmanship at all games, scrimmages, and practices.

2 I will show respect to umpires, opposing team members, opposing coaches, teammates, and fans.

3 I am expected to attend all practices or games unless I am ill or have been excused by my coach. Illness may require a written

parental note.

4 I will be on time for practices and games.

5 I will do what is best for the team by playing any position the coach asks me to if the need arises.

6 At the end of the season, I will hand in all uniforms and all equipment that has been issued to me.

7 I realize dedication is very important and know that if I am in school on a given day I am expected to also be at practice that day.

8 I understand there are Saturday practices and/or games I must attend and there are also practices and/or games during vacations that

I am expected to attend. Furthermore, should short-term family commitments impede my participation on the team, upon return, I understand that I

will be required to work to regain my previous position on the team. As a member of the ATHLETIC PROGRAM, I agree to follow these rules and realize that failure to adhere to any one of the rules may result in disciplinary action and/or dismissal from the program

Signed: _________________________________________________________ Date: ______________________

Parent/Guardian Signature: _________________________________________ Date: _____________________

INTERSCHOLASTIC INSURANCE POLICY/PARENTAL APPROVAL

The Board of Education carries an interscholastic insurance policy that provides medical benefits on an "excess" basis only. For

parents who already have medical insurance, this represents secondary coverage that will only be paid after the primary carrier(s) first pay their

portion of all medical bills. The purpose of this policy is to pay for some portion of the medical expenses not covered by personal or group

insurance that most parents usually carry for their families. As with all insurance policies, this policy has limitations and it does not guarantee

coverage for "all" medical expenses not covered by other primary insurance. Only when there is no medical insurance in the family, will this

policy pay primary benefits, and even then it will only pay up to the limits of the policy.

I understand that athletic transportation has been reduced due to budgetary restraints. I agree to assume responsibility for transportation of

my son/daughter, for athletics or cheerleading activities, to and from home and school on Saturdays, Sundays and holidays, for early morning or

night practices and from school to home after competitions of away games or activities. I am fully aware that participation in any co-curricular

activity may result in injury. I realize it is impossible to predict all of the various types of injuries that a student might incur participating in

athletics. I fully understand that a serious physical injury/ accident is possible. I completely understand the above implications. We, the undersigned, the parents and/or guardians of _________________

__________________________(Name of athlete) do hereby consent to his/her participation in the Governor Livingston HS Interscholastic

Athletic Program for the school year 20___ - 20___. We acknowledge that we have been fully informed of the physical hazards in the

participation of any or all athletic activities and the risk of physical injury which may occur to my son/daughter as a result of participation in

such athletic activity. I have read the statement concerning the rules of training, proper conduct, and responsible behavior as established in

the Athletic Policy and by the coach(es) my son/daughter has agreed to participation under. I understand the rules and penalties involved and

will encourage my son/daughter to abide by them. I will make certain that he/she fulfills his/her obligations and responsibilities as stated in

Part I.

I give permission for the Governor Livingston Sports Medical Staff to assess and treat illnesses and injuries that occur during athletic contests and events. _____ Yes _____ No

Date: ___________________

TO BE ELIGIBLE:

Parent/Guardian: ____________________________________________

PART III: ATHLETIC ELIGIBILITY

N.J.S.I.A.A.

ATTENTION PARENTS

1. To be eligible for athletic competition during the first semester (September 1 to January 31) of the 10th grade or higher, or the second year

of attendance in the secondary school or beyond, a pupil must have passed 25% of the credits required by the State of New Jersey for

Graduation, during the immediately preceding academic year.

2. To be eligible for athletic competition which begins during the second semester (February 1 to June 30) during the ninth grade or higher,

the pupil must have passed the equivalent of 12 3/4% of the credits required by the State of New Jersey for graduation at the close of the

preceding semester (January 31). Full year courses shall be equated as one-half of the total credits to be gained for the full year to

determine credits passed during the immediately preceding semester.

3. The above paragraphs 1 and 2 shall not apply to incoming students from grammar school (grade 8). 4.Notwithstanding the provisions of

paragraph 1 and 2 above, a pupil who is eligible at the beginning of a sports season shall be allowed to finish that season.

This is my ________semester in Governor Livingston HS, and my _____semester since first entering the ninth grade. Last semester I attended _______________________School in _________________City, ______State.

7

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):

_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

List all medications here:

Medication Name Dosage Frequency

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

Concussion or head injury (including “bell rung” or a “ding”)? Y / N / Don’t Know Memory loss? Y / N / Don’t Know Knocked out? Y / N / Don’t Know A seizure? Y / N / Don’t Know Frequent or severe headaches (With or without exercise)? Y / N / Don’t Know Fuzzy or blurry vision Y / N / Don’t Know 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:

Restriction from sports for heart problems? Y / N / Don’t Know Chest pain or discomfort? Y / N / Don’t Know

Heart murmur? Y / N / Don’t Know High blood pressure? Y / N / Don’t Know Elevated cholesterol level? Y / N / Don’t Know

Heart infection? Y / N / Don’t Know Dizziness or passing out during or after exercise without known cause? Y / N / Don’t Know Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? Y / N / Don’t Know Racing or skipped heartbeats? Y / N / Don’t Know Unexplained difficulty breathing or fatigue during exercise? Y / N / Don’t Know 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:

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

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

Nasal fractures or frequent nose bleeds? Y / N / Don’t Know Wear braces, retainer or protective mouth gear? Y / N / Don’t Know 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:

Numbness, a “burner”, “stinger” or pinched nerve? Y / N / Don’t Know A sprain? Y / N / Don’t Know A strain? Y / N / Don’t Know Swelling or pain in muscles, tendons, bones or joints? Y / N / Don’t Know Dislocated joint(s)? Y / N / Don’t Know Upper or lower back pain? Y / N / Don’t Know

Fracture(s), stress fracture(s), or broken bone(s)? Y / N / Don’t Know Do you wear any protective braces or equipment? Y / N / Don’t Know

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

_____________________________________________________________________________

_____________________________________________________________________________

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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’tKnow (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

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 Date of Signature:

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

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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?

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

Femoral Pulses YES

Lungs: Auscultation/Percussion YES

Chest Contour YES

Skin YES

Abdomen (liver, spleen, masses) YES

Assessment of physical maturation or YES Tanner Scale

Testicular Exam (Males Only) YES

Neck/Back/Spine: YES

Range of Motion YES

Scoliosis ABSENT

Upper Extremities: (ROM, Strength, YES Stability)

Lower Extremities: (ROM, Strength, YES Stability)

Neurological: Balance & Coordination YES

Hernia ABSENT

Evidence of Marfan Syndrome ABSENT

ABNORMAL FINDINGS/COMMENTS

Standing makes it: Louder Softer No Change

Squatting makes it: Louder Softer No Change

Valsalva makes it: Louder Softer No Change

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Most recent immunizations and dates administered: __________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________ Medications currently prescribed, with dose and frequency:

Medication Name Dosage Frequency

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.

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

A. Cleared for participation in all sports without restrictions.

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

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: ___________________________________________________________________

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’s 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 Marching Band

Ice Hockey Pole vault Running/Cross Country

Lacrosse Gymnastics Strength Training

Soccer Skiing Swimming

Wrestling Softball Tennis

Volleyball Track

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

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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: ______________

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: ____________________________________________________________

NJDOE/APPEF Revised 3/10 Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

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Governor Livingston High School Sports Medicine 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 • Sensitivity to light/sound

• Nausea/vomiting • Feeling of sluggishness or fogginess

• Balance problems or dizziness • Difficulty with concentration, short term

• Double vision or changes in vision memory, and/or confusion 15

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:

www.cdc.gov/concussion/sports/index.html www.nfhs.com

www.ncaa.org/health-safety www.bianj.org www.atsnj.org

__________________________________ _______________________________ __________

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

__________________________________ _______________________________ __________

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

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Berkeley Heights Public Schools

Berkeley Heights, NJ

Dear Parent/Guardian:

Your son/daughter __________________________________

_____ Is cleared to participate on a school athletic squad or team based on the School Physician’s evaluation of

your child.

_____ We have received your child Sports Medical Exam Form from your physician. The form is complete and

your child may participate in athletics based solely on the medical.

_____Your child’s physical expires on ____________. Submit completed forms on or before the expired date to

ensure that your child can participate in sport without interruption.

_____Participation NOT Approved - Reason(s) for Disapproval:

_____ Administration of Medication form (5330) needs to be filled out on a school

year basis for Asthma & or Epipen.

_____Clearance note from licensed care provider needed.

_____Medical Records indicate your child’s physical is expired.

All forms can be downloaded by visiting http://www.bhpsnj.org/~glweb/. Click on

Health Office or Athletics.

Asthma & Epipen Conditional Clearance: If your son/daughter has a diagnosis of Asthma or an allergy, it is the

responsibility of the student and student’s family/guardian to ensure that the students have rescue medication with

them at all practices games or meet.

Dr. Richard Bezozo

School Physician

Revised 2010

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