College of Southern Nevada Spirit Squad Tryout Packet 2019 ...€¦ · Come to the CSN Spirit Squad...

College of Southern Nevada

Spirit Squad Tryout Packet

2019-2020

Come to the CSN Spirit Squad Tryout Clinic

at the CSN Sports Center

3200 Cheyenne Ave. Las Vegas, NV 89030

Join us April 27th 2019 from 9-11am in the CSN Sports Center to learn some skills, get any questions

answered, and see what the NEW program is all about!

Cost: $5

CSN SPIRIT SQUAD TRYOUT CLINIC

QUICK FACTS ABOUT CSN SPIRIT SQUAD Schedule

• Practice is typically held 2-3 times a week and all members are required to attend all practices throughout summer, fall, and spring semester.

• The spirit squad will attend and perform at women's volleyball, as well as men's and women’s soccer games. We will also attend baseball and softball games to support those teams.

• Members are required to attend all home games.

Expectations

• Squad members must be full time student (at least 12 credit hours) and maintain at least a 2.0 semester and cumulative GPA.

• Each squad member will be required to participate in any fundraisers set forth by the advisor and/or coach(es).

• Each member will purchase their own shoes, bag, warm ups, and practice gear.

• Attendance to all home games will be required. • All squad members are required to have health insurance

in order to participate. • Squad members are expected to act as an ambassador for

the school at all times. Whether in or out of uniform, members must act professional and uphold the values of the College of Southern Nevada. Failure to do so may result in dismissal from the squad.

College of Southern Nevada Spirit Squad / Mascot Tryout Information 2019-2020

Tryouts for the 2019-2020 season will be held May 10th & 11th 2019

Tryout Location:

3200 East Cheyenne Ave.

Las Vegas, NV 89030

CSN Sports Center

(DATE)

(Clinic Day 4-7pm)

4:00 - 4:30 PM Check-in

4:30 - 5:00 PM Warm-up

5:00 - 6:30 PM Learn Material

6:30 – 7:00 PM Open Gym

(DATE)

(Tryout Day 10:00am-2:30pm)

10:00 -11:00 AM Warm-up

11:30 AM Tryouts Begin

*Cuts may be made throughout day*

Tryout Policies: - NO videotaping of tryout material will be allowed. - Tryouts and Clinics are closed to the public. - Cell phones must be turned off during tryouts and clinics. - Safety is the number one priority. - Video tryouts must be cleared by CSN Spirit Squad coach beforehand. - Only those with correct paperwork turned in are allowed to participate. - $20 Tryout Fee. ($5 tryout clinic fee will go towards your tryout fee)

Tryout Requirements

In order to try out for the spirit squad and/or mascot position, participants must do the following:

* Have a current 2.0 cumulative and semester/term GPA. * Be at least a high school graduate or on track to graduate by the current semesters end. * If chosen, be willing to commit for the full year (summer, fall, and spring semester). * Have letter of recommendation from this packet filled out preferably by your most recent cheerleading or dance coach. If you have never cheered/danced before, then any athletic coach or supervisor/teacher will do. * Bring in a copy of your high school or college transcript (does not need to be official although it does need to be current). * Your release forms filled out and signed. Signed by parents if under 18. * Completed tryout application. *A current 4x6 photo (that will not be returned). * $20 tryout fee. ($5 tryout clinic fee will go towards tryout fee)

Tryout Suggestions: 1. Please wear formfitting clothing that is modest. It should be clear of team logos as to not influence the judges. (see "Suggested Apparel" below) 2. It is a good idea to bring food and drink with you to tryouts. This day will be stressful and participants won't be allowed to leave during it. 3. Make sure you are putting yourself out there during the clinic as well as the tryout itself. Judges may be in attendance for all or part of the clinic and may be making first cuts if they see fit. 4. Make sure you are always alert to those around you. Safety is the #1 priority and we want everyone to have a safe and enjoyable time. 5. We strongly suggest attending our pre-tryout clinic prior to tryouts. This will help you get an idea of what is expected and give you practice time with other participants as well as time to talk with coaches.

Suggested Apparel:

Girls:

Top: Any form fitting black t-shirt or tank top that is free of logos & a sports bra. Bottom: Black shorts and/or compression shorts. Shoes: Cheerleading shoes are best. If not, any athletic shoes will do.

**No jewelry of any kind will be allowed. This includes (but is not limited to) belly button rings, earrings, necklaces, rings, etc.

Guys: (These guidelines are the same for both male spirit squad participants and mascot participants.)

Top: Any black t-shirt or athletic top that is free of logos. Bottom: Black basketball-type athletic shorts. Shoes: Any athletic shoes will do.

** No jewelry of any kind will be allowed. This includes (but is not limited to) belly button rings, earrings, necklaces, rings, etc.

Judging Criteria

CSN Spirit Squad and Coyote Mascot are representatives of the College of Southern Nevada. They are expected to always look and act in a professional, clean manner.

Spirit Squad members are part of the Athletic Department and are always expected to act as such, in or out of uniform.

CHEERLEADERS/DANCERS Voice Quality: Voice tone, clarity, and projection in cheers Presence: Enthusiasm, sharpness of motions, crowd appeal, energy, and professionalism Dance: Knowledge of dance, technique, and execution of movements Cheer: Crowd encouragements, sharpness, and motion placement Stunting: Body placement, execution, and versatility Tumbling: Precision, variety, and technique Jumps: Height, execution, and technique At tryouts, you will be taught a dance as well as two cheers. You will also be

asked to perform jumps, tumbling, and stunting (cheerleaders only). An interview may take place if the judges deem necessary.

Questions? Contact: Tiffany Boulter - CSN Head Spirit Squad Coach (801) 427-2443 [email protected]

Judging Criteria



YELL LEADERS

Voice Quality: Voice tone, clarity, and projection in cheers Presence: Enthusiasm, sharpness of motions, crown appeal, energy, and professionalism Cheer: Crowd encouragements, sharpness, and motion placement Stunting: Body placement, execution, and versatility Tumbling: Precision, variety, and technique Jumps: Height, execution, and technique

At tryouts you will be taught a cheer. You will also be asked to perform jumps, stunts and tumbling. An interview may take place if the judges

deem necessary.


Judging Criteria



COYOTE MASCOT

Tryout participants will be judged on creativity, appeal, versatility, and crowd

interaction.

At tryouts you will be asked to prepare and perform a brief skit (1-5 minutes) as well as any special skills you have that would add to the

element of the character (i.e. tumbling, stunting, dancing, magic tricks, juggling, etc.).

Please bring any props or music that you will be using.

** Participants are encouraged to tryout for both mascot and yell leader positions.


College of Southern Nevada

Spirit Squad / Mascot Application 2019-2020

Circle position applying for (you may circle more than one):

Cheerleader Dancer Yell-Leader Mascot

Name:

Address: City: Zip: _______________

Email:

Birth date: ______________________________________

Cell Phone: ______________________________________

Age: ________ Height: _____________

Last semester/term GPA:

High School or College Currently Attended:

___________________________________________________________________

Cheer/Dance Experience:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

____________________________

Why do you think you would be a good asset to the College of Southern Nevada

Spirit Squad

_____________________________________________________________________________

Sizes: Shoe: ________ Shirt: ________ Shorts/Spankies: ________ Warm Up Jacket: ________ Warm Up Pant: _________

I hereby give my approval for myself or my son/daughter to audition for the College of

Southern Nevada Spirit Squad. I understand that cheer and dance involve the risks of falling

and injury and I release College of Southern Nevada, the CSN Spirit Squad Advisor, Coaches,

Clinic Instructor and Administration from any responsibility related to injury.

Applicant:

Date: ____________________

Parent/Guardian (if under 18):

Date: ___________________

Emergency Contact Phone Numbers:

______________________________________________________________________________

Primary Insurance Company:

Policy #: _____________________________________________________________________________

Please attach with this application (and bring with you to tryouts):

• A current photo (that will not be returned)

• An up-to-date high school or college transcript

• Your SEALED letter of recommendation from past coach

or supervisor

• Your release forms

For Office Use Only:

[ ] Application [ ] Tryout Fee Paid [ ] Photo [ ] Letter of Recommendation

[ ] Transcript [ ] Release Forms

CSN Spirit Squad Tryouts Letter of Recommendation

Applicant: _____________________________ Email: ________________________________ Phone #: ______________________________

Please provide the respondent an envelope with your name on the front.

Respondent: ____________________________ Phone #: _______________________________ What is your relation to the applicant? _________________

This form will remain confidential. Please sign the back of the sealed envelope. Please return to applicant to bring to the 1st day of tryouts.

Please assess the applicant by checking the boxes contained in the below chart.

How long have you known the applicant? ___________

What are their strengths? ________________________________________________________________ _________________________________________________________________________________________

What are their weaknesses? ______________________________________________________________ _________________________________________________________________________________________

In the space below, please share your personal evaluation of this applicant. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Please continue on the back of this sheet if necessary.)

Thank you for your evaluation of this applicant. If you would like to contact me for any reason I can be reached by phone: 801.427.2443 or by email: [email protected]

Excellent Above Average

Average Below Average

Poor

Attitude Work Ethic

Team Player Reliability Leadership

Teachability

COLLEGE OF SOUTHERN NEVADA OFFICE OF INTERCOLLEGIATE ATHLETICS

TRY-OUT RELEASE & WAIVER OF LIABILITY FORM

I______________________________acknowledge that I am completely aware of the inherent risk associated (student-athlete name)with_______________________participation in a tryout for that sport. I understand that, in addition to the risks (sport)of injury, which may include death, my participation in that sport may cause aggravation to pre-existing injuries. Knowing this, I take full responsibility for any injury that may occur as a result of my participation in the try-out. Further, in consideration of the College of Southern Nevada granting me permission to participate in this try-out, I hereby agree to irrevocably and unconditionally release, hold harmless, and indemnify NSHE Board of Regents, the College of Southern Nevada and their officers, employees and agents (hereinafter referred to as the “College”) from any liability, demands, claims, and causes of action in the event that I become injured in any way as a result of my participation in the try-out period. I warrant that I am in adequate physical condition, and physically able to perform this try-out, and that I have no known physical condition which could be materially worsened or aggravated by my participation, unless stated below:

It is my understanding that the College of Southern Nevada Office of Intercollegiate Athletics may deny my participation in a try-out date due to a medical condition found in my history. I understand that any pre-existing medical condition may have to be corrected prior to the try-out and/or acceptance to the team. In addition, all costs associated with any tests, consultation, and/or medical procedures needed to gain approval/certification for participation are the responsibility of myself, and/or parent(s) / guardian(s). I further acknowledge that I am signing this waiver voluntarily, with complete understanding of the terms and conditions herein, and that, as applicable, I have discussed my participation and the related risks with my parent(s) and/or guardian(s).

Student-Athlete Signature Date

Student Printed Name

Parent/Guardian Signature (if under 18 years of age) Date

Parent/Guardian Printed Name

Maintained by Athletic Manager Copy to Head Coach Copy to Compliance Officer Approved by Legal 11/25/14

Athletics Health Insurance Info & Attached Questionnaire (1) Rev 11/17

Health Insurance Requirements for Student Athletes

Every year, CSN Athletics requires the athlete and his/her parent or guardian to:

What does the athlete need for eligibility? A comprehensive medical or health insurance plan. CSN Athletics requires that all student athletes maintain a comprehensive health insurance plan with hospital, professional and extended benefits. The plan MUST provide:

• Full coverage in the state of Nevada.

• Out of state and/or out of area coverage for injuries during any away games or practices; and

• Coverage for intercollegiate sports-related injury or illness.

Who normally supplies health insurance coverage for athletes?

Employer group health insurance plans - This coverage is normally provided for the athlete by the employer of the athlete’s parent or guardian. Coverage is typically comprehensive. Individual health insurance plans – This coverage is arranged and purchased by the athlete. It is important for the athlete to select a comprehensive health insurance plan that meets the eligibility requirements above. State Medicaid insurance plans – Out-of-state Medicaid plans DO NOT meet CSN Athletics requirements. Although Medicaid plans provide comprehensive coverage within the plan’s state, they rarely provide coverage in another state. The athlete must obtain the equivalent Medicaid coverage in Nevada to meet the eligibility requirements.

Who is responsible for maintaining the athlete’s health insurance coverage?

Both the athlete and his/her parent or guardian. Both are responsible for maintaining a comprehensive health insurance plan that meets CSN Athletics' requirements for the duration of the athlete’s participation in intercollegiate sports. One or both must immediately report to CSN Athletic Trainers any discontinued coverage or change in plans by completing a new Athletic Insurance Questionnaire and submitting a new insurance I.D. card so the information on file at CSN is always current.

What happens when an athlete is injured?

1. Immediately after the injury, the athlete must report to a CSN Athletic Trainer who will examine the injuryand refer, if necessary, to the team physician. The team physician may suggest or initiate further referral toother medical consultants. In situations where the athlete cannot see the Athletic Trainer immediately, theathlete must inform the Athletic Trainer about the injury and any treatment received as soon as possible. Itis the athlete’s responsibility to assure that the Athletic Trainer is notified.

The athlete receives medical treatment under the athlete’s comprehensive health insurance plan, and isresponsible for paying all deductibles, co-pays and uncovered medical expenses.

2.

1. Complete and sign the Athletics Insurance Questionnaire (see form on next page);

2. Provide copy of the front and back of the athlete’s valid insurance I.D. card; and

3. Immediately report discontinued or any change to athlete’s health insurance coverage that may arise duringthe year to CSN Athletic Trainers.

4. The athlete must maintain health insurance coverage the entire year to participate in intercollegiate sportsat College of Southern Nevada. CSN does not provide secondary insurance.

Athletics Health Insurance Info & Attached Questionnaire (2) Rev 11/17

Athletic Insurance Questionnaire Instructions: A completed and signed questionnaire in blue or black ink and a copy of the valid insurance I.D. card (front & back) must be submitted to the CSN Athletic Training Room. Incomplete forms will not be accepted. No athlete will be allowed to participate in any intercollegiate sport without proof of comprehensive health insurance coverage – there are NO exceptions!

Athlete’s Name: ________________________________________________Sport(s):________________________________

Parent/Guardian’s Name: _____________________________Relationship:____________________Date of Birth: ___________________

Home Address: _________________________________City:___________________State:__________Zip:_______________

Cell Phone:____________________________ Work Phone: ______________________________

*Emergency Contact for Athlete/Relationship*_____________________________________________________Cell #_______________________

Health Insurance Plan Information - I am insured under a (check only one box and provide company information):

Primary Care Physician (as listed in your health plan):___________________________________Phone #: _______________________

I have verified with my insurance company that my plan provides (policy owner’s initials only):

_____ (initials) Full coverage in the state of Nevada.

_____ (initials) Full coverage out of state and/or out of area for injuries at away games or practices.

_____ (initials) Full, comprehensive health insurance coverage for intercollegiate sports-related injury or illness.

Important: If you initial, but did not actually verify that your insurance company will respond as stated above, you are financially responsible for paying all uninsured medical expenses resulting from the athlete’s injury or illness.

You MUST attach a photocopy of your valid insurance I.D. card (front and back) to this form

_____ (athlete’s initials) I will continue to maintain a comprehensive health insurance plan for the duration of my participation in intercollegiate sports at CSN. I understand that it is my responsibility, and that of my parent and/or guardian, to immediately report discontinued coverage or any change in health insurance plans to the CSN Athletic Trainers.

_____ (athlete’s initials) I am not aware of any medical illness or condition that will interfere with my health and safety while participating in intercollegiate athletics. I understand and acknowledge that a medical emergency may develop which necessitates the administration of medical care, dental care, hospitalization or surgery. Therefore, in event of such emergency, I hereby authorize College of Southern Nevada, its authorized employee(s), representative(s) or agent(s), to arrange or provide any necessary emergency medical treatment including the administration of anesthetics and surgery.

______________________________ ____________________ Signature of Athlete Date

______________________________ ____________________ Signature of Insurance Policy Owner

_______________________________ Signature of Parent/Guardian

(if under 18)

Date

Print full name

Athlete's SSN:_____________________________________ E-mail address:________________________________________

Home Address: _________________________________City:___________________State:_________Zip:_______________

Cell Phone: ______________________________ Date of Birth: _________________ Sex:______ Male_____Female

Parent or guardian’s employer group health insurance plan

Insurance Company Name:___________________________ Policy Number:__________________________________ Group Number:_______________________________________

Insurance Phone #:____________________________________

Individual health insurance plan State Medicaid health insurance program

Insurance Address:__________________________________City:_____________________State:___________Zip:____________

Policy Owner's Date of Birth:____________________

Occupation:__________________________________Address:__________________________Phone #:________________

________________________ Date

Policy Owner's Name:_________________________

Policy Owner's Occupation: ______________________________________Address:__________________________Phone #:________________

STUDENT ATHLETE CONSENT FOR MEDICAL TREATMENT AND DISCLOSURE OF MEDICAL INFORMATION

Rev. 08/2017

(please complete all sections of this form)

College of Southern Nevada Consent for Medical Treatment

I (Athlete’s Name): _______________________________ hereby give my consent for any medical treatment that may be required for any injury or illness that I may sustain or acquire while engaged in collegiate athletics as a player for the College of Southern Nevada1 (CSN). I understand that the personnel of CSN will evaluate and treat any injuries that occur during my athletic participation at CSN within their training, credentialing, and scope of professional practice to prevent, care for, and rehabilitate athletic injuries. This includes immediate first aid and treatment. I understand that it will be my responsibility to seek any other follow-up care such as X-ray, physician care, and rehabilitation.

I understand that CSN may from time to time utilize athletic training students, medical residents, medical students, dental students, nurse practitioner students and nursing students in my care under the supervision of a certified athletic trainer, physician/dentist or nurse practitioner. I understand that outside medical professionals may also be consulted as deemed necessary for my care. For coordination of my care and services, I understand that I may be provided with referrals to off campus specialists.

Informed Consent: If any condition requires an outpatient surgical procedure, the practitioner responsible for my care will explain to me the procedure to be performed, the general nature and extent of risks involved in such procedure and the alternative methods, if any.

I understand that if I sustain a potentially life threatening injury or illness, and in the event that my emergency contact is unable to be contacted within a reasonable period of time, I do hereby appoint an appropriate official of CSN as my attorney in fact to make any and all decisions which he or she believes to be in my best interest as to the obtaining of emergency medical care, and I fully release them from any liability for such decisions or actions as may be taken under those circumstances. I agree to be liable for any and all of the expenses incurred on my behalf.

Athlete’s Signature: Date:

Signature of Parent or Legal Guardian: Date: (If athlete is under the age of 18)

1 The College of Southern Nevada is an entity governed by the Board of Regents of the Nevada System of Higher Education.

Page 1 of 7

STUDENT ATHLETE CONSENT FOR MEDICAL TREATMENT AND DISCLOSURE OF MEDICAL INFORMATION

Rev. 08/2017

Release of Medical Information

CSN is dedicated to protecting and maintaining the privacy of all students and staff individually identifiable health information as covered under the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Therefore, all health and insurance information acquired by the Athletic Department is handled confidentially within the offices of the Athletic Department. CSN reserves the right to discuss and disclose medical and insurance information with appropriate medical providers related to injuries from athletic competition.

However, any disclosure of medical information regarding an athlete’s injury outside of these resources will be at the sole discretion of the athlete. If an athlete wishes to disclose information to ANY person or entity (this will include parents of those 18 years of age and older) the athlete will be required to fill out Release of Medical Information form. All forms regarding information releases are located in the office of the Athletic Department and must be picked up, filled out and submitted to the Athletic Director. Any information released will be done by the Athletic Director or his designee, and only to the student or those who the student has in writing authorized to receive the information. Coaches are directed to not release any information relating to athletic injuries and should refer all questions to the Athletic Director. Parents and other individuals wishing further information on this subject are encouraged to contact the Athletic Director.



Page 2 of 7

STUDENT ATHLETE ACKNOWLEDGEMENT AND WAIVER OF LIABILITY

Rev. 08/2017

I am aware that playing or practicing to play/participate in any sport can be a dangerous activity involving many risks of injury. I acknowledge that even with the best coaching, use of the most advanced protective equipment and strict observance of rules, injuries are still a possibility. I understand that the dangers and risks of playing or practicing to play/participate in sports include, but are not limited to: death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to all bones, joints, ligaments, muscles, tendons and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my body, general health and well-being. I understand that the degree and risks of playing or practicing to play/participate in sport may result not only in serious injury, but in a serious impairment of my future abilities to earn a living, to engage in other business, social and recreational activities and generally enjoy life.

I also acknowledge that it is essential for my well-being that I not participate or practice to play/participate in the above sport unless I am in good health and physical condition. With this in mind I have truthfully answered the questions on the Medical History Survey, and I have advised the Athletics Director of any limitations on my activities for medical reasons.

Because of the dangers of participating in the above sport, I recognize the importance of following coaches’ instructions regarding playing technique, training and other team rules, etc., and agree to obey such instructions. I also understand that it is my responsibility to inform my coach or the athletic training staff of any conditions or equipment that I consider to be unsafe. Further, I recognize the importance of following orders given by physicians and athletic trainers regarding any limitations or treatments they feel necessary for my health and well-being.

In consideration of College of Southern Nevada (CSN) permitting me to try out for /participate on the CSN athletic team(s) and to engage in all activities related to the team, including but not limited to, trying out, practicing in or playing/participating in that sport, I hereby assume all risks associated with participation and agree to hold the Board of Regents of the Nevada System of Higher Education, its officers, employees, agents, representatives, coaches, physicians, athletic trainers, and volunteers harmless from any and all liability, actions, causes of action, debts, claims or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to CSN athletic team(s). The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees and all members of my family.



Page 3 of 7

MEDICAL HISTORY SURVEY - GENERAL HEALTH (To be completed by athlete prior to physical)

Name: _____________________________________________________ Sport(s): ______________________________ (please print) Last First Middle Date of Birth:

_________________________ Sex: M ____ F____

Home Address: ______________________________________________ Home Phone: (_____)____________________

______________________________________________ Emergency Name/Relation: _______________________________ Hm# _________________ Wk# ________________ Cell#_________________ HEALTH HISTORY: (To be completed by the athlete)

YES NO YES NO 9. MENTAL HEALTH (Circle each item) Frequent Nightmares, Trouble Concentrating, Feeling of Depression, Tendency to worry, and Memory Loss, Have used Narcotics, Tobacco, Amphetamines, Cocaine, Stimulants, LSD, or Other Hallucinogenic more than once. Use of Alcohol, Marijuana, Tranquilizers, Sleeping Pills, Considerable Nervousness, Difficulty Sleeping, Considered Suicide, Lose Temper Often.

10. BLOOD DISORDER (Circle each item)Anemia, Any unusual Bleeding, Disease or Enlargement of Glands/Lymph Nodes, Sickle Cell Disease.

11. CHORNIC DISEASE (Circle each item)Diabetes, Congenital Problems, Hypertension, Rheumatic Fever, Other _________________.

12. ADDITIONAL MEDICAL HISTORY(Circle each item) Cancer, Operations, Recent gain or loss of Weight, Serious Illness, Sexual Problems, Skin Disorder/Infection, STD’s, Unusual Fatigue, Other ________________________________.

13. ALLERGIES (Circle each item)Medications/Drugs, Bee Stings, Foods, Hay Fever, Other _________________________.

14. PAST ILLNESSES (Circle each item)Measles, Mumps, Rubella, Chicken Pox, Other________________________________.

15. DRUGS RECENTLY TAKEN (Circleeach) Cortisone, ACTH, Anticoagulants, Tranquilizers, Mood Elevators, Anti-Convulsants, Hypotensive (High Blood Pressure Medicines), Aspirin.

16. IMMUNIZATION HISTORY (Date foreach) Tetanus Diphtheria Booster _______________ Polio ________________________________ Measles/Mumps/Rubella__________________ Hepatitis A 1.____________2._____________ Hepatitis B1.____________2.______________

3.__________________________ Varicella ______________________________ Flu __________________________________ Pneumococcus ________________________ Other ________________________________

1. HEAD 6. GASTROINTESTINALa. Major dental problems a. Abdominal Painb. Dizziness/Fainting b. Recent Changes in Appetitec. Encephalitis c. Recent Changes in Bowel Habitd. Frequent Headaches d. Recent Constipatione. Head Injuries e. Frequent Diarrheaf. Migraine f. Digestive Disorderg. Seizures/Convulsions g. Difficulty Swallowingh. Periods of Unconsciousness h. Gastric or Other Ulcers

2. EYES i. Recurrent Vomitinga. Allergies j. Hemorrhoids/Fistulab. Eye disease or injury k. Other Ano-rectal Disorderc. Wear Glasses l. Hepatitisd. Wear Contacts m. Hernia

3. EARS/NOSE/THROAT n. Intestinal Wormsa. Frequent Colds o. Black Bowel Movementb. Ear Trouble p. Vomiting Bloodc. Hearing problems q. Jaundiced. Frequent Nose Bleeds r. Intestinal Inflammatione. Sinusitis s. Gall Bladder Diseasef. Frequent Sore Throat 7. GENITOURINARYg. Operation a. Blood, Albumin, Sugar in Urine

4. NECK b. Kidney Diseasea. Stiffness c. Kidney Stonesb. Thyroid Trouble d. Bladder Diseasec. Enlarged Glands e. Painful Urination

5. CHEST/HEART/LUNGS f. Frequent Urinationa. Breast disease or masses g. Sexually Transmitted Diseaseb. Chest pain/palpitation h. Genital Disorderc. Heart Disease/Murmur i. Prostatic/Testicular Disorderd. High Blood Pressure j. Othere. Rapid or irregular pulse 8. MUSCULOSKELETAL/NEUROLOGICALf. Varicose veins a. Arthritis or Rheumatismg. Asthma b. Vertebrae Disc Problemsh. Chronic cough c. Swollen or Painful Jointsi. Valley Fever d. Bone Infectionsj. Emphysema e. Amputationk. Lung Disease f. Speech Defectl. Night sweats g. Paralysis, Tremor, Musclem. Pneumonia h. Neuralgia, Numbnessn. Tuberculosis i. Back Troubleo. Pleurisy j. Seizures (Epilepsy)p. Wheezing k. Passing Out/Faintingq. Shortness of Breath l. Other Injuriesr. Coughing up Bloods. Stroke Page 4 of 7

MEDICAL HISTORY SURVEY - ORTHOPAEDIC (To be completed by athlete prior to physical)

ATHLETES NAME:

Rev. 08/2017

FRACTURES: 1. Have you ever broken (fractured) a bone? If yes please fill in the appropriate boxes below. YES NO

BODY PART DATES BODY PART RIGHT LEFT DATES Skull Collar Bone Nose Upper Arm Face Forearm Jaw Wrist Neck Hand Spine Thigh Pelvis Lower Leg Ribs Foot Fingers Right 1____, 2____, 3____, 4____, 5____ Left 1____, 2____, 3____, 4____, 5____ Toes Right 1____, 2____, 3____, 4____, 5____ Left 1____, 2____, 3____, 4____, 5____ 2. Did the fracture require surgery or create any residual defect? If yes, please describe the defect or type ofsurgery, date, physician, and location of the hospital.

YES NO

3. Have you ever had a calcium deposit from in your thigh or anywhere else following a bad bruise? If yes, where is the calcium deposit located?

YES NO

4. Have you ever had a bone spur develop and if so, where? YES NO

DISLOCATIONS:1. Have you ever dislocated a joint? If yes, please fill out the appropriate boxes on the chart below: YES NO

Right Left # of times Dates Right Left # of times Dates Shoulder Elbow A-C Joint Wrist Knee Cap Hip Knee Fingers Neck Toes Ankle 2. Have you ever had surgery for a dislocation? If yes, describe surgery type, date, physician, and location of hospital below:

MUSCLE INJURIES:1. Have you ever had a severe muscle pull or strain? YES NO 2. Has this injury reoccurred? If yes, list the muscle(s) involved and date(s): YES NO

NECK:1. Have you ever sustained a serious neck or cervical injury? YES NO 2. Did you have numbness, burning or sharp pain in your arms or legs? YES NO 3. Have you ever had an injury producing weakness or numbness of your arms or legs or both? YES NO 4. Were you ever transported by ambulance for a neck injury? YES NO If yes, did you have neck or spinal X-rays

taken? YES NO

5. Have you ever had neck surgery? If yes, describe surgery type, date, physician, and location of hospital below: YES NO

6. Have you ever had a burner or stinger (stretched or pinched nerve)? YES NO 7. Do you currently have any weakness due to a neck or spinal injury? If yes, give the location(s) of the weakness. YES NO

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ATHLETES NAME:

SPINE:1. Have you ever injured your back? If yes, how many times? Please provide details regarding each injury includingdates, treatment, rehabilitation, etc.

YES NO

2. Were you ever diagnosed with a spinal defect of any type? If yes, provide details of defect? YES NO

3. Have you ever had back surgery? If yes, described surgery type, date, physician, and location of hospital below. YES NO

SHOULDERS:1. Have you ever had a significant shoulder joint injury? L R YES NO 2. Have you ever had an A-C sprain or separation? L R YES NO 3. Has your shoulder ever felt like it was unstable of slipping? L R YES NO 4. Have you ever had a problem with your shoulder repeatedly coming out of place? L R YES NO 5. Do you have any problems with your shoulder when trying to throw? L R YES NO 6. Do you have any problems with your shoulder with overhead activities? L R YES NO 7. Have you ever had shoulder surgery? If yes, describe surgery type, date, physician, and the location ofhospital below.

L R YES NO

ELBOW, WRIST, HAND, FINGER:1. Have you ever had an elbow injury or problem? L R YES NO 2. Have you ever had a wrist injury or problem? L R YES NO 3. Have you ever had a problem with hand or finger injury? L R YES NO 4. Do you have a finder deformity as a result of this injury? If so, which finger? L R YES NO 5. Have you ever had elbow, wrist or hand/finger surgery? If yes, describe surgery type, date, physician, and the locationof hospital below.

YES NO

KNEES:1. Have you ever had a significant knee injury? If yes, please describe the injury(s) you have sustained? L R YES NO

If you have had a significant knee injury or knee surgery, answer the following questions: A. Were you placed on a rehabilitation program?

YES NO

B. Do you wear any type of preventative/protective brace when you practice or play? YES NO 2. Does your knee ever swell or collect fluid? L R YES NO 3. Did you have surgery for your knee injury(s)? If yes, please describe the surgery type, date, physician, andthe location of the hospital where surgery was performed:

L R YES NO

4. Have you had surgery on either knee more than once? L R YES NO 5. Have you ever suffered from patellar tendinitis or jumper’s knee? L R YES NO 6. Have you ever been diagnosed with Osgood-Schlatter’s disease? L R YES NO

ANKLES:1. Have you ever sustained a severe ankle sprain? L R YES NO 2. Have you ever sustained a “high ankle sprain” or syndesmosis sprain? L R YES NO 3. Have you ever had surgery on your ankle(s)? If yes, describe the surgery type, date, physician, and locationof the hospital below.

L R YES NO

FEET AND TOES:1. Have you ever had a problem with bunions? L R YES NO 2. Have you ever had a problem with turf toe or sprained great toe? L R YES NO 3. Have you ever had a problem with ingrown toenails? L R YES NO

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Rev. 08/2017

Physical Form: MUST BE COMPLETED BY EXAMINING MEDICAL PROVIDERS

Athlete’s Name: Date: (please print) Last First Middle

Measurements and other Findings: 1. Height ______________________2. Weight ______________________3. Blood Pressure:

Systolic __________ Diastolic __________ 4. Pulse ________________________5. Vision

Right: 20/_______ Corrected to 20/_______ Left: 20/_______ Corrected to 20/_______

Clinical Evaluation:

Orthopedic evaluation:

Comments (please describe any abnormalities found and identify by number before comment):

Medical provider’s Statement: Athlete is released for full sport participation at CSN. Yes No Athlete is not release for full participation until the following exams are completed (explain):

Athlete may not participate in athletics at CSN for the following reasons:

Medical provider’s signature: Date:

Medical provider’s address:

Medical Provider’s phone number(s):

Athlete’s Statement: I understand that this physical is for no other purpose than to clear me for athletic participation at CSN. I understand it is not a physical for illnesses that may develop in the future. I agree that the information that I have provided on this physical and medical history form are complete and accurate.

Athlete’s signature: Date:

Normal Abnormal 8. Eyes9. Ears10. Nose11. Mouth/Throat12. Head13. Abdomen14. Genitalia15. Heart16. Chest and Lungs17. Lymphatic18. Neurologic19. Mental status

Normal Abnormal 20. Neck21. Shoulder22. Elbow23. Wrist and Hand24. Spine25. Hip26. Knee27. Lower Leg28. Ankle and Foot

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6. Any abnormal heart or lung sounds? ___ Yes ____ No If yes explain: ______________________________________________________________________________________________________________________

7. Has the athlete had any pre-existing or current orthopedic injuries, or any past surgeries ? _____________________________________________________________________________________________________________________________________________

College of Southern Nevada Spirit Squad Tryout Packet 2019 ...€¦ · Come to the CSN Spirit Squad...

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Transcript of College of Southern Nevada Spirit Squad Tryout Packet 2019 ...€¦ · Come to the CSN Spirit Squad...