PLEASE RETURH THIS TO SGHOOL TOMORROW

Dear Parent,

Your child's school district has a contract with The Screen Team to perform a sports physical.This service will benefit you by providing a sports physical without having to take time out of your busyschedule to sit in a doctor,s office to the physical.

Please complete the authorization below and all the attached forms and have your child give them tohis/her coach' sjllilLt Plllsicrit$ sre pr$\:iql*r! firr c]rildtsr rviih Ltc,"{j*qid. Chips. }rrj'aie Ins}iinncr. or.tltts+.lvitl:.ro iilsr,riil*s *,rv*r?se, {nrta,:I s{iE*756-{ir76 fbi.nnn ,tu*sti,,r}s.

You will Egllrg$iyp a bitl for any of our services but you might receive an explanation of benefits from

PLEASE FILL THIS OUT IN NKtiitf;4$r; t1rltu_uUU

CIIILD'S NAME:

TIO]VIEROOM TEACHER:

l. Yes, I authorize mv child to receive sPoRTS pHystrcAl-., at his/her

school

(Medicalexam incrudes IN ORDER: HEIGHT, WEIGHT, BLooD PRESSURE, puLSE,HEART RATE, OXYGEN LEVEL BY FINGER MONITOR; EAR, NQSE, AND TFTR9AT. * EXAM BY NURSE PRACTITIONER, HEART AND LI]NGS WITH STETHOSCOPE, EXAMOF ARMS, LEGS, AND JOINTS, QUESTIONS ABOUT HOW THEY ARE DOING; }READING THE EYE CHART. THAT IS THE END OF THE EXAM.)

2. MEDICATION ALLERGIES:

3. IIEALTH PROBLEMS:

,SIGN HERE: X* * * * * !t rr *GUARDIAN'S SIGNATURE AnOVn PLEASE * * * * * * * * * n * rr *,k * * * *

PLEASE SEE NEXT PAGE FOR CONSENT FOR SERVTCES (2 PAGES FOR yOU TO CHECK AND S|GN)

ffiffi

THIS F'ORM HAS TO BE SIGNED AND TURNED BACK IN TO SANDY/SUNFLOWER CLINIC IN ORDER FOR THE CHIiD TO BE SEEN.

tlorthSunflower

edicalEenter

Dedicated to Csmmunity Healtfi:aa;8{0 North oak [venue ' p.o. Box 369 , Terephon o giztzss-zltt, fax 6521?56.41 14guleville, Mississippi 38?7 I

ACKNOWLEDGEMENT OF'NOTICE OF PRIVACY AND CONSENT TOUSE/DISCLOSEHEALTHINF,ORMATION (

Iacknowledge that I have received a copy of North Sunflower Medicar center,sIgti:t of Privacy Practices. I understand tr,ut as part;i;y healthcare, North SunflowerMedical center originates and maintains health records describing child,s health history,symptoms, examination and test results, diagnoses, treatment and any plans for future care ortreatment. I understand this information serves as:

o { basis for planning my care and treatmento I means of communication among the many health professionals who contribute to mycareo { source of information for apprying my diagnosis to any b,lo { means by which reimbursement agencies can certifu that services billed were actuallyprovided, ando { tool for routine health care operations, such as assessing quality and,reviewing thecompetence of the health care professionals.

I request the following restrictions to the use or disclosure of my health information:

Signature of patient or p"iror.a ..p..o"tffi Date

WitnessDate

North Sunflower Rural Health Clinic - Patient tnformation

lds Name

Mailing Adress

arital Status:

S M D WSEPPatients Primary Doctor

Male Female

Emergency Contact lnformation

k Phone

Payor lnformation

Medicaid/MSCAN/CHtpS/Magnotia

Name on Card

Blue Cross/State of MS/Other private tnsurance

Name on Card Policy Number

SS# of Policy Holder Birthdate of Policy Holder

Paient/ Guardian lhformatioil

Parent/ Guardian's Name Relationship

Lafayette County School District100 Commodore Drive

Oxford, Mississippi 38655

Tel ephone: 662-23 4-327 IFax: 662-236-3019 Adam Pugh, Ph-D.

Superintendent

CONSEIYT r0RM

L The Parent or Guardian do hereby give mypennission forparticrpate in the qporfs program atl-qfayette County School Sptem. As tle Parent or Guardian, f wflItake responsibility for cost due to athletic injury while participating in the sport of choice.Due to the rising cost of insuranee premiuins; the Lafayette County School District uo longer

Parent or Guardian: Date'.

'1 l(ri.ts. r ru_El\ I' I urilYr

I grant pemrission for my child. to receive.anymedical treafueat deemednecessaryin the event of an emergetrcy.Rehabilitation.

Parent orGuardian:

f also grant the authority for consent to treat to Cornerstone

Card lIolderName and Date ofBirth:

Group Number:

ID Nunrber of Insurance Card llolder:

Athlete'sName:

Athlete's Social Securi-f Number:

Parent or Guardiari Phone Number(s) :

to

3overed Athlete:I-ast First Intial

lhe above at]r-lete has opted to waive their rigbts uader the U.S. Depar@ent ofHealth and Hunanleso.urces guidelines. The above mentioned athlete is aware that this waiver can berevoked byubmitting in writing the intention of doing so. By signing this ielease the athlete allows the sharing ofiedical information between his/her rnedical provider, Comerstone Rehabilitation, the coaches ofthlete's sport, and school adminiskation.

overed Athlete's Signahre: Date:

rent or Guardian Signahre: Date:

V*renr*/ar€;,rt= QleO-ULcor^ p"qL +^q-ppq#*%,.^

DO NOT FOLO FORMMISSISSIPPI ATHLETIC PAHTICIPATION FOHM

ATHLETIC HEALTH HISTOBYPlaase Prinl

Name OateSchml Grade Soorl(sl

Work PhoneWor.k Phone

Ser M F Oate of BirthAddressFamily !,hisicianPa/ent/Giiardian Name

FJ,MILY tl| EDICAL HISTOBYHas any member.o, l,our family irnder age 50 had these conditions?

WhomYes NoDtrDtrtrDOBtrtrtrCo,trilDtrD

ConditionHeart AttackSudden DeathStoke,.Hearl Disease,l High PressureDiabelesSickleceil AnemiaArt-hril's.EpilepsyKidney Disease .

ATHLETE'S OHTHOPAEOIC HISTORYHas the athlste fiad any of lhe ,ollowing injuries?

Yes NoDBtrtrtrDDtratr00ADon

ConditionHead lnjury/ ConcussionShoulder L / IElbow.L/'H'HipKnee L/FlChronic Shin SplintsFootL/RPinched Nerve

Yes No CondilionC tr Neck lniury/ Stingertr tr Arm./Wrist/HaodL/Rtr .tl Backtr D Thish L/ RD tr lowerLegl/FlD D Ankle L/ Rtr D Severe Muscle StrainD D Chesl

Dale

Preyious Surgeries:ATHLETE'S MEDICAL HISTOAY

Has lhe athlete fiadany.of trlese.condilions?

Yes f,lo Condition0 tr Hearl Llurmurn n SeizuresD O Kidney Diseasetr D lrreouiar.Pulseil D sin;h Testicle0 D Hioil Bjood Pressuretr D DiizylFaintingtr n Surgery-WhatType?

Organ l.ossStrortaess ofbrealh / coughing

Overnight in hospitalHemia .ffapid $/eighl loss / qainTake.supplemenls / vitaminsfleal related problems.Menstrual iregirlaritiesFlecenl Mononucleosis /Enlarged Splein

Dfltrtrtr0tr

trtr

trCatrtrDtrtrDtrtrtrDD

dudnq €xercisetr XnockedoutA Hear{DiseaseE Diabetes'n LiverDiseaseD Tuberculosis

tr - eireig+ iFcor.G,$i -.-_Dale oI lasl i.staaus iminuniza'iicrTo.lhe besl o{ ou knovr'ledge, we have given lrue and accunte inlormation and +ve hercby gran! permission lorthephysical sueening evaluafroP.

.We unds$iand W eualualion inuolues a limiteC examination and the.scdening E no! ii!;nded io nor will ir previntinjuqr or buddin death.l4/efurrher understand lhal lfE'.e?€,ni;aliotl uill be provided uithcu expectdtiin of ,paynent and that lhe ihysicianLria *r"y inet i.Autprolessionals providiog services.may be immune lrom tiability under Missbsippi law. '

WAIVER FOffMThis haiver, executed this _ Cay ol 200_______. by M.D,.

3nd -=-.--*.::.. , pat'tenl is execuled in compliance with lJlississippi larv. wilh the lull undersrariding lhat

if a physician voluntarily provides needed medical br.health services to any prografi al an accrediled schooi h the slate wiihout exp;clatioil ofpaymeht. lhe physicianwill be iinmune {rom liability.lolany civil action arising but oi rhe provision of those medical and/or health care serviceswhich were Provided in good laith on a charitable basis. Such immunily does not extend to willful acts or gross negligenbe.

Typed or Printed Nam6 of Patient Sigiialirre ot Palienl

--r-. , lr i , ,, ,irrrrriltft'"11'? tufl*"'Gu"'LiT /"fti'i"o'1f'-'noid . , ,' t' -fr' ' '

lnformatiqn telowto.be fil,ed out by physiclan onlyHeightOrthopaedic Exam

Spine / Neck.Ceruical

Lumbar

Uppei.ExtremityShoulder .

ElbowWristHand / Fingers

tower ExtremityHip '

KneeAnkle

Weight Blood Pressure

Generai Heallh Comrnents

Fhq's;c'g'n'Porho >

Pulsa. :, . General.Medical Exam

.Norm : Abnl Norm Abnt , ' . Norm Abnt

FLEXIBILTTY LEFt RIGHT

Comments

Iil.

NeckHipsHams

FLEXIBIIITYShoulder0uadsHeelcords

LEFT fIGHT

Feel

Other CommentsOFTIONAL EXAMSDENTAL123432 31 30Commeils

12 13 1423 22 21

ComrEntsivtsloN L-- f{_

15 '620 19

56783101129 28 27 26 2s 24 18 t7

I i From thls limited screerring I se no reason why this.student crnnot participale in ath,eticsI I St0dent needs ltirthar'ivaluatiori as described

-

M.D.Typed orPrinted Name oI Physician

MSMOC 62 Bry 3./03

pHysrcrAN - wHrrE scHool - cAN;i;;"lI"lf illffi,o*. ",roOO NOT FOLD FOFM

X W"nl"

c* furm

?pgd'd*"& ,

$rnpl o,\ Wr'r-

Mtsstsstppt H|GH scHool AcTtvtTtEs AssoctATtoN, tNc.Concussion lnformation Form

(Required by MHSAA Annuotly)

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or joltto the head, or by a blow to another part of the body with the force transmitted to the head. They canrange from mild to severe and can disrupt the way the brain normally works. Even though mostconcussions are mild, all concussions are potentiallv serious and mav result in complications inctudingprolonged brain damaee and death if not recognized and managed properlv. ln other words, even a"ding" or a bump on the head can be serious. You cannot see a concussion and most sports concussionsoccur without loss of consciousness. Signs and symptoms of concussion may show up right after theinjury or can take hours or days to fully appear- lf your child reports any symptoms of concussion, or ifyou notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:o Headachesr "Pressure in head"e Nausea orvomitingo Neck painr Balance problems or dizzinesso Blurred, double or fuzzy visiono Sensitivity to light or noise

Amnesia

"Don't feel right"Fatigue or low energySadness

Nervousness or anxietylrritabilityMore emotional

elrng s

r Feeling foggy or groggyo Drowsinessr Change in sleep patterns

Signs observed byteammates, parents and coaches include:o Appears dazed

Confusion

Concentration or memory problems(forgetting game plays)

Repeating the same question/comment

a

a

a

a

a

a

a

a

a

a

a

a

a

Vacant facial expressionConfused about assignmentForgets plays

ls unsure of game, score, or opponentMoves clumsily or displays incoordinationAnswers q uestio ns slowlySlurred speechShows behavior or personality changesCan't recall events prior to hitCan't recall events after hitSeizures or convulsionsAny change in typical behavior or personalityLoses consciousness

(Continued on next page)

What can happen if mv child keeps on plaving with a concussion or returns too soon?

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

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

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

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

concussion before completely recovering from the first one. This can lead to prolonged

recovery, or even to severe brain swelling (second impact syndrome) with devastating and even

fatal consequences. lt is well known that adolescent or teenage athletes will often fail to report

symptoms of injuries. Concussions are no different. As a resul! education of administrators,

coaches, parents and students is key to a student-athlete's safety-

MHSM Concussion Policv:r An athlete who reports or displays any symptoms or signs of a concussion in a practice

or game setting should be removed immediately from the practice or game. The athlete

should not be allowed to return to the practice or game for the rernainder of the day

regardless of whether the athlete appears or states that he/she is normal.

The athlete should be evaluated by a licensed, qualified medical professional working

within their scope of practice as soon as can be practically arranged-

lf an athlete has sustained a concussion, the athlete should be referred to a licensed

physician preferably one with experience in managing sports concussion injuries.

The athtete who has been diagnosed with a concussion should be returned to play only

after full recovery and clearance by a physician. Recovery from a concussion, regardless

of loss on consciousness, usually take 7-14 days after resolution of all symptoms.

Return to play after a concussion should be gradual and follow a progressive return to

competition. An athlete should flot return to a competitive game before demonstrating

that he/she has no symptoms in a full supervised practice-

Athletes should not continue to practice or return to play while still having symptoms of

a concussion. Sustaining an impact to the head while recovering from a concussion may

cause Second lmpact Syndro,me, a catastrophic neurological brain injury.

Remember, it is better to miss one game than to miss the whole season-

I have reviewed this information on concussions and am aurare that a release by a medical doctor is

required before a student may return to play under this poliry.

Student-Athlete Na me P rinted Student-Athlete Signature Date

Parent Name Printed Parent Signature Date