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10700 Oleander Avenue, Fontana 92337 | (909) 357-6300 ext. 16202 | fax: (909) 357-7546

ATHLETIC CLEARANCE PACKET

ATTENTION! This packet is to be turned into the Athletics Office Only. Your coaches and any office staff, outside of

the Athletics Office, are not responsible for these forms or your athletic clearance. You are not able to

practice or compete until you are completely cleared.

Below is the list of items needed to be eligible to participate in any sport activity here at Jurupa Hills.

Physical Form must be completed, signed, stamped and dated after May 1

st of the current school year,

by a physician. If not completed, student will not be eligible to participate. All physicals must be

submitted to Chanel Burrell or Cynthia Garcia only. This can be done by email, fax, uploaded

to your online account or by personally handing it in. All contact information is below. Coaches

do not accept any physicals! All physicals expire on the last day of school. *Per CIF Bylaw 503, all sports physicals must be completed by an MD or DO only. No PA, NP, or DC may clear an

athlete for participation.

CIF Acknowledgment Forms Please complete the required attached forms (pg. 10-11). Students will not be eligible to play

without both forms complete and on file in the athletics office.

Online Athletic Clearance Account An online account must be created and filled out and all waivers need to be electronically

signed at the following link. https://www.athleticclearance.com Instructions are on pg. 2.

Please make sure that you sign up for your school and your school year!

All items are required and must be completed for participation.

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Athletic Clearance Instructions Athletic Director: Kristen Braun

Athletic Trainer: Chanel Burrell | BurrCR@fusd.net Athletic Secretary: Cynthia D. Garcia | Garccd@fusd.net

All Jurupa Hills High School athletes must complete the online athletic clearance FOR EACH SPORT they are going to participate in during the 2019-2020 school year. They must also have a new physical on file dated 5/1/2019 or later. Be-low are the instructions for completing the online clearance. Did you complete the online athletic clearance in 18-19 school year? If so, you may use your same account for this school year. If you are new to online athletic clearance, please create a new account for your family.

1. Visit www.athleticclearance.com

2. Log in with your user name and password.

3. Select the “New Clearance” button (upper left corner) to get started.

4. Select Year, School and Sport.

5. Complete any required fields for student information, educational history, insurance, medical history, and consent.

6. Press “Submit” and print out your signature page.

1. Visit www.athleticclearance.com

2. Review the tutorial video for a quick reference instructional guide.

3. Click the “register” link to create an account. Provide a valid email address and password.

4. Once you create an account you will be asked to enter the code that appears.

5. Select the “New Clearance” button (upper left corner) to get started.

6. Select Year, School and Sport.

7. Complete any required fields for student information, educational history, insurance, medical history, and consent.

8. Press “Submit” and print out your signature page. Complete your clearance for multi-sport athletes at the same time! 1. If your student plays more than one sport click “New Clearance” and complete for each sport your student is interested

in playing for the school year.

2. Turn in the completed signature form (s) and a completed physical (or you can upload your physical directly to your

online account) to the athletic office to complete the process.

3. You will receive an email once your athlete has been cleared for each sport. Important: Keep for your records: Username: ______________________________ Password: _______________________________

RETURNING Athletic Clearance Families:

NEW Athletic Clearance Families:

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You are receiving this information sheet about prescription opioids because of Senate Bill 1109 (effective September 22, 2018 now Education Code § 49476: 1. There are several risks with taking prescription opioids. This bill requires the state to inform student athletes and

their families of those risks. 2. The bill also requires mandatory and continued education in order to be aware of those risks. I acknowledge that I have read and understand the provided document regarding prescription opioid information:

SENATE BILL 1109 (effective September 22, 2018), now Education Code § 49476:

STUDENT-ATHLETE SIGNATURE PRINT STUDENT-ATHLETE NAME DATE

PARENT/GUARDIAN SIGNATURE PRINT PARENT/GUARDIAN NAME DATE

You are receiving this information sheet about Heat Illness because of California state law AB 2500 (effective January 1, 2019), now Education Code § 49475: 1. The law requires a student athlete who has been removed from practice or play after displaying signs and symp-toms associated with heat illness must receive a written note from a licensed health care provider before returning to practice. 2. Before an athlete can start the season and begin practice in a sport, a Heat Illness information sheet must be signed and returned to the school by the athlete and the parent or guardian. Every 2 years all coaches are required to receive training about concussions (AB 1451), heat illness (AB 2500) as well as certification in First Aid training, CPR, and AEDs (life-saving electrical devices that can be used during CPR). I acknowledge that I have read and understand the CIF Heat Information Sheet:

CALIFORNIA STATE LAW AB 2500 (effective January 1, 2019), now Education Code § 49475:

STUDENT-ATHLETE SIGNATURE PRINT STUDENT-ATHLETE NAME DATE

PARENT/GUARDIAN SIGNATURE PRINT PARENT/GUARDIAN NAME DATE

On July 1, 2017, Assembly Bill 1639, known as the Eric Paredes Sudden Cardiac Arrest (SCA) Prevention Act went into effect. This requires the pupil and their parent or guardian to read, sign, and return an SCA form of acknowledgement before the pupil participates in any athletic activity. Districts may use this form, a form located on the California Interscholastic Association (CIF) website, or design their own form. An SCA acknowledgment form must be signed and returned to the school site each school year. I acknowledge that I have read and understand the symptoms and warning signs of SCA and the new protocol to incorporate SCA prevention strategies into my/my student’s sports program or activity:

CALIFORNIA STATE LAW AB 1639 (effective July 1, 2017), now Eric Paredes Sudden Cardiac Arrest:

STUDENT-ATHLETE SIGNATURE PRINT STUDENT-ATHLETE NAME DATE

PARENT/GUARDIAN SIGNATURE PRINT PARENT/GUARDIAN NAME DATE

CIF ACKNOWLEDGEMENT FORM Please Sign all three fields and return to the athletics office.

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You are receiving this information sheet about concussions because of California state law AB 25 (effective January 1, 2012), now Education Code § 49475: 1. The law requires a student athlete who may have a concussion during a practice or game to be removed from the activity for the remainder of the day. 2. Any athlete removed for this reason must receive a written note from a medical doctor trained in the management of concussion before returning to practice. 3. Before an athlete can start the season and begin practice in a sport, a concussion information sheet must be signed and returned to the school by the athlete and the parent or guardian. I acknowledge that I have received and read the CIF Concussion Information Sheet:

CALIFORNIA STATE LAW AB 25 (effective January 1, 2012), now Education Code § 49475:

STUDENT-ATHLETE SIGNATURE PRINT STUDENT-ATHLETE NAME DATE

PARENT/GUARDIAN SIGNATURE PRINT PARENT/GUARDIAN NAME DATE

CIF CONCUSSION ACKNOWLEDGEMENT AND SYMPTOM CHECKLIST

Please Sign ALL fields and return to the athletics office.

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JURUPA HILLS HIGH SCHOOL – ATHLETICS 10070 Oleander Avenue Fontana, CA 92337 | (909) 357-6300 ext 16202 | fax: (909) 357-7546

PHYSICAL EVALUATION FORM (To be completed by a Medical Doctor (MD), Osteopathic Doctor (DO), or Physician’s Assistant (PA-C)).

Name: ____________________________________________________ Date of Birth: ________________ Age: ____

Sex: ________ Height: ____________ Weight: ____________ Pulse: ___________ BP: _______/_______

Vision: R_______/20 L_______/20 | Corrected with glasses or contacts: Y N | Anisocoria: Y N

a. Do you feel stressed out or that you are under a lot of pressure? b. Do you ever feel very sad or hopeless? Do these feelings cause you to stop doing activities that you enjoy? c. Do you feel safe, whether at home or at school?

d. Have you ever tried smoking or do you currently smoke? e. Have you recently tried alcohol, even if it was just one drink? f. Have you ever taken steroids, pills or shots, without a prescription from your doctor?

2. Physician: Please consider reviewing questions on cardiovascular symptoms or conduct extra cardiovascular screening.

1. Physician: Please ask these follow-up questions on issues that are more sensitive:

Medical Normal Musculoskeletal Normal Explain Abnormal Findings

General Appearance Neck

Skin Back

Eyes/Ears/Nose/Throat Shoulder/Upper Arms

Hearing Elbow/Forearms

Lymph Nodes Wrist/Hand/Fingers

Heart Hip/Buttock/Pelvis

Pulses Thigh

Lungs Knee

Abdomen Lower Leg

Genitourinary (Males Only) Ankle

Neurologic Function Foot/Toes

Student athlete is cleared to participate in interscholastic sports without restriction

Student athlete is cleared for sports without restriction, with recommendations for

further evaluation or treatment for:

Student athlete is not cleared: (Reason)

Name of Physician: Date:

REQUIRED

MD OFFICE STAMP

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General Yes No

Has a doctor ever denied or restricted you from participating in sports?

Do you have an ongoing medical condition? If so, please specify below.

Have you ever had surgery?

Have you ever passed out during or after an exercise?

Have you ever had shortness of breath, pain or tightness in your chest during exercise?

Does your heart skip beats or flutter during exercise?

Has your doctor ever told you that you have any heart problems? (E.g. high blood pressure, cholesterol, murmur, etc.)

Have you ever had a test such as an ECG/EKG for your heart?

Have you ever had an explained seizure or a seizure disorder?

Has a family member died of heart problems, or has had an unexpected sudden death before age 50?

Does anyone in your family have a heart condition, pacemaker or defibrillator?

Have you ever had any broken bones, dislocated joints or had a stress fracture?

Have you had injuries that have required an x-ray, MRI, CT scan, injection, a brace, cast, or crutches?

Have you had an injury to a ligament, muscle or tendon that caused you to miss a practice/game?

Do any of your joints become painful, swollen, feel warm, look red, or become difficult to bend?

Do you have a history of connective tissue disease or juvenile arthritis?

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

Is there anyone in your family that has asthma?

Were you born without or are you missing a kidney, testicle, spleen or other organ?

Do you have or have you had groin pain or a painful bulge in the groin or area?

Do you have rashes, skin irritations, sores or have had a staph infection or MRSA?

Have you ever been diagnosed with a head injury or concussion?

Have you had a hit to the head or body that has caused confusion, headaches, and memory or concentration problems?

Have you ever had numbness, tingling, or weakness in your arms/legs after being hit or falling?

Have you ever become ill or have gotten muscle cramps while exercising in the heat?

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

Do you have any problems with your eyes or vision or wear glasses or contact lenses?

Do you worry about your weight, whether with gaining or losing?

Are you on a special diet or do you avoid certain foods?

Have you ever had an eating disorder?

Do you have any questions/concerns that you would like to discuss with the doctor?

Have you had a menstrual period?

Do you feel that your periods are regular (about once a month)?

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

Please list all medications and/or supplements that you are currently taking:

Do you have allergies? ____ If yes, please specify: Medicines Seasonal/Pollens Foods Animals Stinging Insects

Other:

Name: _________________________________ Date of Birth: ___________ Age: ____ Sex: ___ Grade: _____

HISTORY FORM

(To be completed by both parent/guardian and student prior to receiving the physical examination).