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CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT TRYOUT PACKET 2019-2020 NAME: S#: SPORT: PLEASE NOTE: 1. This packet must be completed in ink and turned into the Athletics Department for approval by a staff member before the Student- Athlete may try out for a varsity team. 2. The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1

CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT …The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1. ... NJCAA

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Page 1: CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT …The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1. ... NJCAA

CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT

TRYOUT PACKET 2019-2020

NAME:

S#:

SPORT:

PLEASE NOTE:

1. This packet must be completed in ink and turned into the AthleticsDepartment for approval by a staff member before the Student-Athlete may try out for a varsity team.

2. The enclosed Varsity Sports Examination Form is the only physicalexamination form accepted by the Athletic Department.

1

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Index

Cuyahoga Community College Athletics Required Forms

Student-Athlete Agreement 3

Agreement for the Use of Name and Likeness 4

Student-Athlete Policies and Procedures 5

Student-Athlete Academic Progress Report Procedures 7

NJCAA & OCCAC Required Forms

Code of Conduct 13

NJCAA Amateurism Questionnaire 15

NJCAA Eligibility Affidavit 17

Required Physical Examination Forms

Student-Athlete Contact Information Summary 21

Student-Athlete Insurance Information 22

Medical Release and Authorization 23

Physical Examination Form 25

History Form 26

Clearance Form 27

Supplemental History Form 28

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ATHLETICS DEPARTMENT

STUDENT-ATHLETE AGREEMENT

STUDENT NAME: _________________________ S#:______________________

I am aware that playing or practicing in any sport can be a dangerous activity involving MANY RISKS OR INJURY. I understand that the dangers and risks of playing or participating in the below sport include, but are not limited to, DEATH, SERIOUS NECK AND SPINAL INJURIES WHICH MAY RESULT IN COMPLETE OR PARTIAL PARALYSIS OR BRAINDAMAGE, SERIOUS INJURY TO VIRTUALLY ALL BONES, JOINTS, LIGAMENTS, MUSCLES, TENDONS, AND ORTHER ASPECTS OF THE MUSCULAR-SKELITAL SYSTEM AND SERIOUS INJURY OR IMPAIRMENT TO OTHER ASPECTS OF MY BODY, GENERAL HEALTH AND WELL BEING.

Because of the dangers of participating in the below sport, I recognize the importance of following the coach’s instructions regarding playing techniques, training, rules of the sport, other team rules, and to obey such instructions.

Inconsideration of Cuyahoga Community College (Tri-C) permitting me to practice, play or tryout for Tri-C’s _________________ (indicate intercollegiate sport) team, and to engage in all activities related to the team, including practicing, playing, and travel. I hereby voluntarily assume any and all risks associated with participation and agree to exonerate and save harmless Tri-C, their agents, servants and employees, the athletic staff of Tri-C the physicians and other practitioners of the healing are treating me, from and all liability, claims, causes of action or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the Tri-C _________________ (indicate intercollegiate sport) team.

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.

I hereby agree to submit any disputes that may arise between myself and Tri-C, its agents, servants and employees, the athletic staff of Tri-C, the physicians and other practitioners of the healing arts treating me, and all their agents, trustees, servants and employees, in connection with my activities at Tri-C, to binding arbitration before three arbitrators, in accordance with the Rules of the American Arbitration Association.

________________________________________________ _______________

Student-Athlete Signature Date

________________________________________________ _______________

Parent/Guardian Signature (if under 18) Date

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ATHLETICS DEPARTMENT

AGREEMENT FOR THE USE OF NAME AND LIKENESS

Grantor Name (print): _________________________________________________

Email address: _____________________ Phone number: __________________

THIS IS A RELEASE OF YOUR RIGHTS. READ CAREFULLY BEFORE SIGNING.

For good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I grant irrevocable permission to Cuyahoga Community College District (the “College”) and its trustees, officers, students, vendors, consultants, agents and employees (collectively, the “affiliates”) to use my name, photograph, video, likeness, voice, statements associated with event(s) in any and all manner and media throughout the world, in perpetuity. I waive any right that I may have to inspect or approve any such use.

I agree that the materials may be edited, adapted, expanded, revised, or modified at the sole discretion of the College and its affiliates. I consent to use of the materials in connection with publicity, advertising, promotion, publication and any other purposes. I understand that the College and its affiliates may use the materials in any media or format it chooses, whether or not for profit, including without limitation television, radio, print, promotional materials and internet.

I warrant and represent that this agreement does not in any way conflict with any existing commitment on my part. I agree that the College is not under any obligation to exercise any of the rights, licenses and privileges herein granted.

I agree that no aspect of this agreement or participation in the event(s) makes me an employee of the College.

I agree to release, waive, forever discharge, and covenant not to sue the College and its affiliates from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that I may have or that hereafter accrue to me, arising out of or relating to my participation in the event(s), the College’s or any affiliate’s exercise of rights granted by this agreement, including without limitation, claims for compensation, defamation, infringement, and invasion of privacy. In addition, I hereby hold harmless and indemnify the College and its affiliates from any and all liability, claims, actions, suits, losses and costs or related causes of action for damages arising out of or relating to my participation in the event(s), the College’s or any affiliate’s exercise of rights granted by this agreement, including without limitation, claims for compensation, defamation, infringement and invasion of privacy. I also understand that this agreement binds my heirs, executors, administrators, and assigns, as well as me.

AGREED AND ACCEPTED:

Grantor Signature: ___________________________________ Date: ___________

Parent/Guardian Signature: ____________________________ Date: ___________ (If grantor is under 18)

Parent/Guardian Name (print): ___________________________________________

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ATHLETICS DEPARTMENT

STUDENT-ATHLETE POLICIES AND PROCEDURES It is important that we establish the best possible understanding between student-athletes and coaches about their respective goals, responsibilities, commitments, procedures, and policies.

It is equally important to understand the discipline that it will take in areas of academics, athletics, and your social life to earn the respect and success we want you to achieve.

I. The student-athlete’s primary goals at Cuyahoga Community College (Tri-C) are:a. To make progress towards graduation and an Associate Degreeb. To contribute to a championship teamc. To reach your full potential as a teamd. To reach your full potential, academically and athletically, as an individual

II. Disciplinary action will be taken when a student-athlete does not meet the expectations andresponsibilities outlined here.

a. The penalty procedure is as follows: The penalty assigned will be determined by the head coachbased on the seriousness and type of violation and the individual involved. If the penalty is of asevere nature, the Athletic Director and/or Dean of Student Affairs may impose furtherdisciplinary action.

b. Types of penalties:i. Physical exercise

ii. Suspensioniii. Termination

III. Individual Expectations and Responsibilitiesa. You will abide by the Cuyahoga Community College, the Ohio Community College Athletic

Conference and the National Junior College Athletic Association’s Codes of Conduct.b. You will not vocalize, comment, or gesture in any way to opponents, fans, or umpires.c. You will not use vulgar and/or abusive language.d. You will show respect to our equipment. The proper use, storage of, and care of equipment and

supplies will be the responsibility of players and coaches.e. You are responsible for all equipment and uniforms issued to you. You will be charged for the

full replacement cost for any equipment or uniform that is lost, damaged, or stolen.f. Theft or horseplay involving any team or teammate’s personal items or equipment will not be

tolerated.g. You will report any injury/illness to the coach or trainer immediately. You will go to the trainer

before or after but not during practice. You are encouraged to meet with the trainer often.h. You will keep the good of the team in mind at all times. You will be unselfish. Your positive

attitude means more than your ability to the growth of the team.i. You will handle your responsibilities and assignments, no matter how small they may seem,

with pride and 100% effort.j. Your membership on this team is a privilege, not a right. Privileges can be revoked; rights may

not. Improper representation of the team or college, through a social media outlet such asFacebook, Twitter, Instagram, Snapchat, etc. may be a violation and result in disciplinarysanctions.

k. You will be positive and respectful when talking about your team, your teammates, yourcoaches, and your school.

l. You will respect all orders from college employees, including administrators, instructors, staff,other coaches, et al.

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m. A 2.0 cumulative GPA from fall semester is required to qualify for an athletic scholarship forspring semester.

IV. Off the Fielda. You will be in good standing academically and athletically eligible at all times.b. You will complete all Student-Athlete Academic Progress Reports by the deadlines specified.c. You will show respect to administrators, instructors, staff, and fellow students at all times.d. You will be on time and attend every class. You will notify your teachers in advance if you need

to miss class for a game.e. If your need to miss practices for academic purposes, you will discuss it with your coach in

advance. Every effort should be made to handle these situations on your own time.f. You will remember hat, as a student-athlete, you are highly visible and you will conduct yourself

so as to earn respect from others at all times. This is important, not only for our program, butfor you as an individual as well.

V. Team Travela. You will be early or on time to the bus or you will be left behind.b. You will travel to and from the games with the team.c. You will dress appropriately. You will look clean, neat, and well groomed.d. You will not be loud on the bus. You will respect those around you and their need to study.e. You will conduct yourself in a dignified fashion at the hotels.f. You will remember the first reason we travel is to compete not socialize. We encourage you to

have fun but not detract from the primary purpose you are traveling.g. No alcoholic beverages or prohibited drugs are permitted on any team trip.h. Curfews will be strictly enforced.

The College premises shall be tobacco-free, thus supporting a healthy environment for all who are on the grounds of any College locations. This policy applies to all individuals, including but not limited to employees, students and visitors who may be located inside or outside of any buildings, residences or parking lots on the grounds of any of our College locations. Tobacco is defined as all products derived from, or containing tobacco, including and not limited to those listed below.

• Cigarettes (e.g. cloves, bidis, kreteks)• Cigars and cigarillos• Hookah smoked products• Pipes and oral tobacco (e.g. spit and spitless, smokeless, chew, snuff)• Nasal tobacco• Electronic cigarettes and vapes or any other product intended to mimic tobacco products and/or deliver

nicotine other than for the purpose of cessation, or that contains tobacco flavoring

It is the responsibility of all students, faculty, staff and visitors to observe, adhere to and respect the College’s Tobacco Free policy. Students, faculty and staff are encouraged and empowered to respectfully inform others about the policy in an ongoing effort to support the College’s goal of becoming tobacco-free and improving individual health and well-being.

I have read, understand and will follow the Student Athlete Policies and Procedures outlined in this document.

_______________________________________________ _______________ Printed Name (Student-Athlete) S#

_______________________________________________ _______________ Signature (Student-Athlete) Date

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ATHLETICS DEPARTMENT

STUDENT-ATHLETE ACADEMIC PROGRESS REPORT PROCEDURE

I. All student-athletes are required to submit a Student-Athlete Academic Progress Report* to the AthleticDepartment from each of their respective credit course instructors by the specified due dates (see“Student-Athlete Academic Calendar” – available in the Athletic Office) following the 5th and 11th weeksof the Fall and Spring semesters. Student-Athlete Academic Progress Report forms will be provided bythe Athletic Department.

*For online courses only, student-athletes should print their grades from Blackboard. If the cumulativegrade in the online course is not decisively a ‘C’ or better, including if no grades are posted, student-athletes are required to submit an email from their instructor stating their grade/progress in the course.

II. For in-season student-athletes on the official NJCAA/Cuyahoga Community College rostera. All student-athletes who submit Student-Athlete Academic Progress Reports from each of their

respective credit course instructors with a ‘C’ or better by the specified due dates (see “Student-Athlete Academic Calendar” – available in the Athletic Office) are eligible to participate in allpractices and game.

b. Failure to submit a Student-Athlete Academic Progress Report from each of their respectivecredit course instructors by the specified due dates (see “Student-Athlete Academic Calendar”– available in the Athletic Office) will result in the student-athlete missing any scheduledgame(s) until the form is submitted and may result in the loss of athletic scholarship funds (ifapplicable).

c. Any student-athlete who submits a Student-Athlete Academic Progress Report at the 5th weekof the semester with a grade below a ‘C’ will be required to attend tutoring in that subject areauntil the grade is a ‘C’ or better. The student-athlete will also be required to submit a Student-Athlete Tutoring Form every Thursday by 4:00 pm to the athletic department. Failure to submitthe weekly tutoring form will result in the student-athlete being required to attend a mandatorymeeting with the Athletic Director.

d. Any student-athlete who receives a grade below a ‘C’ at the 5th week of the semester and receivesa grade below ‘C’ at the 11th week of the semester in the same course will result in the student-athlete missing the first scheduled game following the specified due date. The student-athletewill also be required to attend tutoring until the grade is a ‘C’ or better and submit a Student-Athlete Tutoring Form every Thursday by 4:00 pm to the athletic department. Failure to submitthe weekly tutoring form will result in the student-athlete being required to attend a mandatorymeeting with the Athletic Director and may result in the loss of athletic scholarship funds (ifapplicable).

III. For 1st year out-of-season student-athletesa. All student-athletes who submit Student-Athlete Academic Progress Reports from each of their

respective credit course instructors with a ‘C’ or better by the specified due dates (see “Student-Athlete Academic Calendar” – available in the Athletic Office) are eligible to participate in allpractices.

b. Failure to submit a Student-Athlete Academic Progress Report from each of their respectivecredit course instructors by the specified 5th or 11th week due date (see “Student-AthleteAcademic Calendar” – available in the Athletic Office) will result in the student-athlete missingthe first scheduled game of the upcoming season and may result in the loss of athleticscholarship funds (if applicable). Failure to submit a Student-Athlete Academic Progress Report

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from each of their respective credit course instructors by both the specified 5th and 11th week due dates (see “Student-Athlete Academic Calendar” – available in the Athletic Office) will result in the student-athlete missing the first three scheduled games of the upcoming season and may result in the loss of athletic scholarship funds (if applicable).

c. Any student-athlete who submits a Student-Athlete Academic Progress Report at the 5th weekof the semester with a grade below a ‘C’ will be required to attend tutoring in that subject areauntil the grade is a ‘C’ or better. The student-athlete will also be required to submit a Student-Athlete Tutoring every Thursday by 4:00 pm to the Athletic Department. Failure to submit theweekly tutoring form will result in the student-athlete being required to attend a mandatorymeeting with the Athletic Director.

d. Any student-athlete who received a grade below a ‘C’ at the 5th week of the semester and receivesa grade below ‘C’ at the 11th week of the semester will result in the student-athlete missing thefirst scheduled game of the upcoming season. In the instance that the student-athlete did notmeet an earlier specified due date, the student-athlete will miss and additional game. Thestudent-athlete will also be required to attend tutoring until the grade is a ‘C’ or better andsubmit a Student-Athlete Tutoring Form every Thursday by 4:00 pm to the athletic department. Failure to submit the weekly tutoring form will result in the student-athlete being required toattend a mandatory meeting with the Athletic Director and may result in the loss of athleticscholarship funds (if applicable).

IV. For 2nd year out-of-season Spring student-athletesa. All student-athletes who submit Student-Athlete Academic Progress Reports from each of their

respective credit course instructors with a ‘C’ or better by the specified due dates (see “Student-Athlete Academic Calendar” – available in the Athletic Office) are eligible to participate in allpractices.

b. Failure to submit a Student-Athlete Academic Progress Report from each of their respectivecredit course instructors by the specified 5th or 11th week due date (see “Student-AthleteAcademic Calendar” – available in the Athletic Office) will result in the student-athletemissing the first scheduled game of the upcoming season and may result in the loss of athleticscholarship funds (if applicable). Failure to submit a Student-Athlete Academic ProgressReport from each of their respective credit course instructors by both the specified 5th and11th week due dates (see “Student-Athlete Academic Calendar” – available in the AthleticOffice) will result in the student-athlete missing the first three scheduled games of theupcoming season and may result in the loss of athletic scholarship funds (if applicable).

c. Any student-athlete who submits a Student-Athlete Academic Progress Report at the 5th weekof the semester with a grade below a ‘C’ will be required to attend tutoring in that subject areauntil the grade is a ‘C’ or better. The student-athlete will also be required to submit a Student-Athlete Tutoring Form evert Thursday by 4:00 pm to the Athletic Department. Failure to submit the weekly tutoring form will result in the student-athlete being required to attend a mandatorymeeting with the Athletic Director.

d. Any student-athlete who receives a grade below a ‘C’ at the 5th week and receives a grade belowa ‘C’ at the 11th week in the same course will result in the student-athlete missing the firstscheduled game of the upcoming season and may result in the loss of athletic scholarship (ifapplicable). In the instance that the student-athlete did not meet an earlier specified due date,the student-athlete will miss an additional game. The student-athlete will also be required toattend tutoring until the grade is a ‘C’ or better and submit a Student-Athlete Tutoring Formevery Thursday by 4:00 pm to the athletic department. Failure to submit the weekly tutoringform will result in the student-athlete being required to attend a mandatory meeting with theAthletic Director.

V. For 2nd year out of season Fall student-athletes

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a. Failure to submit a Student-Athlete Academic Progress Report from each of their respectivecredit course instructors by the specified due dates (see “Student-Athlete Academic Calendar”– available in the Athletic Office) will result in the student-athlete being required to attend amandatory meeting with the Athletic Director and may result in the loss of athletic scholarshipfunds (if applicable).

b. Any student-athlete who submits a Student-Athlete Academic Progress Report at the 5th weekof the semester with a grade below a ‘C’ will be required to attend tutoring in that subject areauntil the grade is a ‘C’ or better. The student-athlete will also be required to submit a Student-Athlete Tutoring Form every Thursday by 4:00 pm to the Athletic Department. Failure tosubmit the weekly tutoring form will result in the student-athlete being required to attend amandatory meeting with the Athletic Director.

c. Any student-athlete who receives a grade below a ‘C’ at the 5th week and receives a grade below‘C’ at the 11th week in the same course will result in the student-athlete being required to attenda mandatory meeting with the Athletic Director and may result in the loss of athletic scholarship funds (if applicable). The student-athlete will also be required to attend tutoring until the gradeis a ‘C’ or better and submit a Student-Athlete Tutoring Form every Thursday by 4:00 pm to theathletic department. Failure to submit the weekly tutoring form will result in the student-athletebeing required to attend an additional mandatory meeting with the Athletic Director.

VI. Student-Athlete Academic Progress Reports and Student-Athlete Tutoring Forms will be randomlyaudited. Any student-athlete found forging or altering their form(s) will be disciplined through the Deanof Student Affairs office following the College’s Student Conduct policy.

VII. Failure to adhere to the Student-Athlete Academic Progress Report Procedure as detailed above mayresult in the loss of your athletic scholarship funds (if applicable) and a balance due on your Collegeaccount.

I have read the above Student-Athlete Academic Progress Report Procedure and agree to abide by it as long as I am a student-athlete at Cuyahoga Community College.

_______________________________________________ _______________ Printed Name (Student-Athlete) S#

_______________________________________________ _______________ Signature (Student-Athlete) Date

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NJCAA & OCCAC Required Forms

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ARTICLE XX

CODE OF CONDUCT FOR ALL NATIONAL EVENTS, CONTESTS AND TOURNAMENTS

SPONSORED BY THE NATIONAL JUNIOR COLLEGE ATHLETIC ASSOCIATION

This code of conduct applies to all region, district and national events, contests and tournaments sponsored by the National Junior College Athletic Association. Violations of the code of conduct occurring during the regularly scheduled season events shall be referred to the respective conference or region Standards and Ethics Committee. The jurisdiction of the NJCAA Code of Conduct ends when colleges competing in such tournaments arrive back on their respective campuses.

Code of Conduct A. Participants shall recognize the responsibility for proper conduct at any national tournament, event or contest sponsored by the NJCAA or its

member colleges.B. Coaches shall recognize and assume responsibility for the actions of themselves and the team members. Each coach who has participants

competing in the event shall be responsible for informing each participant about the Code of Conduct.

Behavior Coaches, players and institutional personnel must remember that they are representatives of an institution of higher learning, its faculty, administration and student body. As such, they are expected to conduct themselves in a manner which would reflect credit on their team, institution, region and the NJCAA. Student-athletes, coaches and institutional personnel who are participating in NJCAA events are subject to all NJCAA rules, regulations and penalties as stated in the NJCAA Handbook as well as local, state and federal laws.

Inappropriate and unacceptable behavior by coaches, players or institutional personnel will not be tolerated before, during, or after contests; at the hotel or in public while representing their college. This Code of Conduct does not replace Article XVIII of the NJCAA Handbook. Unacceptable forms of behavior include, but are not limited to:

1. Fighting2. Taunting3. Inappropriate celebration4. Disrespectful attitude toward opponents, officials, tournament administrators5. Use of profane and vulgar language6. Use of tobacco, drugs and/or alcohol7. Disrespectful attitude toward host hotel personnel8. Unlawful activities

Derogatory Comments Coaches, athletes or institutional personnel shall not make derogatory public comments regarding administration of a tournament or officiating of contests during post game interviews or at other times; to print or broadcast media, in news releases or institutionally produced news releases or under any conditions when their comments may become public. The head coach shall be fully responsible for assuring that no public comments are made by the coaching staff, student-athletes or institutional personnel about officiating, fighting or other incidents which occur during contests.

A coach shall not address or permit anyone in the team area to address uncomplimentary remarks to any game official during the progress of a contest or engage in conduct which might incite student-athletes or spectators against officials.

Reporting Violations of the Code of Conduct may be reported to the Executive Director of the NJCAA or his/her designee.

Procedures and Penalties Immediate Action Where immediate action is needed to alleviate or control a situation, the Executive Director or his/her designee shall have the authority to act at his/her sole discretion. Examples of events which would require immediate action include, but are not limited to, the following:

Allegation of serious misconduct requiring immediate suspension of institutional personnel or student-athletes from competition.

Instances where the Executive Director or his/her designee deems it necessary to protect the equity and integrity of the competition.

Protection of the event’s officiating program, particularly in an instance where public comments by an institutional representative mayaffect competition.

Any instance or circumstance which might affect the safety of officials, participants or spectators attending the event.

Penalties-Immediate Action The Executive Director or his/her designee may issue any penalty that he/she believes appropriate to any student-athlete or institutional personnel who has violated the regulations pertaining to conduct when the Executive Director or his/her designee concludes that immediate action is required. The actions of the Executive Director or his/her designee shall be final and binding but shall be reported to the Standards and Ethics Committee within one (1) week.

Timely Action In cases where immediate action is not required but where sanctions are warranted, the Executive Director or his/her designee may issue the following penalties:

Reprimand: The NJCAA Executive Director or NJCAA Standards and Ethics Committee may issue a letter of reprimand to the coach, player or institutional personnel who violates the regulations pertaining to conduct. Copies of the letter of reprimand will be sent to the Director of Athletics and the President of the institution.

Probation, suspension and other penalties: If the misconduct is serious enough, the Executive Director or his/her designee may issue other penalties which may include, but are not limited to, probation, suspension or disqualification of the coach, player or institutional personnel from participating in one or more contests.

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ATHLETICS DEPARTMENT

CODE OF CONDUCT The college’s goal is excellence in education and scholarly pursuit. As student-athletes, you are not above the rules and regulations of Cuyahoga Community College. You are expected to follow all policies implemented by the College with no exception.

All student-athletes are representatives of the athletic department. Actions taken by you not only affect you, but they also affect the other athletes, coaches, and athletic department personnel.

The Student Conduct and Academic Code can be found at the end of the Student Handbook provided by the College along with other policies that have been adopted by the College. It is your responsibility to know this Conduct Code, as well as the Ohio Community College Athletic Conference Code of Conduct (see below) and National Junior College Athletic Association Code of Conduct (see below).

OCCAC CODE OF CONDUCT

The Ohio Community College Athletic Conference and Cuyahoga Community College encourage and promote sportsmanship by all participants. Sportsmanship is a team effort involving student-athletes, coaches, spectators, and officials.

In the spirit of fair play, you are expected to use language and behavior that shows respect for the participants and officials of this event.

Violations of this standard of conduct will result in team penalties and possible removal from the area (gym, field, court).

OCCAC PLEDGE OF SPORTSMANSHIP

As an athlete representing Cuyahoga Community College, I understand I am expected to adhere to the principles of sportsmanship and fair play. The officials, participants, coaches, fans, and college personnel should be treated with respect.

The following conduct is contrary to the spirit of fair play and will play and will not be tolerated: vulgar or profane language, trash talking, baiting, demeaning celebrations, racial or ethnic comments, the use of unwarranted physical contact, or other intimidating actions directed at anyone.

I understand if I violate this rule of conduct, I will be penalized in the contest and may be ejected from the game.

_______________________________________________ _______________ Signature (Student-Athlete) Date

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NJCAA AMATEURISM QUESTIONNAIRE

Name: _______________________________________________________________________________ (First, Middle, Last)

Sport(s): _________________________________

College Name: _______________________________________ Date of Birth: ________________ Age: _______

Please be advised that this is a questionnaire used in the recruiting process in order to help the institution determine your eligibility under NJCAA eligibility rules. Please be honest with your answers.

All Educational Background (high school, college, etc.):

Year(s) Name of Country Tuition Paid by Graduation Where did School (e.g., parents, coach, Date you live?

team, government)

All Athletics Participation:

Team Team Contact League Dates of Number of List Expenses Name Information Affiliation Participation Contests

Played Received

Additional Questions:1. Did you participate with any teams after your 19th birthday or full-time enrollment in college? Yes ___No __

If Yes, please explain what team you participated and the years of participation. _______________________________

______________________________________________________________________________________________

2. Did you receive any money above expenses for your participation on any of the teams mentioned? Yes ___No __If Yes, please explain what you received and which team(s) provided the payments.____________________________

______________________________________________________________________________________________

3. Did any members of your team receive money above expenses for their participation on any of the teams on which youparticipated (e.g., salary, bonus)? Yes ____ No ____ I don’t know ____If yes, please indicate which team provided the payments above expenses to your teammates. ___________________

______________________________________________________________________________________________

4. Did you sign any type of agreement to participate on any of the teams mentioned above? Yes ____ No ____If yes, please indicate for which team and please provide a copy of the agreement. ____________________________

______________________________________________________________________________________________

Please continue on to the next page. (Page 2 - NJCAA Amateurism Questionnaire Continued)

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5. Did any of the teams you participated on call themselves professional? Yes ____ No ____ I don’t know ____

If yes, which team(s)? _____________________________________________________________________________

6. Did you have a written or verbal agreement with an agent or agency to represent you while you were participating inathletics? Yes ____ No ____

7. Have you or any of your family ever accepted any benefits from an agent or anyone associated with an agent?Yes ____ No ____ I don’t know ____

8. Have you ever accepted any benefits not listed on this form from anyone other than your parents? Yes ____ No ____

9. Have you ever been involved in an advertisement or promotion? Yes ____ No ____ I don’t know ____

If yes, please describe: ____________________________________________________________________________

10. Have you ever accepted any prize money based on your place finish for your participation in athletics?Yes ____ No ____ If yes, please complete the information below:

Name of Team Date of Name/Type Prize Money Expenses Competition of Competition Received

Recruiting:

1. How did you learn about this institution? _______________________________________________________________

______________________________________________________________________________________________

2. Who contacted you (e.g., by email, letters, telephone calls, in-person visits, etc.) and encouraged you to attend this

institution? ______________________________________________________________________________________

3. Please list all official visits taken.

______________________________________________________________________________________________

______________________________________________________________________________________________

4. Did you or someone on your behalf ever utilize a recruiting service or another individual to assist you in finding thisinstitution or to assist you in obtaining an athletics scholarship? Yes ____ No ____ I don’t know ____ If yes, who assisted you? Please explain.

______________________________________________________________________________________________

______________________________________________________________________________________________

I understand that information falsified or omitted can make me ineligible for ALL future college competition in compliance with the National Junior College Athletic Association Eligibility Rules.

Student-Athlete Signature: ______________________________________________ Date: ______________________

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NJCAA Eligibility Affidavit

SPORT: ______________________ Date: _____________

Fill in all applicable information on this form to assist in determining eligibility for the NJCAA.

Personal Information: Name: ________________________________ Birth Date: __/__/____ ID Number : ________________

(First, Middle, Last)

Student’s College Address: ____________________________ ________________________________ Street Address City, State, Zip Code

Phone Number(s) at College: ________________________________ Email Address: _______________________

Other Information: Parent’s Home Address: ___________________________ __________________________________

Street Address City, State, Zip Code

Phone Number: ________________________________ Parents’ Names: ________________________________

Foreign Born Students:

Do you have an I-20 Form on file at this college? Yes _____ No _____

High School Information: Name of High School(s) you have attended: _________________________________________________

City, State & Country: ________________________________________________________________

Did you graduate?: Yes* _____ No _____ High School Graduation Date (month/date/year): __/___/____

Were you home schooled? Yes _____ No _____ Did you graduate? Yes* _____ No _____

Check here if you have earned a *GED or state department of education approved high school equivalency test Yes_____ No_____ If yes, enter the date earned (month/date/year): __/___/____ * Enclose a COPY of your High School Transcript, and GED Certificate or state department of education approvedhigh school equivalency test (if applicable).

Additional Information: 1. Did you take any college credit classes while in high school? Yes* _____ No _____

* If yes, from what college(s)? _________________________________________________________* If yes, those transcript(s) from each college must be on file at this college.

2. Have you ever signed a Letter of Intent form with any institution? Yes _____ No _____

If yes, specify the College: __________________________________ Date (day/month/year): ____/____/______

3. Have you ever participated in a sport in a country other than the United States? Yes _____ No _____

Sport(s)? _______________________ Country: ________________________ Dates: ___________________

If yes, describe the situation: ______________________________________________________________________

______________________________________________________________________________

4. Have you ever been red-shirted for a season? Yes _____ No _____If yes, list the dates of that season, name of college, and describe the situation. ________________________

______________________________________________________________________________

______________________________________________________________________________

(Page 2 - NJCAA Eligibility Affidavit Continued) 17

Page 18: CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT …The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1. ... NJCAA

5. Have you ever participated in practices, scrimmages, and/or games for an intercollegiate team other than thiscollege? Yes _____ No _____ If yes, name the school, date, sport, and describe the situation. _____________

______________________________________________________________________________

______________________________________________________________________________

6. Have you ever played on a club team at a college or university? Yes _____ No _____ If yes, name the school,sport and dates. _______________________________________________________________

______________________________________________________________________________

7. Do you currently play on any other sport teams (i.e. USAV, city recreational leagues, indoor soccer, AAU, etc.)Yes _____ No _____. If yes, please provide the name of team, location, and dates of participation.______________________________________________________________________________

8. Have you ever received money beyond expenses for participating in any athletic event? Yes _____ No _____

Did anyone on your team receive money beyond expenses for participating in any athletic event? Yes ____ No ____If yes, describe the situation below and the NJCAA Amateurism Questionnaire should be completed and includedwith the eligibility file. _______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

List ALL Colleges Attended Full-Time and/or Part-Time after High School All transcripts from all previous institutions must be included.

College: ________________________ Dates: _____________________ Full-time or Part-time? (circle one)

College: ________________________ Dates: _____________________ Full-time or Part-time? (circle one)

College: ________________________ Dates: _____________________ Full-time or Part-time? (circle one)

College: ________________________ Dates: _____________________ Full-time or Part-time? (circle one)

Additional Explanations: NOTE: If you attended college part-time or were not attending college for any period of time following high school graduation, please document your employment and military history during those times in the space below. If you were unemployed at any time, please list those dates below. The NJCAA requires that you account for any time not enrolled full-time. Please use the space below. Please record months and years when referring to dates. _______________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

I understand that information falsified or omitted can make me ineligible for ALL future college competition in compliance with the National Junior College Athletic Association Eligibility Rules.

Student-Athlete Signature: ______________________________________________ Date: ______________________

Coach Signature: _____________________________________________________ Date: ______________________

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Required Physical Examination

Forms

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ATHLETICS DEPARTMENT

STUDENT-ATHLETE INFORMATION SUMMARY

STUDENT NAME:__________________________ S#:______________________ (Full Legal Name)

DATE OF BIRTH:__________________________ (dd/mm/yyyy)

ADDRESS:_________________________________________________________ (Street, City, State, Zip)

TRI-C EMAIL:_________________________ PHONE #:_________________

PARENT/GUARDIAN INFORMATION SUMMARY

PARENT/GUARDIAN NAME: __________________________________________

PARENT/GUARDIAN PHONE #: _______________________________________

PARENT/GUARDIAN EMAIL: _________________________________________

EMERGENCY CONTACT NAME: _______________________________________

EMERGENCY CONTACT PHONE #: _____________________________________

FEMALE MALE

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Page 22: CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT …The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1. ... NJCAA

ATHLETICS DEPARTMENT

STUDENT-ATHLETE INSURANCE INFORMATION

STUDENT NAME: _________________________ S#:______________________

1. DO YOU HAVE GROUP MEDICAL COVERAGE THROUGH YOUR PARENT/GUARDIAN?

2. DOES YOUR PARENT/GUARDIAN HAVE GROUP MEDICAL INSURANCE COVERAGETHROUGH THEIR EMPLOYER?

POLICY HOLDER PHONE #: _____________________________________

If you have medical insurance coverage, and you and/or your son/daughter is not covered or is partially covered due to policy limitations, please explain.

________________________________________________________________________

________________________________________________________________________

I/we agree that all information provided in this document is accurate and complete to the best of my/out knowledge. I/we understand that any incorrect or undisclosed information can result in duplicate payments creating a substantial overpayment. The responsibility of such overpayment will be the obligation of the undersigned to reimburse in full, upon request, all amounts deemed refundable.

Signature (Parent/Guardian): _______________________________ Date: ____________

Signature (Student-Athlete): ________________________________ Date: ____________

YES NO

YES NO

The following information can be found on your medical insurance card.

(Will accept a copy of front and back of insurance card if student-athlete’s name is present on card)

POLICY HOLDER NAME: _____________________________________________

INSURANCE COMPANY NAME: ________________________________________

POLICY #: _____________________________

INSURANCE COMPANY ADDRESS: _____________________________________

_______________________________________________________________

INSURANCE COMPANY PHONE #: _____________________________

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ATHLETICS DEPARTMENT

MEDICAL RELEASE AND AUTHORIZATION

STUDENT NAME: _________________________ S#:______________________

Please read the following consent form carefully. If you are under 18 years of age, a parent/guardian must also read and sign this form.

MEDICAL CONSENT

I hereby grant permission to Cuyahoga Community College team physicians and/or their consulting physicians to render to my son or daughter or myself any treatment for medical or surgical care that they deem reasonably necessary to the health and well-being of the student-athlete.

I also hereby authorize the athletic trainers at Cuyahoga Community College who are under the direction and guidance of the Cuyahoga Community College team physicians to render to my son or daughter or myself any preventative first aid, rehabilitative or emergency treatment that they deem reasonable and necessary to the health and well-being of the athlete. This includes practices, games, and travel.

Also, when necessary for executing such case, I grant permission for hospitalization.

________________________________________________ _______________

Student-Athlete Signature Date

________________________________________________ _______________

Parent/Guardian Signature (if under 18) Date

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Page 25: CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT …The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1. ... NJCAA

■ �Preparticipation�Physical�Evaluation��PHYSICAL�EXAMINATION�FORM

Name __________________________________________________________________________________ Dateofbirth __________________________

PHYSICIAN REMINDERS1. Consideradditionalquestionsonmoresensitiveissues

•Doyoufeelstressedoutorunderalotofpressure?•Doyoueverfeelsad,hopeless,depressed,oranxious?•Doyoufeelsafeatyourhomeorresidence?•Haveyouevertriedcigarettes,chewingtobacco,snuff,ordip?•Duringthepast30days,didyouusechewingtobacco,snuff,ordip?•Doyoudrinkalcoholoruseanyotherdrugs?•Haveyouevertakenanabolicsteroidsorusedanyotherperformancesupplement?•Haveyouevertakenanysupplementstohelpyougainorloseweightorimproveyourperformance?•Doyouwearaseatbelt,useahelmet,andusecondoms?

2. Considerreviewingquestionsoncardiovascularsymptoms(questions5–14).

EXAMINATION

Height Weight Male Female

BP / (/)Pulse VisionR20/ L20/ Corrected Y N

MEDICAL NORMAL ABNORMAL FINDINGSAppearance• Marfanstigmata(kyphoscoliosis,high-archedpalate,pectusexcavatum,arachnodactyly,

armspan>height,hyperlaxity,myopia,MVP,aorticinsufficiency)Eyes/ears/nose/throat• Pupilsequal• HearingLymphnodesHearta

• Murmurs(auscultationstanding,supine,+/-Valsalva)• Locationofpointofmaximalimpulse(PMI)Pulses• SimultaneousfemoralandradialpulsesLungsAbdomenGenitourinary(malesonly)b

Skin• HSV,lesionssuggestiveofMRSA,tineacorporisNeurologicc

MUSCULOSKELETALNeckBackShoulder/armElbow/forearmWrist/hand/fingersHip/thighKneeLeg/ankleFoot/toesFunctional• Duck-walk,singleleghop

aConsiderECG,echocardiogram,andreferraltocardiologyforabnormalcardiachistoryorexam.bConsiderGUexamifinprivatesetting.Havingthirdpartypresentisrecommended.cConsidercognitiveevaluationorbaselineneuropsychiatrictestingifahistoryofsignificantconcussion.

 Clearedforallsportswithoutrestriction

 Clearedforallsportswithoutrestrictionwithrecommendationsforfurtherevaluationortreatmentfor _________________________________________________________________

____________________________________________________________________________________________________________________________________________

 Notcleared

 Pendingfurtherevaluation

 Foranysports

 Forcertainsports_____________________________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________________________

Recommendations _________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If condi-tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Nameofphysician(print/type)_____________________________________________________________________________________________________Date________________

Address___________________________________________________________________________________________________________Phone_________________________

Signatureofphysician_______________________________________________________________________________________________________________________,MDorDO

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

Page 26: CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT …The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1. ... NJCAA

■ �Preparticipation�Physical�Evaluation��HISTORY�FORM

(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports for any reason?

2. Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes InfectionsOther: _______________________________________________

3. Have you ever spent the night in the hospital?

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No

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

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

7. Does your heart ever race or skip beats (irregular beats) during exercise?

8. Has a doctor ever told you that you have any heart problems? If so, check all that apply: High blood pressure A heart murmur High cholesterol A heart infection Kawasaki disease Other: _____________________

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected during exercise?

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No

13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No

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

18. Have you ever had any broken or fractured bones or dislocated joints?

19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture?

21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)

22. Do you regularly use a brace, orthotics, or other assistive device?

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

24. Do any of your joints become painful, swollen, feel warm, or look red?

25. Do you have any history of juvenile arthritis or connective tissue disease?

MEDICAL QUESTIONS Yes No

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

27. Have you ever used an inhaler or taken asthma medicine?

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

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

31. Have you had infectious mononucleosis (mono) within the last month?

32. Do you have any rashes, pressure sores, or other skin problems?

33. Have you had a herpes or MRSA skin infection?

34. Have you ever had a head injury or concussion?

35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

36. Do you have a history of seizure disorder?

37. Do you have headaches with exercise?

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

39. Have you ever been unable to move your arms or legs after being hit or falling?

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

41. Do you get frequent muscle cramps when exercising?

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

43. Have you had any problems with your eyes or vision?

44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

46. Do you wear protective eyewear, such as goggles or a face shield?

47. Do you worry about your weight?

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

49. Are you on a special diet or do you avoid certain types of foods?

50. Have you ever had an eating disorder?

51. Do you have any concerns that you would like to discuss with a doctor?

FEMALES ONLY

52. Have you ever had a menstrual period?

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

54. How many periods have you had in the last 12 months?

Explain “yes” answers here

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

Signature of athlete __________________________________________ Signature of parent/guardian ____________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

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■■■ �Preparticipation�Physical�Evaluation��CLEARANCE�FORM

Name ___ ____________________________________________________ Sex  M  F Age _________________ Date of birth _________________

 Cleared for all sports without restriction

 Cleared for all sports without restriction with recommendations for further evaluation or treatment for _______________________________________________

___________________________________________________________________________________________________________________________

 Not cleared

 Pending further evaluation

 For any sports

 For certain sports _____________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________

Recommendations _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type) ___________________________________________________________________________________ Date ________________

Address _________________________________________________________________________________________ Phone _________________________

Signature of physician _____________________________________________________________________________________________________, MD or DO

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Other information _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

Page 28: CUYAHOGA COMMUNITY COLLEGE ATHLETIC DEPARTMENT …The enclosed Varsity Sports Examination Form is the only physical examination form accepted by the Athletic Department. 1. ... NJCAA

■■■ �Preparticipation�Physical�Evaluation��THE�ATHLETE�WITH�SPECIAL�NEEDS:�SUPPLEMENTAL�HISTORY�FORM

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

1. Type of disability

2. Date of disability

3. Classification (if available)

4. Cause of disability (birth, disease, accident/trauma, other)

5. List the sports you are interested in playing

Yes No

6. Do you regularly use a brace, assistive device, or prosthetic?

7. Do you use any special brace or assistive device for sports?

8. Do you have any rashes, pressure sores, or any other skin problems?

9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?

11. Do you use any special devices for bowel or bladder function?

12. Do you have burning or discomfort when urinating?

13. Have you had autonomic dysreflexia?

14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

15. Do you have muscle spasticity?

16. Do you have frequent seizures that cannot be controlled by medication?

Explain “yes” answers here

Please indicate if you have ever had any of the following.

Yes No

Atlantoaxial instability

X-ray evaluation for atlantoaxial instability

Dislocated joints (more than one)

Easy bleeding

Enlarged spleen

Hepatitis

Osteopenia or osteoporosis

Difficulty controlling bowel

Difficulty controlling bladder

Numbness or tingling in arms or hands

Numbness or tingling in legs or feet

Weakness in arms or hands

Weakness in legs or feet

Recent change in coordination

Recent change in ability to walk

Spina bifida

Latex allergy

Explain “yes” answers here

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

Signature of athlete __________________________________________ Signature of parent/guardian __________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.