FRANKLIN TOWNSHIP ATHLETIC DEPARTMENT...6 FRANKLIN TOWNSHIP ATHLETIC DEPARTMENT 500 Elizabeth Ave * Somerset, NJ 08873 * Phone: (732) 302-4200 ext. 6402 ATHLETIC CODE OF CONDUCT All

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FRANKLIN TOWNSHIP ATHLETIC DEPARTMENT 500 Elizabeth Ave * Somerset, NJ 08873 * Phone: (732) 302-4200 ext. 6402

Name: ___________________ ID#: __________ Grade: ____ Sport: ___________________

MANDATORY ACKNOWLEDGEMENT OF DOCUMENT REVIEW

Page Information Sheet Initials

Student Parent

2 Personal Insurance Information / Emergency Contacts (must be completely filled out)

3 Directions for Packet Completion & Parental Consent Form for Franklin Web Site

4 Informed Consent & Request / Permission to Play

5 Parent/Guardian Permission for Communication w/ Student’s Cell Phone

6-7 Athletic Code of Conduct (additional signatures on actual form required)

8-9 Sudden Cardiac Death Information & Awareness

10-11 Concussion & Head Injury Fact Sheet & Acknowledgement Form

12 NJSIAA Steroid Testing Consent Form

13 Student Allergy & Asthma Identification Form (must check appropriate box)

14 Authorization for Administration of Epinephrine Auto-Injector at School

15-16 Authorization for Administration of Asthma Prescription Medication Individual Asthma Emergency Treatment Plan

17 Health History Update - Sports

18-21 Health History Questionnaire (HHQ) Pre-participation Physical Examination (PPE)

22-26 NJ State Opioid Use & Misuse Educational Fact Sheet, Eye Safety Sheets and Sign off Sheet

I hereby certify that I have read the required athletic materials and have understood their meaning, application and procedures and take full responsibility for my child and his/her actions while a participating member of the Franklin Township Athletic Program. I also certify that all information contained on this card is true and factual to the best of my knowledge. I hereby give permission for the information contained on this card and in my child’s physical examination to be shared with the school’s Athletic Trainer.

Parent Name (Printed) Parent Signature Date

Student Name (Printed) Student Signature Date

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INSURANCE INFORMATION

Insurance: The school has an insurance policy through Bollinger Insurance, which covers our student-athletes in case of an injury. This policy only covers the excess, which goes uncovered by your insurance provider. **Please note that if your child is injured, all medical care must be coordinated through your insurance provider first.** If you do not have insurance, please indicate this below. Bollinger will then become your primary insurance provider. All information will be kept confidential.

____ Yes, I/We do have private insurance. Provider Name: _______________________________________

____ No, I/We do not have private insurance.

EMERGENCY MEDICAL RELEASE INFORMATION

Student’s Name

Grade:

Student ID #

Parent/Guardian Name: Relationship:

Home Phone: Cell Phone: Work Phone:

Alternate Contact #1 Relationship:

Home Phone: Cell Phone: Work Phone:

Alternate Contact # 2 Relationship:

Home Phone Cell Phone: Work Phone:

I/We ____________________________________, do hereby give permission to the attending physician to give medical assistance to my/our child in the case of emergency in my/our absence.

Parent/Guardian Signature: Date:

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DIRECTIONS FOR PACKET COMPLETION

The following information is provided in order to assist you in completing the necessary forms prior to participation in athletics. Participation in extra-curricular athletics is a privilege for the student. Proper completion of the required forms is required for participation. The completion of these forms is governed by both state law (NJAC 6A:16), NJSIAA Rule and Board Policy. Without proper completion of these forms, as well as a current physical examination by an approved medical provider, your child will not be allowed to participate. There are also academic requirements that must be met prior to athletic participation.

1. Every student wishing to participate in sport must by law obtain a physical examination on a NJSIAA State mandated form, no more than 1 year prior to the season.

2. If a student is applying for a second or third sport in the same school year, they must complete a Update Packet. This packet is located in the Athletic Office and must be completed in full no more than 60 days prior to the first practice. Update Packets cannot be more than 60 days old. All information must be current. The Update Packet must be signed by both the parent/guardian and student on all pages. You must indicate a current sport in the space provided.

3. Incomplete forms will be returned, and will delay participation. 4. All students and their parents must read and agree to abide by the Code of Conduct. Acceptance of the

terms is indicated by both the parent and student signing the Code of Conduct. Lack of both signatures on the code of conduct will be interpreted to mean that you refuse to agree to the terms and do not wish to participate in sport.

5. You must notify the District Athletic Trainer of any injury requiring an Emergency Room or visit to a Doctor or other provider within 24 hours of the exam.

PARENT/GUARDIAN ATHLETIC CONSENT FORM FOR WEB SITE

We have included this parental consent form to both inform you and to request permission for your child’s photo/image and personally identifiable information to be published on the district and/or school’s web site.

As you are aware, there are potential dangers associated with the posting of personally identifiable information on a web site since global access to the Internet does not allow us to control who may access such information. These dangers have always existed; however, we as schools do want to celebrate your child and his/her work. The law requires that we ask for your permission to use information about your child.

Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information the athletic department may use includes the student-athlete’s name, photo or image, height, weight, jersey number, position, year in school and letter award received prior year(s).

A BOX MUST BE CHECKED TO VALIDATE THIS FORM Please choose one of the following choices:

I/We GRANT permission for a photo/image that includes this student without any other personal identifiers to be

published on the school and/or district’s public Internet site.

I/We GRANT permission for this student’s photo/image and name to be published on the school and/or district’s

public Internet site.

I/We GRANT permission for this student’s photo/image and all other personal identifiers listed above to be published

on the school and/or district’s public Internet site.

I/We DO NOT GRANT permission for photo/image that includes this student to be published on the school and/or

district’s public Internet site.

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STATEMENT OF INFORMED CONSENT

Dear Parent/Guardian, Your child wishes to participate in the Franklin interscholastic athletic program. While every reasonable precaution is taken by our staff members to prevent injury, parents are required under the law to assume the responsibility for consenting to participation, and to risk the liability of injury. You must know and understand that your child’s participation presents certain risks inherent to sport and exercise. Your signature below, as well as your child’s, acknowledges that you understand and accept such risks. Dr. John A Ravally, Superintendent of Schools Please print clearly: Name: __________________________________________ Male Female (please circle) Present Grade: __________________ Student ID#: _________________ Address: ________________________________________________________________________ Email: __________________________________________ Home #: __________________________ Cell #: ______________________________ Date of Birth: _____________________________Place of Birth: ____________________________

STUDENT’S REQUEST FOR ENROLLMENT ON AN INTERSCHOLASTIC TEAM To the Board of Education, I ask permission for my child to be allowed to participate in interscholastic athletics. I acknowledge that physical hazards may be encountered in the conduct of the sport and in all arrangements incidental there to. I waiver all claims for damages, remuneration, reimbursement or any other expense in case of personal injury, in the conduct of the program and in all arrangements incidental there to. I also agree to insure the return of all uniforms and equipment loaned to my child in a timely manner. I accept financial responsibility for the replacement of said uniforms and equipment if they are not returned within 5 school days after the last contest or practice in which my child participates. My signature below shall act as proof of my agreement and acknowledgement of the above facts. SCHOOL ATTENDING: FHS______ FMS _______ OUT OF DISTRICT SCHOOL: ___________________ I REQUEST ENROLLMENT FOR THE FOLLOWING SPORT: ___________________________________ Parent / Guardian Signature: _______________________________________Date: _____________ Parent / Guardian Name (Please Print): ________________________________________________

**THIS FORM MUST BE COMPLETED IN FULL AND SIGNED BY BOTH THE PARTICIPANT AND THE PARENT OR GUARDIAN.**

INCOMPLETE FORMS WILL BE RETURNED AND MAY DELAY PARTICIPATION!

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2016-2017

Parent/Guardian Permission for Communication with

Student’s Cell Phone

In accordance with Franklin township Pubic Schools Policy 4119.24/4219.24: Electronic

Communication by District Staff, the Franklin High School & Franklin Middle School

coaches named below have my permission to communicate by text messaging or phone

message to the cell phone of my child,

________________________ _______________ _________________________

Student’s Name Student ID Number Student Cell Number

It is understood that the communication must be related directly to the activity or school

business and that an identical message will be sent to the primary contact noted in the

Genesis System.

_________________________ ___________________________ ___________

Parent/Guardian Name Parent/Guardian Signature Date

Coach’s Name Athletic Team School

“Excellence, Opportunity, and Affirmation for Every Child”

Franklin High School Athletics

500 Elizabeth Avenue

Somerset, NJ 08873

732-302-4200 ext. 6403

c-732-586-8587

[email protected]

Kenneth Margolin

Director of Athletics, FTPS

mailto:[email protected]

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ATHLETIC CODE OF CONDUCT

All student athletes participating in both the high and middle schools interscholastic athletic programs are held to the highest standard of character and sportsmanship. Each coach will issue our Board of Education approved Athletic Code of Conduct contract. The Code of Conduct must be signed by both the participant and his/her parent or guardian and returned to the coach prior to the first interscholastic contest. Failure to do so may result in delay of participation.

ACADEMIC ELIGIBILITY The New Jersey Interscholastic Athletic Association Rules and Regulations regarding eligibility are mandatory. In addition, the Franklin School District Board of Education has adopted the following guidelines for students participating in all school athletics. All 7th and 8th grade students must pass all classes to be eligible for athletics. Failure of any classes constitutes removal from the athletic team for that season. All 9th grade students will automatically be eligible in his/her first semester. To be eligible in the second semester he/she must have achieved one half of 30.0 or 15.0 credits for participation in spring activities. All students entering 10th – 12th grades will be required to achieve 30.0 credits in the year prior to participation in the first semester of a school year. To be eligible in the second semester, the student must have achieved 15.0 credits.

These academic requirements will apply to all cheerleaders, student managers, student trainers, and athletes. Additional information regarding eligibility can be obtained upon request from the Director of Athletics or principal.

AGE ELIGIBILITY A student cannot participate if he/she has reached the age of 19 prior to September 1st of the current school year. A 9th grade student cannot reach the age of 16 prior to September 1st of his/her freshmen year.

ATTENDANCE ELIGIBILITY In order for a student to participate in a scheduled athletic event, practice, or school function, he/she must be in school on the day of the event or the last day of school prior to the Saturday event based on the following time frame: 1) entry to school before 8:00am – no note required – eligible to practice or play 2) entry to school between 8:01 – 10:33am – note required, approval by athletic director – upon approval, eligible to practice or play 3) entry after 10:33am – note required – not eligible to play or practice. An excuse from a doctor or prior written approval from the Director of Athletics or an administrator is the only VALID excuses. Excessive absenteeism, tardiness, and cutting classes will not be tolerated. These offenses justify removal from a team with consent of the Director of Athletics.

ATHLETIC EQUIPMENT ACCOUNTABILITY Athletic equipment used by student participants must be returned or paid for at the end of the sport season and prior to the issuance of any awards or recognition. Equipment will not be issued for any upcoming season until all equipment accounts are cleared from the preceding season.

AWARDS Awards are to be considered a privilege. They therefore can be revoked or recalled (including violations of any ATHLETIC CODE POLICIES).

CAUSE FOR SUSPENSION FROM AN ATHLETIC TEAM

To be eligible, a student must have an acceptable academic, citizenship, and disciplinary record. Gambling, stealing, the use of tobacco (in any form), possession, sale, and use of drugs (including steroids), and/or alcoholic beverages are prohibited. Also, any form of bullying/intimidation in the form of a written, verbal or physical act as well as any inappropriate

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photos, language, video and comments on any Social Media and will be disciplined as follows: A first offense violator shall be suspended from play for a period of at least one-week. This will include all games and practices.

Additional offenses for the same violation listed above will result in his/her dismissal for the remaining part of the season, involving intervention with the director of athletics.

In addition, Board Policies and the Student Handbook, clearly detail all aspects of drug, alcohol, substance use and abuse, including other sanctions. Suspension for cause other than the above-mentioned are at the discretion of the coach and the director of athletics. These violations include, but are not limited to insubordination, profanity, fighting, unsportsmanlike conduct, and unexcused absence from practice, unsatisfactory attitude, and a failure to follow any additional rules and regulations that the coach deems necessary to maintain discipline and facilitate the efficient execution of daily procedures. Imposed suspensions in excess of one week require consultation with the Director of Athletics. Parental notification by the Athletic Director, or his/her designee involved, will be required in all cases of suspension. Student-athletes may be sent out for drug testing at the discretion of the Athletic Director or accordance with the NJSA 18:40 Formal Intervention procedures. If a student athlete is found positive to drug, alcohol or steroid use the student athlete must follow the policy in the FTBOE student code of conduct and additionally cannot return to practice or games until all mandatory SAC sessions have been completed. Discipline referrals and school suspensions are justification for suspension or removal from a team.

CONFLICTING ACTIVITIES DURING SPORT SEASON Prior to the start of any season, an athlete must realize his/her obligation to the team and refrain from scheduling any conflicting activity during that season.

INJURIES Any athlete, who sustains an injury during a school related athletic activity, must report it to his/her coach IMMEDIATELY, which in turn will report it to the district Athletic Trainer. The Athletic Trainer will then be responsible for providing this information to the school nurse. If any injury occurs outside of school it must be reported to the coach prior to the athlete’s next practice or game.

TRANSPORTATION TO AND FROM ATHLETIC EVENTS No student-athlete is permitted to use personal transportation to or from any away athletic event. Official school transportation will be provided, originating at the school and returning back to the school. In a family emergency this rule will be waived as long as prior approval is given by the director of athletics.

PERSONAL CONDUCT As an athlete, pride in your school, team and yourself is all part of good sportsmanship. Your pride is reflected in your personal conduct. Student athletes will not violate the rules of common decency with each other. They shall respect the authority of coaches and other school staff and shall conform to request made by them. In addition, an athlete’s appearance should be a matter of pride, which means cleanliness and neatness in dress and equipment. Student athletes are expected to dress properly when representing their team and school at any athletic or academic function. _______________________________________________ _________________________ Athlete’s Signature Date _______________________________________________ Athlete’s Name (Please Print) _______________________________________________ _________________________ Parent/Guardian Signature Date _______________________________________________ Parent/Guardian’s Name (Please Print)

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Sports-Related Concussion and Head Injury Fact Sheet and Parent/Guardian Acknowledgement Form

A concussion is a brain injury that can be caused by a blow to the head or body that disrupts normal functioning of the brain. Concussions are a type of Traumatic Brain Injury (TBI), which can range from mild to severe and can disrupt the way the brain normally functions. Concussions can cause significant and sustained neuropsychological impairment affecting problem solving, planning, memory, attention, concentration, and behavior. The Centers for Disease Control and Prevention estimates that 300,000 concussions are sustained during sports related activities nationwide, and more than 62,000 concussions are sustained each year in high school contact sports. Second-impact syndrome occurs when a person sustains a second concussion while still experiencing symptoms of a previous concussion. It can lead to severe impairment and even death of the victim. Legislation (P.L. 2010, Chapter 94) signed on December 7, 2010, mandated measures to be taken in order to ensure the safety of K-12 student-athletes involved in interscholastic sports in New Jersey. It is imperative that athletes, coaches, and parent/guardians are educated about the nature and treatment of sports related concussions and other head injuries. The legislation states that:

• All Coaches, Athletic Trainers, School Nurses, and School/Team Physicians shall complete an Interscholastic Head Injury Safety Training Program by the 2011-2012 school year.

• All school districts, charter, and non-public schools that participate in interscholastic sports will distribute annually this educational fact to all student athletes and obtain a signed acknowledgement from each parent/guardian and student-athlete.

• Each school district, charter, and non-public school shall develop a written policy describing the prevention and treatment of sports-related concussion and other head injuries sustained by interscholastic student-athletes.

• Any student-athlete who participates in an interscholastic sports program and is suspected of sustaining a concussion will be immediately removed from competition or practice. The student-athlete will not be allowed to return to competition or practice until he/she has written clearance from a physician trained in concussion treatment and has completed his/her district’s graduated return-to-play protocol.

Quick Facts • Most concussions do not involve loss of consciousness • You can sustain a concussion even if you do not hit your head • A blow elsewhere on the body can transmit an “impulsive” force to the brain and cause a

concussion

Signs of Concussions (Observed by Coach, Athletic Trainer, Parent/Guardian) • Appears dazed or stunned • Forgets plays or demonstrates short term memory difficulties (e.g. unsure of game, opponent) • Exhibits difficulties with balance, coordination, concentration, and attention • Answers questions slowly or inaccurately • Demonstrates behavior or personality changes • Is unable to recall events prior to or after the hit or fall

Symptoms of Concussion (Reported by Student-Athlete) • Headache • Nausea/vomiting • Balance problems or dizziness • Double vision or changes in vision • Sensitivity to light/sound • Feeling of sluggishness or fogginess • Difficulty with concentration, short term memory, and/or confusion

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What Should a Student-Athlete do if they think they have a concussion? • Don’t hide it. Tell your Athletic Trainer, Coach, School Nurse, or Parent/Guardian. • Report it. Don’t return to competition or practice with symptoms of a concussion or head

injury. The sooner you report it, the sooner you may return-to-play. • Take time to recover. If you have a concussion your brain needs time to heal. While your

brain is healing you are much more likely to sustain a second concussion. Repeat concussions can cause permanent brain injury.

What can happen if a student-athlete continues to play with a concussion or returns to play to soon?

• Continuing to play with the signs and symptoms of a concussion leaves the student-athlete vulnerable to second impact syndrome.

• Second impact syndrome is when a student-athlete sustains a second concussion while still having symptoms from a previous concussion or head injury.

• Second impact syndrome can lead to severe impairment and even death in extreme cases.

Should there be any temporary academic accommodations made for Student-Athletes who have suffered a concussion?

• To recover cognitive rest is just as important as physical rest. Reading, texting, testing-even watching movies can slow down a student-athletes recovery.

• Stay home from school with minimal mental and social stimulation until all symptoms have resolved.

• Students may need to take rest breaks, spend fewer hours at school, be given extra time to complete assignments, as well as being offered other instructional strategies and classroom accommodations.

Student-Athletes who have sustained a concussion should complete a graduated return-to-play before they may resume competition or practice, according to the following protocol:

• Step 1: Completion of a full day of normal cognitive activities (school day, studying for tests, watching practice, interacting with peers) without reemergence of any signs or symptoms. If no return of symptoms, next day advance.

• Step 2: Light Aerobic exercise, which includes walking, swimming, and stationary cycling, keeping the intensity below 70% maximum heart rate. No resistance training. The objective of this step is increased heart rate.

• Step 3: Sport-specific exercise including skating, and/or running: no head impact activities. The objective of this step is to add movement.

• Step 4: Non contact training drills (e.g. passing drills). Student-athlete may initiate resistance training.

• Step 5: Following medical clearance (consultation between school health care personnel and student-athlete’s physician), participation in normal training activities. The objective of this step is to restore confidence and assess functional skills by coaching and medical staff.

• Step 6: Return to play involving normal exertion or game activity. For further information on Sports-Related Concussions and other Head Injuries, please visit: www.cdc.gov/concussion/sports/index.htm l www.nfhs.com www.ncaa.org/health-safety www.bianj.org www.atsnj.org __________________________________ _______________________________ __________ Signature of Student-Athlete Print Student-Athlete’s Name Date __________________________________ _______________________________ __________ Signature of Parent/Guardian Print Parent/Guardian’s Name Date

http://www.cdc.gov/concussion/sports/index.htm

http://www.nfhs.com/

http://www.ncaa.org/health-safety

http://www.bianj.org/

http://www.atsnj.org/

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

NJSIAA STEROID TESTING POLICY

CONSENT TO RANDOM TESTING

In Executive Order 72, issued December 20, 2005, Governor Richard Codey directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying for championship games.

Any student-athlete who possesses, distributes, ingests or otherwise uses any of the banned substances on the attached page, without written prescription by a fully-licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA's sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition. The NJSIAA will test certain randomly selected individuals and teams that qualify for a state championship tournament or state championship competition for banned substances. The results of all tests shall be considered confidential and shall only be disclosed to the student, his or her parents and his or her school. No student may participate in NJSIAA competition unless the student and the student's parent/guardian consent to random testing.

By signing below, we consent to random testing in accordance with the NJSIAA steroid testing policy. We understand that, if the student or the student's team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances.

Signature of student-athlete________________________ Date ____________

Signature of parent/guardian _______________________ Date ____________

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FRANKLIN TOWNSHIP PUBLIC SCHOOLS 1755 Amwell Rd. * Somerset, NJ 08873-5200 *

Dear Parent/ Guardian: Please complete the following medical information regarding your child and return completed form to the Athletic Department Student’s Name ________________________________ Grade _______________ Check the appropriate statement/s:

My Child has asthma and currently uses an inhaler. (Please complete and return attached medication orders and parental permission with this form.)

My Child has a food and/or bee sting allergy and currently used an epinephrine auto-injector (EpiPen, Twinject). (Please complete and return attached medication orders and parental permission with this form.)

My child has a history of asthma, but has not required medication in the past two years.

My child has a history of food and/or bee sting allergy, but does not require the use of an epinephrine auto-injector (EpiPen, Twinject). (Please provide documentation from your healthcare provider stating such.)

My child does not have asthma.

My child does not have a food and/or bee sting allergy. Parent Signature: ________________________________ Date: ___________

*Please note that failure to complete and/or return this form may affect your child’s ability to participate in a sport/s.

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Health History Update Questionnaire: Short Form To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose physical

amination was completed more than 90 days prior to the first day of official practice shall provide a health history

update questionnaire completed and signed by the student’s parent or guardian

NAME: GRADE: DATE OF LAST PHYSICAL:

Since the last pre-participation physical examination, has your son/daughter:

1. Been medically advised/recommended not to participate in a sport by a practitioner? NO YES

If yes, explain in detail:

2. Sustained a concussion, been unconscious or lost memory from a blow to the head? NO YES


3. Broken a bone/fractured, sprained/strained or dislocated muscles or joints? NO YES


4. Fainted or blacked out? NO YES


5. Experienced chest pains, shortness of breath or heart racing? NO YES


6. Has there been a recent history of fatigue and unusual tiredness? NO YES


7. Been hospitalized, had significant medical illness/surgery or emergency room visit? NO YES


8. Since the last physical exam, has there been a sudden death in the family, or had any member of the

family under the age of 50 had a heart attack or “heart trouble”? NO YES


9. Started or stopped taking any “over the counter” or prescribed medications? NO YES

Medication: Dosage: Rationale:

Medication: Dosage: Rationale:

10. Developed a food, drug or environmental allergy? NO YES

Describe:

11. Has a prescribed Epinephrine Auto-Injector? NO YES

12. Has prescribed asthma medication(s)? NO YES

Medication:

It is your parental responsibility to make sure that your child has their asthma (rescue) inhaler and epinephrine auto-injector

with them for all try0outs, practices and games/meets. You must complete the parent medication permission form, and bring

the two inhalers and/or two auto0injectors, one each for the nurse and coach.

I attest that all of the above information is correct and I till agree and will abide by the policies that I signed for in the original

sports participation packet.

Parent Signature: Date:

All items negative/School Nurse approved:

School MD: Approved NOT Approved More information needed

School Physician’s signature:

■ 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 a copy of 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 Infections

Other: _______________________________________________

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

New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71


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?


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


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.



PHYSICAL EXAMINATION FORMName __________________________________________________________________________________ Date of birth __________________________

PHYSICIAN REMINDERS

1. Consider additional questions on more sensitive issues• Do you feel stressed out or under a lot of pressure?• Do you ever feel sad, hopeless, depressed, or anxious?• Do you feel safe at your home or residence?• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?• During the past 30 days, did you use chewing tobacco, snuff, or dip?• Do you drink alcohol or use any other drugs?• Have you ever taken anabolic steroids or used any other performance supplement?• Have you ever taken any supplements to help you gain or lose weight or improve your performance?• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION

Height Weight Male Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Y N

MEDICAL NORMAL ABNORMAL FINDINGS

Appearance

• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

• Pupils equal

• Hearing

Lymph nodes

Heart a

• Murmurs (auscultation standing, supine, +/- Valsalva)

• Location of point of maximal impulse (PMI)

Pulses

• Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)b

Skin

• HSV, lesions suggestive of MRSA, tinea corporis

Neurologic c

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

Functional

• Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.bConsider GU exam if in private setting. Having third party present is recommended. cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

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 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).

Name of physician, advanced practice nurse (APN), physician assistant (PA) (print/type)____________________________________________ Date of exam ________________

Address ________________________________________________________________________________________________________ Phone _________________________ Signature of physician, APN, PA _____________________________________________________________________________________________________________________

©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

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, a physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained

to the athlete (and parents/guardians).


■■■ �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, advanced practice nurse (APN), physician assistant (PA) ____________________________________________________ Date _______________

Address _________________________________________________________________________________________ Phone _________________________

Signature of physician, APN, PA _____________________________________________________________________________________________________

Completed Cardiac Assessment Professional Development Module

Date___________________________ Signature_______________________________________________________________________________________

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.New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

26

Documents

FRANKLIN TOWNSHIP ATHLETIC DEPARTMENT...6 FRANKLIN TOWNSHIP ATHLETIC DEPARTMENT 500 Elizabeth Ave * Somerset, NJ 08873 * Phone: (732) 302-4200 ext. 6402 ATHLETIC CODE OF CONDUCT All