Checklist for Participation in Athletics

Dear Parent(s)/ Guardian(s),

Enclosed you will find the documentation required in order for your child to participate in athletics at HPCA. Please read ALL information completely. ALL forms MUST be completed BEFORE your child will be allowed to participate in any athletic related activity at HPCA. This includes tryouts, practices, matches, meets or games.

*Please use the following checklist as a guideline. If we do not have the forms listed below BEFORE tryouts, your child WILL NOT be allowed to participate.

Pre-participation Requirements: _____ A Pre-participation Physical (2 pages: physician’s clearance and health history) – good for 365 days from the date of a medical provider’s signature. (Pages 3 and 4) _____ Gfeller-Waller Student-Athlete & Parent/Legal Custodian Concussion Statement – required by law annually (Concussion Information Sheet must be reviewed by parents and athletes prior to signing this form) (Pages 5 and 6)

____ Athletic Participation/Emergency Contact/Permission to Treat/Medical Release Form (Page 2) *Return pages: 2 (completed and signed by parent/guardian and student-athlete)

3 (completed and signed by parent/guardian and student-athlete) 4 (completed and signed by physician, nurse practitioner, physician’s assistant, or DO) 6 (completed and signed by parent/guardian and student-athlete) 7 (completed and signed by parent/guardian) ____________________________________________________________________________________________________________

IMPORTANT INFORMATION:

1. Athletic Training Services: We are proud to offer part-time Athletic Training/ Sports Medicine services to our injured/ ill athletes on site at no extra cost. Our Certified Athletic Trainer will be present at many of your child’s games and is available for consult upon request.

“Athletic Trainers (ATs) are health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions.”

2. Returning to participation following injury/ illness:

In the event that your child’s athletic participation is restricted due to injury/ illness that requires medical evaluation off-campus a release note IS REQUIRED for return to participation.

A valid clearance note shall include:

1) Athlete’s Name 2) Nature of the injury/ illness. 3) Date of clearance.

a. This may include multiple dates as sometimes athletes will be allowed to return in stages (no participation, limited participation, full participation).

b. Physicians may also leave return to play at the discretion of an Athletic Trainer. 4) Medical Provider’s Signature

*PLEASE NOTE: Concussions and Skin Lesions require a specific clearance form. These forms can be obtained online at hpcacougars.org/forms.

Updated April 15, 2015 Athletic Pre-Participation Packet - Page 1/7

Athletic Participation/Emergency Contact/Medical Release Form

High Point Christian Academy 2015-2016

Student Name__________________________________________ Birth Date____________ Sport(s) _________________________

Parent Email: ________________________________________________________________________________________________

____________________________________________________________________________________________________________

EMERGENCY CONTACT/PARENT/GUARDIAN INFORMATION (please include area code with phone numbers)

Mother/Guardian Name: _________________________________________Cell #:__________________ Work #:________________

Father/Guardian Name: _________________________________________ Cell #:___________________Work#:________________

In the event that a parent/guardian cannot be reached contact the following:

Name________________________________Relationship_________________Cell#_______________Work#___________________

___________________________________________________________________________________________________________

STUDENT’S HEALTH HISTORY *Date of last tetanus shot? _______________

Does your child have a diagnosed medical condition? NO YES, circle all that apply:

Allergies Asthma Cancer Cerebral Palsy Diabetes High Blood Pressure Heart Condition

Seizures/Epilepsy Sickle Cell Trait/Anemia Other health condition not listed: ____________________________________

If your child has ASTHMA does he/she require an INHALER? NO YES

If your child has ALLERGIES, does he/she require an EPIPEN? NO YES, please list all allergies: ___________________

____________________________________________________________________________________________________________

**Please make sure emergency equipment (EpiPen, Inhaler, Glucometer, Insulin, Glucose, etc.) is available at all times

during practice and games.

Does your child take ANY medications and/or supplements, prescription and/or over-the-counter? NO YES, please list and

include dosage: ______________________________________________________________________________________________

Does your child have any medical conditions, religious and/or cultural beliefs that may limit healthcare (i.e. no blood products,

implants that may limit imaging, etc.)?____________________________________________________________________________

___________________________________________________________________________________________________________

PHYSICIAN/INSURANCE INFORMATION

Physician: Phone: _____________________________

Dentist: Phone: _____________________________

Health Insurance Carrier: Policy #: ____________________________

Under the name of: Relationship: ________________________ ____________________________________________________________________________________________________________

PERMISSION TO PARTICIPATE/ASSUMPTION OF RISK I/We give my permission for my/our child to participate in athletic competition throughout the current school year. I/we understand that the student- athlete will be

under the supervision and direction of an HPCA coach. I/We understand that there is a risk of injury involved with athletic participation. Sports injuries can be severe and in some cases may result in permanent disability or even death. I/We freely, knowingly and willfully accept and assume the risk of injury that might occur from

participating in athletics. I/We agree to hold harmless High Point Christian Academy (HPCA), its affiliated organizations, employees, agents, and representatives,

including volunteer and other drivers, from any and all claims arising from my/our child’s participation. This release agreement does not apply to claims of intentional (criminal) misconduct or gross negligence by the school, its employees, or volunteers. If such circumstances are proved in a court of law, I/we acknowledge and agree

that the school can assume no financial liability beyond its actual liability insurance policy in force.

PERMISSION TO TREAT/RELEASE OF MEDICAL INFORMATION I/we give consent for the school’s Sports Medicine Staff (Certified Athletic Trainer/Team Physician/School Nurse/First Responders) to provide emergency, first aid,

preventative or rehabilitative treatment to our son/daughter if he/she becomes injured while participating in athletics. I/we understand that the Sports Medicine Staff will work within the confines of their specific professional certifications and licensures. In case of medical emergency, I/we request that a member of the Sports Medicine

Staff or a Coach contact me/us. If the Sports Medicine Staff or Coach cannot reach a parent/guardian after conscientious effort, I/we give permission for the Sports

Medicine Staff or Coach to call paramedics or any licensed physician or dentist. If a life-threatening emergency exists, I/we give permission for the Sports Medicine Staff or Coach to call paramedics immediately and then contact me/us as soon as possible thereafter. I/we authorize and consent to any x-ray examination, anesthetic,

medical, dental, or surgical treatment, and/or hospital care which, in the best judgment of a licensed physician or dentist is deemed advisable. I/we agree to assume the

financial responsibility for expenses incurred as a result of emergency transport and/or the previously mentioned services being provided. I/We give permission for the release of health information including verbal, print, fax, and electronic media, for the treatment of my/our child, within FERPA/HIPPA guidelines, to the appropriate

Sports Medicine Staff, coaches and/or attending health care providers.

By signing below, I/we attest that the provided information is correct and that I/we understand and agree to the statements above regarding Permission to Participate,

Assumption of Risk, Permission to Treat and Release of Medical Information. Also, I/we commit to report ALL injuries and illnesses to the Sports Medicine Staff.

Parent/Guardian Signature: _______________________________________________________ Date: ______________________

Student-Athlete Signature: ________________________________________________________ Date: ______________________

Updated April 15, 2015 Athletic Pre-Participation Packet - Page 2/7

Patient’s Name: __________________________ Age: ___ Sex: ____ Sport(s): _____________________________

This is a screening examination for participation in sports. This does not substitute for a comprehensive examination with your

child’s regular physician where important preventative health information can be covered.

Athlete’s Directions: Please review all questions with your parent or legal custodian and answer them to the best of your

knowledge. Not disclosing accurate information may put you at risk during sports activity.

Parent’s Directions: Please assure that all questions are answered to the best of your knowledge. If you do not understand or

don’t know the answer to a question please ask your doctor. Not disclosing accurate information may put your child at risk

during sports activity.

Physician’s Directions: We recommend carefully reviewing these questions & clarifying any “Yes”/ “Don’t Know” answers.

PLEASE ELABORATE ON ALL “YES” ANSWERS BELOW. (Example: medication names, dosages, type/ name of condition(s), dates of incident(s), specific area of injury, etc.)

Yes No Don’t Know

1. Does the athlete have any chronic medical illnesses (diabetes, asthma, kidney problems, etc)? 2. Does the athlete have one of any paired organ (eyes, kidneys, lungs, etc)? 3. Has the athlete ever had an organ removed/ organ transplant? 4. Is the athlete presently taking any medications or pills? If so, please list name and dosage below. 5. A) Does the athlete have any allergies (medicine, food, insects, latex, etc)? B) Is an EpiPen required? A B A B A B 6. Does the athlete have sickle cell or sickle cell trait? If yes, circle which. 7. Has the athlete ever had a head injury? Examples: “bell ringer”, “knocked out”, “concussion”, etc… 8. Has the athlete ever had a heat injury (heat cramps, syncope or stroke) with activities? 9. Has the athlete ever passed out or nearly passed out DURING exercise, emotion, or startle? 10. Has the athlete ever fainted or passed out AFTER exercise? 11. Has the athlete had extreme fatigue (been really tired) with exercise (different from other children)? 12. Has the athlete ever had trouble breathing during exercise, or a cough with exercise? 13. A) Has the athlete ever been diagnosed with exercise-induced asthma? B) Is an inhaler currently required? A B A B A B 14. Has the doctor ever told the athlete that they have high blood pressure? 15. Has the doctor ever told the athlete that they have a heart infection? 16. Has a doctor ever ordered an EKG or other test for the athlete’s heart? 17. Has the athlete ever been told they have a murmur? 18. Has the athlete ever had discomfort, pain, or pressure in his/ her chest during or after exercise? 19. Has the athlete ever complained of their heart “racing” or “skipping beats” (also known as palpitations)? 20. Has the athlete ever had a seizure or been diagnosed with a seizure problem? 21. Has the athlete ever had a stinger, burner, or pinched nerve? 22. A) Has the athlete ever had any problems with their eyes/ vision? B) Does the athlete wear contacts/ glasses? A B A B A B 23. Has the athlete ever sprained/ strained, dislocated/ subluxed, fractured/ broken, or had repeated swelling or

other injury to any bone or joint? If so, mark which (line below) and explain below.

24. A) Has the athlete ever had an eating disorder? B) Do you have any concerns about eating habits/ weight? A B A B A B 25. Has the athlete ever been hospitalized or had surgery? If yes, please elaborate below. 26. Has the athlete had a medical problem or injury since their last evaluation?

FAMILY HISTORY 27. Has any family member had a sudden, unexpected death before age 50 (including from sudden infant death,

car accident, drowning)?

28. Has any family member had unexplained heart attacks, fainting, or seizures? 29. Does the athlete have a father, mother, brother, or sister with sickle cell disease/ trait?

Elaborate on any positive (yes) answers from above. Please list the number of the question followed by explanation.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

By signing below I agree that I have reviewed and answered each question above. Every question is

answered completely and is correct to the best of my knowledge. Furthermore, as parent or legal

custodian, I give consent for this examination and give permission for my child to participate in sports.

Signature of parent/legal custodian: _______________________ Date_________ Parent/ custodian phone #___________________

Signature of Student-Athlete: _______________________ Date: ________

HPCA Med Hx and PPE Page 1/2 Updated April 15, 2015 Athletic Pre-Participation Packet - Page 3/7

Additional page

included for elaboration?

Yes or No

Head Shoulder Thigh Neck Elbow Knee Chest Hip Forearm Shin/calf Back Wrist Ankle Hand Foot

Physical Examination

Final signature (bottom of page) must be that of a Licensed Physician, Licensed Nurse Practitioner, or PA-C.

Patient’s Name: __________________________ Age: ___ Sex: ____ Date of Birth:___________________________

HEIGHT/ WEIGHT BLOOD PRESSURE & PULSE VISION

BP Pulse

Height Location/ Method (Circle

appropriate) R/ L arm

Manual/ auto

R/ L _______

Or Pulse Ox

Corrected? (Circle one)

Glasses/ Contacts

Required for sports?

Yes

Yes

No

No Weight SUPINE (optional) /

BMI (optional) SITTING / Right 20/

STANDING (recommended) / Left 20/ Completed by: (if other than signing provider)

Completed by: (if other than signing provider)

Completed by: (if other than signing provider)

Normal Abnormal Findings Completed by:

(if other than

provider below)

Pulses

Heart

Auscultation

EKG (optional)

Echocardiogram (optional)

Other:

Lungs

Skin

Musculoskeletal

Wrist/ Hand (bilateral)

Elbow (bilateral)

Shoulder (bilateral)

Spine (cervical, thoracic, lumbar, SI)

Hip (bilateral)

Knee (bilateral)

Ankle/ Foot (bilateral)

Neuro (if hx indicates)

HEENT (if hx indicates)

Abdomen (if hx indicates)

Genitalia (if hx indicates)

Other:

CLEARANCE: CLEARED FOR FULL PARTICIPATION IN ANY/ ALL HPCA ATHLETICS

CLEARED AFTER EVAL/ REHAB FOR:________________________________________________

***MEDICAL WAIVER FORM REQUIRED FOR _________________________________________

NOT CLEARED FOR (circle the appropriate and include reason) --- COLLISION/ CONTACT/

NON-CONTACT / NON-STRENOUS/ MODERATELY STRENOUS/ STRENOUS ACTIVITY

DUE TO: __________________________________________________________________________

Name of MD, DO, NP, PA-C _______________________ Office Name:

Signature of above _______________________ Office Address:

Date of Physical Exam: _______________________ Office Phone #:

***The following are considered disqualifying until appropriate medical and parental releases are obtained: post-operative clearance, acute infections,

obvious growth retardation, uncontrolled diabetes, severe visual/ auditory impairment, pulmonary insufficiency, organic heart disease of Stage 2

hypertension, enlarged liver or spleen, a chronic musculoskeletal condition that limites ability for safe exercise/ sport (i.e. Klippel-Feil, Sprengel’s), history of

uncontrolled seizures, absence of one kidney, eye, testicle or ovary, etc) \

Office Stamp?

HPCA Med Hx and PPE Page 2/2 Updated March 29, 2015 Athletic Pre-participation Packet - Page 4/7

Athletic Pre-participation Packet - Page 5/7

HIGH POINT CHRISTIAN ACADEMY ATHLETICS

2015-2016

Transportation Release

[ ]

STUDENT NAME

I give permission for my student to provide his/her own transportation to and from HPCA

practices and/or games when school transportation is not provided. I verify that my child has a

valid driver’s license and the minimum required private automoblie insurance.

I give permission for my student to provide transportation to teammates, as needed. It is

understood that the teammate(s) will have this signed release form on file with the school.

I give permission for my student to ride to practices and/or games with a teammate. It is

understood that the driver will have this signed release form on file with the school.

I understand that the ability of coaches and other school officials to properly supervise students

may be impaired when students are not under their direct control. I agree that the coaches and

HPCA should not be held accountable when students who are authorized to use alternative

means of transportation do so. I understand that coaches reserve the right to refuse requests by

players to leave their teams if, in the coaches’ opinion, it serves the best interest of the

individual or the program.

________________________________________________ ________________

(Parent’s Signature) (Date)

Athletic Pre-participation Packet - Page 7/7