Athletic Paperwork Packet - Frederick County Public Schools

ATHLETICS
“Creating a Culture Committed to Excellence
in Academics, Athletics, & Character Development”
2015-2016
**Football Specific**
Athletic Paperwork Packet
(Must be turned in to the head coach prior to or on the first day of the season)
Starting Date Fall Season - Wednesday, August 12, 2015
Student-Athlete’s Name:
Sport Trying Out For:
__________________________________________________
FOOTBALL ONLY
__________________________________________________
Student-Athlete’s Grade in School:
9th 10th
11th
12th
(Circle One)
Student-Athlete’s Birth Date: __________________________________________________
Month
Day
Year
Years Participated In This High ________________________________________________
School Sport: (not including this year)
1
2
3 (Circle One)
Website: www.fcps.org
Twitter: @FCPSAthletics
TABLE OF CONTENTS
* Football *
ENTIRE PACKET TO BE SUBMITTED BEFORE FIRST TRY OUT DATE
FALL SEASON: AUGUST 12, 2015
1.
GUIDE FOR STUDENT-ATHLETES AND PARENTS (remove from packet and keep for
reference)
2.
CONCUSSION FACT SHEET FOR PARENTS & ATHLETES (remove from packet and keep for
reference)
3.
CONCUSSION AWARENESS PARENT/STUDENT-ATHLETE ACKNOWLEDGEMENT
4.
PRE-PARTICIPATION HEAD INJURY/CONCUSSION REPORTING FORM
5.
SCA INFORMATION & FREQUENTLY ASKED QUESTIONS (remove from packet and keep
for reference)
6.
SUDDEN CARDIAC ARREST PARENT/STUDENT ATHLETE ACKNOWLEDGEMENT
7.
MPSSAA PREPARTICIPATION PHYSICAL EVALUATION FORMS
8.
9.

The history and clearance forms must be completed by a physician and have his/her
signature or stamp.

Both forms must have been completed after May 31, 2015.
AUTHORIZATION FOR PARTICIPATION IN INTERSCHOLASTIC ATHLETICS FORM

This form is required for participation each season.

Student-athletes and parents should together read this entire form, sign and place initials
where necessary.

On the student information side, please include the insurance company name and policy
number. (Note: School insurance must be purchased if athlete does not have insurance
coverage. Feel free to enroll online at www.studentinsurance-kk.com and coverage will
be effective immediately)

Both sides of this form must be signed by the parent or legal guardian & student athlete.
MEDICAL INSURANCE REQUIREMENTS FOR FOOTBALL/PERMISSION FORMS
10. TRANSPORTATION PARENTAL PERMISSION FORM

If bus transportation is not provided, this form is required for student-athletes transported
in private vehicles.
11. HEALTH AND EMERGENCY INFORMATION/STUDENT INFORMATION CARD

This form is to be completed by parents/guardians and will provide the coaching staff and
athletic trainer useful information in case of an emergency.

Our coaches will remove this form and keep it in their med kits.
Once the team is chosen, there is a $90 FCPS athletic fee per season.
This non-refundable fee is required before the first scrimmage/contest.
GUIDE FOR STUDENT ATHLETES
AND PARENTS
GENERAL STANDARDS AND FORMS FOR PARTICIPATION IN
INTERSCHOLASTIC ATHLETICS
PURPOSE: This Athletic Brochure is designed to be useful as a guide to ­student-athletes and parents. The intent is to ­condense
into one brochure that information which is necessary to effectively understand and participate in the athletic ­program in
Frederick County. The brochure includes a collection of information pertaining to state and county procedures and regulations.
There may be questions which arise that may not be covered in this brochure. Remember, this brochure is only a guide. Only open
communications between coaching staff, athletic director, parents, students, and school administrators will ensure an ­effective
athletic program.
ENROLLMENT: Students shall be officially registered, as required by Maryland school laws and attending a member MPSSAA
school. They may represent only the school in which they are registered and at which it is anticipated they will complete their
graduation requirements.
AGE: Students who are 19 years or older as of August 31 are ineligible to ­participate in interscholastic athletics for the school
year ahead.
PHYSICAL EXAMINATION: A student shall be examined and certified as being physically fit to participate in any tryout or
p­ ractice. This examination shall be performed by a qualified physician between June 1 and the first day of practice. All physicals
expire on May 31.
ATHLETIC INSURANCE AND PARENTAL PERMISSION: Every candidate for and participant on an interscholastic team must
provide proof of parental permission and have insurance covering possible accident or injury in school-sponsored games, ­practice
sessions and travel to and from athletic contests. Such coverage may be provided through the purchase of scholastic accident
insurance, or by ­providing proof of similar or superior coverage.
FOOTBALL INSURANCE: The Board of Education offers an insurance policy option which students participating in football
may purchase. Students must show proof of similar or superior coverage and/or purchase the football insurance through the
Board of Education. There is no guarantee that all medical bills and expenses will be borne by the football insurance. There are
­exclusions and limitations that are delineated in the football insurance brochure that every football candidate should receive from
his ­respective coach. If an injury occurs, parents and/or guardians of athletes should anticipate the distinct possibility of incurring
medical expenses that will not be covered by insurance.
The football insurance option available through the school system, if selected, will cover students participating in football only.
Insurance for school time and other sports must be purchased separately.
INTERSCHOLASTIC ATHLETIC FEE: The school system will require that each student pay a nonrefundable fee of $90 for each
team in which he or she is a member.
Fees collected will contribute to the county athletic program to underwrite transportation, coaches salaries, officials’ fees,
­equipment and uniforms.
SEASON OF COMPETITION: Students may participate in interscholastic ­athletic contests a maximum of four seasons in any
one sport in grades 9, 10, 11, and 12.;
OUTSIDE TEAM MEMBERSHIP: The outside participation shall not conflict with the practice or contest schedule of the school
including district, regional and state championship play. A principal and coach must authorize in advance an absence from a
school scheduled practice or competition.
ACADEMIC ELIGIBILITY: Please refer to Regulation 500-24. To participate in extracurricular activities, a high school student
must have a minimum 2.00 grade point average and no “F” grades. The following grades will be used to determine eligibility/
ineligibility: “Traditional” FCPS grades, Dual Enrollment grades and Frederick County Virtual Outside of School (VOS) grades.
Eligibility (except for 9th graders) for fall extracurricular activities is based on the 4th term grades from the previous school
year. An ineligible student may practice but may not accompany the team or group, participate in any interschool competition
(including scrimmages) or be excused from any class for the activity concerned. To ensure continued eligibility, monitor student
grades using Pinnacle, the FCPS Grades Online system. Log in regularly to check grades and assignments or sign up for e-mail
alerts. You choose how often, the day of the week and more. A student who believes an error has occurred in awarding a grade
may appeal to the school principal.
Revised March 2015
ATTENDANCE: Each athlete is required to attend school and classes regularly. On the day of an event (game or practice) an
­athlete must attend for the entire day; in the case of extenuating circumstances, the school administration may waive this rule.
DRUG, ALCOHOL, TOBACCO AND DRUG PARAPHERNALIA POLICY: Alcohol, drug, and tobacco use are extremely serious
offenses. Not only is the quality of life of the student athlete in jeopardy but the quality of life of innocent bystanders may be
in jeopardy as well. Individuals participating in athletics depend on one another to be mentally and physically prepared to give
their best effort each day. This cannot happen if the student athlete is using alcohol, tobacco, or drugs that are not prescribed by
a physician. Athletes using, possessing, or distributing drugs, alcohol, or tobacco on school premises or at a school sponsored
event shall be subject to discipline as outlined in FCPS Regulation 400-8 “Student Discipline.”
SERIOUS ACTS BY STUDENT LEADERS: Students holding leadership positions or representing the school through ­academics,
athletics and/or activities such as a club or organization, who commit an offense classified as a serious, unlawful act in the community or a serious suspendible offense may be removed from the position. Arrest, conviction, or legal judgment is not required.
STUDENT CONDUCT: Any behavior that is deemed disruptive or detrimental to the team may bring consequences ranging from
diminished playing time to dismissal from the team. As a result of misconduct (as described by the principal and/or coach) the
principal and/or coach shall be responsible for deciding appropriate punishment. Any player ejected from a contest will be suspended for the next contest.
HAZING: Hazing will not be tolerated to any degree and will be punishable as outlined in Board regulation 400-8. Any action
taken or situation created that causes or is reasonably likely to cause harassment, physical harm, serious mental or emotional
harm, extreme embarrassment, ridicule, or loss of dignity to another student for purposes of initiation into a student organization
or activity will not be tolerated.
TITLE IX: FCPS BOE supports the provisions of Title IX and believes the implementation of the athletic program should reflect
equity in funding, scheduling, and access to programs and facilities. The supervisor of athletics in cooperation with the athletic
director and building principal will annually evaluate the following areas to insure equity in athletic programs at all FCPS high
schools.
Questions or concerns about the application of Title IX should be directed to the executive director of legal services who serves
as the Title IX coordinator for Frederick County Public Schools.
STARTING DATES FOR PRACTICE: Fall sports, August 12; winter sports, November 14; spring sports, March 1. If the first day
of practice falls on Sunday, practice can begin on Saturday.
OUT-OF-SEASON PRACTICE: Member schools and coaches shall confine all organized or formal practices for all students or
teams to the seasonal limitations. Any individual, group or gathering that has assembled for the purpose of instruction and is
under the direction of any member of the school coaching staff during the school year would constitute a violation.
A coach may coach a team not representing his/her school during the summer months (MPSSAA rules apply). The team may
not use a name connected with the school. The team may not use school uniforms or equipment.
RECRUITING STATEMENT: No coach or school personnel are to discuss or other­wise promote transfers or changes in residence
or residence arrangements with any student, parent or other person of influence or knowingly permit such activity to take place
for the purpose of facilitating athletic participation.
EQUIPMENT RESPONSIBILITY: It is the responsibility of the student-athlete to maintain and return all equipment and uniforms
issued to them. Parents will be financially responsible for any equipment or uniforms which are lost, stolen, or misplaced during
the time the student/athlete is responsible for them. The price of replacing these items will be the actual cost to the school for
purchasing new replacement items. Until any charges for lost equipment have been paid, the ­student-athlete will not receive a
report card or be eligible to participate on any other high school athletic team.
DUAL SPORTS IN A SINGLE SEASON: A student may not participate in more than one high school sport in any one season.
Revised March 2015
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Concussion facts:
• A concussion is a brain injury that affects how your
brain works.
• A concussion is caused by a bump, blow, or jolt to the
head or body.
• A concussion can happen even if you haven’t been
knocked out.
• If you think you have a concussion, you should not
return to play on the day of the injury and not until
a health care professional says you are OK to return
to play.
What are the symptoms of a concussion?
Concussion symptoms differ with each person and with
each injury, and they may not be noticeable for hours
or days. Common symptoms include:
• Headache
• Confusion
• Difficulty remembering or paying attention
• Balance problems or dizziness
• Feeling sluggish, hazy, foggy, or groggy
• Feeling irritable, more emotional, or “down”
• Nausea or vomiting
• Bothered by light or noise
• Double or blurry vision
• Slowed reaction time
• Sleep problems
• Loss of consciousness
During recovery, exercising or activities that involve a
lot of concentration (such as studying, working on the
computer, or playing video games) may cause concussion
symptoms to reappear or get worse.
What should I do if I think I have
a concussion?
DON’T HIDE IT. REPORT IT. Ignoring your symptoms and
trying to “tough it out” often makes symptoms worse.
Tell your coach, parent, and athletic trainer if you think
you or one of your teammates may have a concussion.
Don’t let anyone pressure you into continuing to practice
or play with a concussion.
ET CHECKED OUT. Only a health care professional
G
can tell if you have a concussion and when it’s OK to
return to play. Sports have injury timeouts and player
substitutions so that you can get checked out and the
team can perform at its best. The sooner you get checked
out, the sooner you may be able to safely return to play.
T AKE CARE OF YOUR BRAIN. A concussion can affect
your ability to do schoolwork and other activities. Most
athletes with a concussion get better and return to
sports, but it is important to rest and give your brain
time to heal. A repeat concussion that occurs while your
brain is still healing can cause long-term problems that
may change your life forever.
How can I help prevent a concussion?
Every sport is different, but there are steps you can take
to protect yourself.
• Follow your coach’s rules for safety and the rules of
the sport.
• Practice good sportsmanship at all times.
If you think you have a concussion:
Don’t hide it. Report it. Take time to recover.
It’s better to miss one game than the whole season.
For more information, visit www.cdc.gov/Concussion.
April 2013
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What is a concussion?
A concussion is a type of traumatic brain injury. Concussions
are caused by a bump or blow to the head. Even a “ding,”
“getting your bell rung,” or what seems to be a mild bump
or blow to the head can be serious.
You can’t see a concussion. Signs and symptoms of concussion
can show up right after the injury or may not appear or be
noticed until days or weeks after the injury. If your child
reports any symptoms of concussion, or if you notice the
symptoms yourself, seek medical attention right away.
What are the signs and symptoms of a
concussion?
If your child has experienced a bump or blow to the head
during a game or practice, look for any of the following
signs of a concussion:
SYMPTOMS REPORTED
BY ATHLETE
SIGNS OBSERVED BY
PARENTS/GUARDIANS
• Headache or
“pressure” in head
• Nausea or vomiting
• Balance problems or
dizziness
• Double
or blurry
vision
• Sensitivity to light
• Sensitivity to noise
• Feeling sluggish,
hazy, foggy, or
groggy
• Concentration or
memory problems
• Confusion
• Just “not feeling right”
or “feeling down”
• Appears dazed or
stunned
• Is confused about
assignment or
position
• Forgets an
instruction
• Is unsure of game,
score, or opponent
• Moves clumsily
• Answers questions
slowly
• Loses consciousness
(even briefly)
• Shows mood,
behavior, or
personality changes
How can you help your child prevent a
concussion or other serious brain injury?
• Ensure that they follow their coach’s rules for safety and
the rules of the sport.
• Encourage them to practice good sportsmanship at all times.
• Make sure they wear the right protective equipment for
their activity. Protective equipment should fit properly
and be well maintained.
• Wearing a helmet is a must to reduce the risk of a serious
brain injury or skull fracture.
– However, helmets are not designed to prevent
concussions. There is no “concussion-proof” helmet.
So, even with a helmet, it is important for kids and
teens to avoid hits to the head.
What should you do if you think your child
has a concussion?
SEEK MEDICAL ATTENTION RIGHT AWAY. A health care
professional will be able to decide how serious the
concussion is and when it is safe for your child to return to
regular activities, including sports.
KEEP YOUR CHILD OUT OF PLAY. Concussions take time to
heal. Don’t let your child return to play the day of the injury
and until a health care professional says it’s OK. Children who
return to play too soon—while the brain is still healing—
risk a greater chance of having a repeat concussion. Repeat
or later concussions can be very serious. They can cause
permanent brain damage, affecting your child for a lifetime.
TELL YOUR CHILD’S COACH ABOUT ANY PREVIOUS
CONCUSSION. Coaches should know if your child had a
previous concussion. Your child’s coach may not know about
a concussion your child received in another sport or activity
unless you tell the coach.
If you think your teen has a concussion:
Don’t assess it yourself. Take him/her out of play.
Seek the advice of a health care professional.
It’s better to miss one game than the whole season.
For more information, visit www.cdc.gov/Concussion.
April 2013
A FACT SHEET FOR PARENTS
For official use only:
Name of Athlete_____________________
Sport/season________________________
Date Received_______________________
Concussion Awareness
Parent/Student-Athlete Acknowledgement Statement
I ______________________________, the parent/guardian of ______________________,
Parent/Guardian
Name of Student-Athlete
acknowledge that I have received information on all of the following:

The definition of a concussion

The signs and symptoms of a concussion to observe for or that may be reported by my
athlete

How to help my athlete prevent a concussion

What to do if I think my athlete has a concussion, specifically, to seek medical attention
right away, keep my athlete out of play, tell the coach about a recent concussion, and
report any concussion and/or symptoms to the school nurse.
Parent/Guardian_________________ Parent/Guardian___________________ Date ________
PRINT NAME
SIGNATURE
Student Athlete__________________ Student Athlete____________________ Date ________
PRINT NAME
SIGNATURE
It’s better to miss one game than the whole season.
For more information visit: www.cdc.gov/Concussion.
PRE-PARTICIPATION HEAD INJURY/CONCUSSION
REPORTING FORM FOR EXTRACURRICULAR ACTIVITIES
This form should be completed by the student’s parent(s) or legal guardian(s). It must be submitted to the
Athletic Director, or official designated by the school, prior to the start of each season a student plans to
participate in an extracurricular athletic activity.
Student Information
Name:
Grade:
Sport(s):
Home Address:
Has student ever experienced a traumatic head injury (a blow to the head)?
Yes______ No______
If yes, when? Dates (month/year): ____________________________________
Has student ever received medical attention for a head injury? Yes_______ No________
If yes, when? Dates (month/year): ____________________________________
If yes, please describe the circumstances:
Was student diagnosed with a concussion? Yes________ No_______
If yes, when? Dates (month/year): ____________________________________
Duration of Symptoms (such as headache, difficulty concentrating, fatigue) for most recent concussion:
Parent/Guardian: Name: _______________________________(Please print)
Signature/Date _________________________________
Student Athlete: Signature/Date _______________________________________________________
Sudden Cardiac Arrest (SCA)
Information for Parents and Student Athletes
Definition: Sudden Cardiac Arrest (SCA) is a potentially fatal condition in which the heart suddenly and
unexpectedly stops beating. When this happens, blood stops flowing to the brain and other vital organs.
SCA in student athletes is rare; the chance of SCA occurring to any individual student athlete is about one in
100,000. However, student athletes’ risk of SCA is nearly four times that of non-athletes due to the increased
demands on the heart during exercise.
Causes: SCA is caused by several structural and electrical diseases of the heart. These conditions predispose an
individual to have an abnormal rhythm that can be fatal if not treated within a few minutes. Most conditions
responsible for SCA in children are inherited, which means the tendency to have these conditions is passed from
parents to children through the genes. Other possible causes of SCA are a sudden blunt non-penetrating blow
to the chest and the use of recreational or performance-enhancing drugs and/or energy drinks.



Warning Signs of SCA
SCA strikes immediately.
SCA should be suspected in any athlete who has
collapsed and is unresponsive.
o No response to tapping on shoulders
o Does nothing when asked if he/she is OK
No pulse





Emergency Response to SCA
Act immediately; time is most critical to increase
survival rates.
Recognize SCA.
Call 911 immediately and activate EMS.
Administer CPR.
Use Automatic External Defibrillator (AED).
Warning signs of potential heart issues: The following need to be further evaluated by your primary care
provider.
 Family history of heart disease/cardiac arrest
 Fainting, a seizure, or convulsions during physical activity
 Fainting or a seizure from emotional excitement, emotional distress, or being startled
 Dizziness or lightheadedness, especially during exertion
 Exercise-induced chest pain
 Palpitations: awareness of the heart beating, especially if associated with other symptoms such as dizziness
 Extreme tiredness or shortness of breath associated with exercise
 History of high blood pressure
Risk of Inaction: Ignoring such symptoms and continuing to play could be catastrophic and result in sudden
cardiac death. Taking these warning symptoms seriously and seeking timely appropriate medical care can
prevent serious and possibly fatal consequences.
Information used in this document was obtained from the American Heart Association (www.heart.org), Parent Heart Watch
(www.paretnheartwatch.org), and the Sudden Cardiac Arrest Foundation (www.sca-aware.org). Visit these sites for more
information.
Frequently Asked Questions about Sudden Cardiac Arrest (SCA)
What are the most common causes of Sudden Cardiac Arrest (SCA) in a student athlete?
SCA is caused by several structural and electrical diseases of the heart. These conditions predispose an
individual to have an abnormal rhythm that can be fatal if not treated within a few minutes. Most conditions
responsible for SCA in children are inherited, which means the tendency to have these conditions is passed
from parents to children through the genes. Some of these conditions are listed below.
1. Hypertrophic cardiomyopathy (HCM): HCM involves an abnormal thickening of the heart muscle and it is
the most common cause of SCA in an athlete.
2. Coronary artery anomalies: The second most common cause is congenital (present at birth) abnormalities of
coronary arteries, the blood vessels that supply blood to the heart.
3. Other possible causes of SCA are:
a. Myocarditis: an acute inflammation of the heart muscle (usually due to a virus).
b. Disorders of heart electrical activity such as:
i. Long QT syndrome.
ii. Wolff-Parkinson-White (WPW) syndrome.
iii. Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT).
c. Marfan syndrome: a condition that affects heart valves, walls of major arteries, eyes, and the
skeleton.
d. Congenital aortic valve abnormalities.
4. Commotio Cordis: concussion of the heart from sudden blunt non-penetrating blow to the chest
5. Use of recreational, performance-enhancing drugs, and energy drinks can also bring on SCA.
How can we minimize the risk of SCA and improve outcomes?
The risk of SCA in student athletes can be minimized by providing appropriate prevention, recognition, and
treatment strategies. One important strategy is the requirement for a yearly pre-participation screening
evaluation, often called a sports physical, performed by the athlete’s medical provider.
1. It is very important that you carefully and accurately complete the personal history and family history
section of the “Pre-Participation Physical Evaluation Form” available at
http://www.mpssaa.org/HealthandSafety/Forms.asp.
2. Since the majority of these conditions are inherited, be aware of your family history, especially if any
close family member:
a. had sudden unexplained and unexpected death before the age of 50.
b. was diagnosed with any of the heart conditions listed above.
c. died suddenly /unexpectedly during physical activity, during a seizure, from Sudden Infant Death
Syndrome (SIDS) or from drowning.
3. Take seriously the warning signs and symptoms of SCA. Athletes should notify their parents, coaches, or
school nurses if they experience any of these warning signs or symptoms.
4. Schools in Maryland have AED policies and emergency preparedness plans to address SCA and other
emergencies in schools. Be aware of your school’s various preventive measures.
5. If a cardiovascular disorder is suspected or diagnosed based on the comprehensive pre-participation
screening evaluation, a referral to a child heart specialist or pediatric cardiologist is crucial. Such athletes
will be excluded from sports pending further evaluation and clearance by their medical providers.
For official use only:
Name of Athlete_____________________
Sport/season________________________
Date Received_______________________
Parent/Student Athlete Acknowledgement Statement
Parent/Guardian
I acknowledge that I have read and understand the following:

Sudden Cardiac Arrest (SCA) Information Sheet

Concussion Awareness Information Sheet
_____________________________
PRINT NAME
________________________________________ Date ________
PARENT/GUARDIAN SIGNATURE
Student Athlete
I acknowledge that I have read and understand the following:

Sudden Cardiac Arrest (SCA) Information Sheet

Concussion Awareness Information Sheet
_____________________________
PRINT NAME
________________________________________ Date ________
STUDENT ATHLETE 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 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
MEDICAL QUESTIONS
1. Has a doctor ever denied or restricted your participation in sports for
any reason?
26. Do you cough, wheeze, or have difficulty breathing during or
after exercise?
2. Do you have any ongoing medical conditions? If so, please identify
below:  Asthma  Anemia  Diabetes  Infections
Other: ________________________________________________
27. Have you ever used an inhaler or taken asthma medicine?
29. Were you born without or are you missing a kidney, an eye, a testicle
(males), your spleen, or any other organ?
4. Have you ever had surgery?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
Yes
No
31. Have you had infectious mononucleosis (mono) within the last month?
5. Have you ever passed out or nearly passed out DURING or
AFTER exercise?
32. Do you have any rashes, pressure sores, or other skin problems?
6. Have you ever had discomfort, pain, tightness, or pressure in your
chest during exercise?
34. Have you ever had a head injury or concussion?
33. Have you had a herpes or MRSA skin infection?
35. Have you ever had a hit or blow to the head that caused confusion,
prolonged headache, or memory problems?
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:______________________
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?
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?
40. Have you ever become ill while exercising in the heat?
11. Have you ever had an unexplained seizure?
42. Do you or someone in your family have sickle cell trait or disease?
12. Do you get more tired or short of breath more quickly than your friends
during exercise?
43. Have you had any problems with your eyes or vision?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
41. Do you get frequent muscle cramps when exercising?
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)?
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
16. Has anyone in your family had unexplained fainting, unexplained
seizures, or near drowning?
18. Have you ever had any broken or fractured bones or dislocated joints?
45. Do you wear glasses or contact lenses?
47. Do you worry about your weight?
15. Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator?
17. Have you ever had an injury to a bone, muscle, ligament, or tendon
that caused you to miss a practice or a game?
44. Have you had any eye injuries?
46. Do you wear protective eyewear, such as goggles or a face shield?
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?
BONE AND JOINT QUESTIONS
No
28. Is there anyone in your family who has asthma?
3. Have you ever spent the night in the hospital?
HEART HEALTH QUESTIONS ABOUT YOU
Yes
52. Have you ever had a menstrual period?
Yes
No
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
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?
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
■■ 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
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.
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.
■■ Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM
Name _ __________________________________________________________________________________ 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
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
Consider GU exam if in private setting. Having third party present is recommended.
Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
a
b
c
 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
©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
■■ 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.
191 South East Street  Frederick, Maryland 21701
Transportation of Student(s) to and from FCPS Activities and Events
School Year: ___________
Parental Permission
If bus transportation is not provided by the Board of Education of Frederick County, I understand
and affirm as the parent/guardian of the student(s) named below that I accept full responsibility for the
transportation of my child/children to and from Frederick County Public Schools activities and events,
including those events on school property as well as off-site locations (i.e., athletic team events, field
trips, extracurricular activities) as identified below:
Student(s): ________________________________________________________
________________________________________________________
Event/Activity/Sports Season (i.e., year):
________________________________________________________
________________________________________________________
I understand that the Board of Education of Frederick County is not liable for any resulting injuries
or loss associated with these travel arrangements and further acknowledge that any liability is primarily
assured by the private driver’s automobile insurance.
___________________________________________
Signature of Parent/Guardian
____________________________
Date
Authorized___________________________________
____________________________
Signature of Principal
REFERENCE: FCPS Regulation 400-46
Date
191 South East Street • Frederick, Maryland 21701
Parental Permission to Participate in Interscholastic Football
TO:
Athletic Director of _______________________________________________High School
I hereby give my child, ________________________________, permission to participate in the
interscholastic football program at _________________________________ High School for the
2015-2016 season. I further give permission to the Board of Education to transport my child to
practices or games by appropriate means.
Exposure to Injury
I understand that, in the engagement of contact sports such as interscholastic football, despite the
best efforts of the staff in training the students and selection of modern equipment, it is possible to
suffer injury to participants in such sports. I further understand that such injuries can be severe. I
have certified in the separate Football Medical Insurance Certification Form that I have some form
of medical insurance coverage (either personal or the football insurance program offered by FCPS)
to provide some financial protection against the medical costs which could result from injuries
which are sustained by my child.
Equipment Responsibility
I understand that it is the responsibility of my child to maintain and return all equipment and
uniforms issued to him. I understand that I will be financially responsible for any equipment or
uniforms which are lost, stolen, or misplaced while my child is responsible for them. The price of
replacing these items will be the actual cost to the school for purchasing new replacement items.
Until any charges for lost equipment have been paid, my child will not receive a report card or be
eligible to participate on any other high school athletic team.
I have read, understand and agree to these statements and responsibilities.
Parent’s Signature __________________________________________ Date: ______________
Student’s Signature _________________________________________ Date: ______________
191 South East Street • Frederick, Maryland 21701
TO:
FROM:
RE:
Parents of Students Participating in Interscholastic Football
Kevin Kendro, Supervisor of Athletics & Extracurricular Activities
Medical Insurance Requirements for Students Playing Interscholastic
Football for the 2016-2016 School Year
Students participating in the interscholastic football program offered by ten Frederick County high
schools are required to be covered by some form of medical insurance so that, in the event the student
is injured, the medical bills resulting from such injury will be paid by an insurance company. Parents
can satisfy this medical insurance requirement in several ways.

If the parent participates in an employer-provided medical insurance plan which offers dependent
coverage and the parent has elected dependent coverage, evidence in the form of a group
enrollment card indicating dependent coverage can be shown to the school’s athletic director or
head football coach.

A parent can carry an individual medical insurance policy which provides family coverage.
Evidence of the insurance coverage would be the enrollment card issued by the insurance
company, indicating family coverage.

In the event a parent is not covered by either an employer-provided medical benefits plan or an
individual medical insurance policy, the parent must purchase the special football coverage prior to
the first day of practice on August 12, 2015, provided under the Student Accident Insurance
Program offered through the Board by the Maryland Association of Boards of Education. Feel
free to enroll online at http://www.studentinsurance-kk.com and coverage will be effective
immediately. Remember to print a confirmation of enrollment.
Please see chart below for cost options:
Football Coverage (Grades 10-12)
With Extended Dental
Low Option
$130.00
High Option
$199.00
Note: Any 9th grade student that plays with the Grades 10-12 team must purchase Grades 10-12 football coverage
If you have no other medical insurance coverage, you are required to purchase one of the above total
packages and the insurance must be purchased prior to the first day of practice on August 12, 2015.
Even though a parent already has medical insurance coverage, they still might want to purchase the
special football coverage policy since it provides other benefits in addition to medical benefits, such as
life insurance and dismemberment insurance benefits. Parents of ninth grade students participating in
the ninth grade football program are required to meet the same insurance requirement.
Attached are a medical insurance certification form and a parental permission form that must be
returned to the head football coach in order to allow the student to participate in the football program.
Attachments:
Football Medical Insurance Certification Form
Parental Permission to Participate in Interscholastic Football Form
191 South East Street • Frederick, Maryland 21701
Football Medical Insurance Certification Form
TO:
Head Football Coach of ______________________________________ High School
RE:
Medical Insurance Coverage for Interscholastic Football Participation for
______________________________________________ [Name of Student-Athlete]
FROM:
___________________________________________ Date: ___________________
Signature of Parent/Guardian
Date Form Completed
Please complete the application section below.
_____ The above-referenced student is covered by a group medical insurance policy offered by
my employer, ____________________ [name of employer], under which family
coverage is purchased. (Attach copy of insurance enrollment card for verification.)
_____ The above-referenced student is covered by an individual medical insurance policy
issued by ___________________________ [name of insurance company], under which
family coverage is purchased. (Attach copy of insurance enrollment card for
verification.)
_____ The above-referenced student is not covered by a group insurance policy provided by
my employer or an individual medical insurance policy. Therefore, I am attaching: (1) a
copy of my online confirmation of enrollment at www.studentinsurance-kk.com; or (2) a
copy of my check payable to UnitedHealthcare StudentResources and a copy of the
application submitted to that company.
Parent Name: _________________________________________________________________
Address: _____________________________________________________________________
Parent Contact (H): ________________ (W): _________________ (Cell): ________________
------------------------------------------------------------------Group or individual coverage verified by coach:
Date: ______________________
Coach’s Signature: ________________________________
AUTHORIZATION FOR PARTICIPATION IN INTERSCHOLASTIC ATHLETICS
In addition, it is recognized that all students must ­comply
Frederick County Public Schools
with eligibility regulations that govern athletics in Frederick
As parents or legal guardians of
County Public Schools as issued by the Frederick County
Board of Education and the Maryland State Department of
First
Middle
(Please Print)
Last
Education.
Every candidate for and participant on an interscholastic
We hereby authorize and consent to our child’s participa-
team must obtain and maintain insurance against pos-
tion in interscholastic athletics and sports. We understand
sible accident or injury in school-sponsored games, practice
that the sport in which our child will be participating is
­sessions, and during travel to and from athletic contests.
potentially dangerous, and that physical injuries may occur
Such coverage may be provided by the purchase of ­scholastic
to our child requiring emergency medical care and treat-
accident insurance (through the school); ­otherwise, proof
ment. We assume the risk of injury to our child that may
of similar or superior coverage must be ­presented. Football
occur in an athletic activity.
insurance must be purchased ­­separately from other insur-
In consideration of the acceptance of our child by the
ance options.
Frederick County Public Schools in its athletic program,
and the benefits derived by our child from participation, we
RESIDENCY REQUIREMENTS
agree to release and hold harmless the Board of Education
I also declare and affirm that my child resides within the
of Frederick County, its members, the Superintendent of
attendance area of:
Schools, the principal, all coaches, and any and all other
agents, servants, and/or employees and agree to indemnify
each of them from any claims, costs, suits, actions, judg-
(Name of School)
or is attending
ments, and expenses arising from our child’s participation
in interscholastic athletics and sports.
(Name of School)
We hereby give our consent and authorize the Board of
with the special permission of the Department of Student
Education of Frederick County and its agents, servants, and/
Services of Frederick County Public Schools. A student
or employees to consent on our behalf and on behalf of our
attending a high school without the benefit of residing*
child, to emergency medical care and treatment in the event
within the school’s attendance area and/or special permis-
we are unable to be notified by reasonable attempts of the
sion of the Superintendent of Schools or his designee, is
need for such emergency medical care and treatment.
subject to ­disciplinary action which could result in the loss
We understand and agree that we will be responsible for
of ­athletic eligibility for a period of time, ineligibility in a
all medical bills and costs that may be incurred as a result
specified sport for the forthcoming year, or penalties as may
of medical care and treatment of our child, and agree to
seem justified in the particular case. It is also possible for the
provide proof of insurance coverage of our child against
athlete’s team and school to be penalized.
accidents and injuries in school sponsored games, practice
*Residing means with parents or legal custodians.
sessions and during travel to and from athletic contests.
Students who have made a decision to take part in the
­athletic program will be required to practice and ­participate
in scheduled contests after school and possibly on nonschool days. Supervision at practice, games and travel will
be provided by the school.
Parent or Legal Guardian Signature
Revised 4/10
Date
STUDENT ATHLETE INFORMATION FORM
❏
❏
❏
❏
PARENTS, PLEASE INITIAL EACH ITEM BELOW
By evidence of the signatures below, you are testifying that you:
Initials
Have read FCPS Guide for Student Athletes & Parents
Have read the provisions of the Authorization for Participation in Interscholastic Athletics form
Any
Initials
Understand the eligibility and residency requirements
behavi
Initials
Understand the school system’s concussion policy
or that
is
Initials
Give permission for participation and assume risk for injury that may occur
deeme
Initials
Acknowledge valid insurability by school or private insurance carrier
d
Initials
disrup
Give permission for student’s name and picture to be used for internet and school publications
tive or
detrim
Failure to accurately complete, sign and return to your child’s coach will result in his/her exclusion from participaentaltion in the interscholastic athletic program of the Frederick County Public Schools.
to the
team
may
(Sport)
bring
conse
quenc
(Student’s Signature)
(Date)
es
rangin
g
(Parent/Legal Guardian Signature)
(Date)
from
dimini
Revised 03/15
shed
playin
Initials
YOUR STUDENT
STUDENT ATHLETE INFORMATION CARD
Student’s Name __________________________________ ___________________________ _____
Last
First
MI
Home Phone _______________________ Birthdate _________________ Sex _____ Grade _____
Street Address _____________________________________________________________________
City _________________________________________________________ Zip Code ___________
PARENTS/GUARDIANS
Name
Parent/Guardian #1:
Mr/Ms
Parent/Guardian #2:
Mr/Ms
Alt Emergency Contact:
Mr/Ms
Phone (H)
Phone (W)
Phone (cell)
Alt Phone
Employer
In the course of school activities, FCPS staff and/or the news media occasionally wish to interview, photograph or videotape
students, display their work or publish their names. Unless indicated otherwise below, we will assume permission to do so.
(FCPS cannot control media coverage of events that are open to the public.)
Permission refused ___________
In case
caseofofaccident
accidentororserious
serious
illness,
I request
school
attempt
to contact
If I cannot
be reached,
I hereby
In
illness,
I request
thatthat
school
staffstaff
attempt
to contact
me. Ifme.
I cannot
be reached,
I hereby
authorize
authorize
the head
coach or
assistant
coach
to make
reasonable arrangements
be in the
bestchild.
interest of the child.
the
head coach
or assistant
coach
to make
reasonable
arrangements
to be in the besttointerest
of the
SignatureofofParent
ParentororGuardian
Guardian
__________________________________________ Date
Signature
Date__________________________
HEALTH AND EMERGENCY INFORMATION
HEALTH CARE CONTACTS
Health Care Provider/Physician____________________________________ Phone _____________________________
Dentist________________________________________________________ Phone _____________________________
Health Insurance Co. ____________________________________________ Phone _____________________________
STUDENTS’ MEDICAL HISTORY (CHECK THOSE THAT APPLY):
ADHD
ADD
Allergy: Bee Sting
Allergy: Food
Allergy: Latex
Allergy: Medication
Allergy: Pesticide/Chemical*
Allergy: Seasonal
Anorexia/Bulimia
Asthma
Dental Problem
Diabetes
Disability – Physical
Earaches/Infections – Frequent
Eczema
Fainting Spells
Gastrointestinal Disorder
Headaches – Frequent
Hearing Problem/Wears Aids
Heart Condition
Kidney/Bladder Problems
Menstrual Problems
Orthopedic Condition
Seizure Disorder
Sore Throats – Frequent
Speech Problem
Stomachaches – Frequent
Vision Problem –
Wears Glasses/Contacts
If any of above was checked, please explain. Also include anything about child’s health that will help staff better understand and work
with him/her. _________________________________________________________________________________________________
DOES YOUR CHILD NEED MEDICATION FOR ANY CONDITION?
At Home: Y / N
At School: Y / N
Name of Medication: ________________________________________ Dosage: ________________________________
Reason Needed: ____________________________________________________________________________________
Reminder: You must supply medication form completed by a health care provider for each medicine the student takes at school.