Physical ATHLETIC COVER SHEET/ PERMISSION FORM DATE________________

Physical
ATHLETIC COVER SHEET/ PERMISSION FORM
TO BE COMPLETED BY THE ATHLETE
DATE________________
NAME_______________________________________________ PHONE_______________
ADDRESS____________________________________________ BUS #________________
DATE OF BIRTH______________________________________ GRADE_______________
CIRCLE THE SPORT(S) YOU INTEND TO PARTICIPATE IN
baseball football marching band
basketball soccer softball cheerleading bowling track and field golf volleyball
wrestling The NJ Dept. of Education has mandated that physical examinations are to be conducted at the
student’s medical home (family doctor). For those athletes who choose not to go to their family
doctor, and instead wish the examination to be conducted by Dr. Fillion, the school doctor,
please note that he will be at the High School on 6/1/11 at 8:00 AM. A student physical
conducted by Dr. Fillion on this date will be free of charge. All paperwork must be complete prior
to seeing Dr. Fillion. If you choose for your child to go to your family doctor, all paperwork must
be completed and handed in to any gym teacher, no later than 6/10/11, or your son/daughter will be
ineligible to participate in their requested sport. NO EXCEPTIONS.
1. The forms must be completely filled out. No partially completed forms will be accepted.
2. After the doctor signs the form, it must be stamped with the Doctor’s name, address, and
phone number.
ATHLETIC PERMISSION INFORMATION
I have read and understand the information on both sides of this
COVER SHEET/PERMISSION FORM.
____________________________________
Student Name (print)
_____________________________
Student Signature
____________________________________
Parent/Guardian Name (print)
_____________________________
Parent/Guardian Signature
OFFICE USE ONLY
Nurse _______I ( ) U ( ) Athletic Director________ Principal School Dr. Comments _______ _______ PLEASE READ THE FOLLOWING INFORMATION REGARDING RULES FOR
INTERSCHOLASTIC SPORTS
I give my consent for my son/daughter
________________________________________ to participate in the North Arlington High
School athletic program. I also grant permission for him/her to take the scheduled trips as
a member of the team.
An athlete cannot participate in the next scheduled event (practice or game), if:
1. Sent home by the nurse before the end of the school day unless he/she has a signed
note from his/her parent/guardian stating that he/she is physically able.
2. He/she leaves the building during the day, without permission or an authorized
excuse.
Realizing that such activity involves the potential for injury which is inherent in all sports, I/we
acknowledge that even with the best coaching, use of the most advanced protective equipment
and strict observance of rules, injuries are still a possibility. On rare occasions these injuries can
be so severe as to result in total disability, paralysis, or even death. I/we acknowledge that I/we
read and understand this warning.
TRAINING RULES FOR ALL INTERSCHOLASTIC SPORTS
The following rules and regulations governing athletic participation apply to all interscholastic sports:
1. The participants must meet all the eligibility requirements of the New Jersey Interscholastic
Athletic Association.
2. Athletes are not permitted to participate in outside sports while their activity is in season.
3. The personal conduct of an athlete is very important and he/she should exemplify good
school citizenship at all times. Causes for dismissal include, but are not limited to the
following:
a. Failure to follow school policies
b. Disrespectful to those in authority
c. Smoking, and the use, possession or being under the influence of alcoholic beverages,
narcotics or other controlled dangerous substances.
d. Theft
e. Vandalism of school property
f. Fighting-since the gymnasium and the playing field are considered extensions of the
classroom, and since fighting or other violent behavior in school are considered
suspension offenses, student athletes may also be subject to suspension for fighting
during games or practices.
4. Training rules will be in effect from the first day of practice through the last day of
competition. Anyone who elects to leave, or has been asked to leave a team after the first
scheduled game or competition, may not join any other team until his/her original sport
season is over.
5. A participant will be ineligible for awards if he/she does not remain a member of the squad
until the end of the season and if he/she does not return all equipment loaned to him/her.
Athletes will be expected to pay for any lost or damaged equipment. Each member will
receive a certificate of participation, even if he/she has not earned a varsity letter.
6. Other rules, including curfew hours, etc., may be established by the individual coaches after
approval is given by the Athletic Director.
North Arlington High School Athletic Department 222 Ridge Rd. North Arlington, NJ 07031 Dennis Kenny Assistant Principal/Athletic Director (201) 991‐6800 ext. 2001 Fax (201) 991‐0188 [email protected] School Year 2011‐2012 Dear NAHS Athletes and Parents, I am pleased that you will be participating in the North Arlington High School Athletic program as a student/athlete and spectator this year. As a student/athlete you have the opportunity to enhance your educational experiences, develop skills and achieve personal and team goals. As a parent, you will have the opportunity to see your son/daughter demonstrate his/her talents as an athlete. The athletic program is an integral part of the high school experience. Athletes, spectators, parents and staff all reap the benefits of a strong program. At NAHS, we are fortunate to have a concerned, enthusiastic and experienced coaching staff. Participation in athletics should be a positive experience for all. A quote which is found in the New Jersey State Interscholastic Athletic Association (NJSIAA) handbook states “The member schools, their communities and the whole society desire academic excellence and recognition; activities free from unsportsmanlike acts; and a culture free of substance abuse.” I am sure that we would all agree on those thoughts. The NJSIAA has specific and strict regulations in respect to academic eligibility (number of credits earned), age and conduct of players, coaches and spectators, etc. Attached is a copy of the NJSIAA’s “The Responsibilities of Sportsmanship” and an acknowledgement form that must be signed by each athlete and parent indicating that they have familiarized themselves with that information. Also attached is an information and acknowledgement form in respect to “Substance Use – Rules, Regulations, and Penalties” which also must be signed prior to participation. In addition, each student and parent must sign the “NJSIAA Steroid Testing Policy Consent To Random Testing” form enacted December 20, 2005 by Governor Richard Codey. Before participation in athletics, the sportsmanship and substance use acknowledgements, steroid testing consent form, parental consent form, athletic training permit and emergency information sheet must be completed entirely. Additionally, each athlete is required by the New Jersey State Department of Education to have a medical examination prior to the first practice session of a sport. I look forward to the upcoming season with all of its promise of success and growth for our student/athletes. If you have any questions, please feel free to contact the Athletic Department. Sincerely, Dennis Kenny
Dennis Kenny Assistant Principal/Athletic Director North Arlington High School Athletic Department IMPORTANT: This form must be signed and returned in order for students to participate in the North Arlington High School Interscholastic Athletic Program. ATHLETIC TRAINING PERMIT TO: Parents of students participating in the North Arlington High School Interscholastic Athletic Program, please read carefully and complete. Name: _______________________________________________________ Last First Date of Birth Address: ___________________________________________________ Street Town _______ Grade __________ Telephone # I grant permission for my son/daughter to participate in any of the athletic activities listed below and to receive athletic training services. Circle the sport you grant approval for him/her to participate. I agree to have him/her examined by a doctor in accordance with the rules set forth by the NJSIAA with regard to participation in interscholastic sports. This permission is effective until revoked in writing. CIRCLE THE SPORT(S) YOU INTEND TO PARTICIPATE IN:
baseball football marching band
basketball soccer softball cheerleading bowling track and field golf volleyball
wrestling NJSIAA/North Arlington Board of Education SPORTSMANSHIP INFORMATION ACKNOWLEDGEMENT This is to acknowledge that we, the undersigned, have received and read the New Jersey State Interscholastic Athletic Association’s Information sheet on “The Responsibilities of Sportsmanship.” SUBSTANCE USE – RULES – REGULATIONS & PENALTIES ACKNOWLEDGEMENTS The North Arlington High School Substance use Rules, Regulations and Penalties information has been read and understood. It is agreed that if violations occur, the specified penalties will be applied. My signature below acknowledges my understanding and concurrence of the Athletic Training Permit, sportsmanship responsibilities, and substance abuse rules and regulations. Student Signature: _________________________________ Date: ________________ Parent Signature: __________________________________ Date: ________________ 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.
Beginning in the Fall, 2006 sports season, any student-athlete who possesses, distributes, ingests or otherwise uses
any of the banned substances on the back of this 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.
______________________________________
Student-Athlete Signature
__________________________
Date
______________________________________
Parent/Guardian Signature
________________________
Date
NJSIAA PARENT/GUARDIAN CONCUSSION POLICY ACKNOWLEDGEMENT FORM NJSIAA has mandated that the parents/guardians of a student-athlete who participates in interscholastic athletics
receive on an annual basis, per year the student athlete participates, a concussion information sheet. The studentathlete and their parents/guardians shall sign acknowledging that they have received a copy of the informational
sheet, in addition to the already required pre-participation examination forms. Failure to comply with this provision
shall preclude the student-athlete from participating in athletics related to the desired sport.
For up-to-date information on concussions, you can go to:
www.cdc.gov/ConcussionsInYouthSports
www.nfhslearn.com
Your signature below acknowledges that you have received the concussion information sheet included
in the student-athlete permission packet.
Parent/Guardian Signature: ______________________________
Date: _____________
Student-Athlete Signature: ______________________________
Date: _____________
North Arlington High School/NJSIAA Athletic Eligibility Policy In order to maintain eligibility for participation in athletic activities during the first
semester (September 1 to January 31) in North Arlington High School, a student must complete
27.5 credits in the previous school year. For participation in the second semester (February 1 to
June 30), a student athlete must complete 13.75 credits in the first half of the current school year.
Starting with the class of 2014 a student must complete 30 credits in the previous school year to
participate in the first semester (September 1 to January 31) sports and 15 credits in the first half
of the current school year to participate in second semester (February 1 to June 30) sports.
Also, a student will become ineligible for the next sports season after any marking period
in which they receive two failing grades, or two incompletes, or any combination of a failing
grade and an incomplete. Adherence to this requirement will be monitored by the Director of
Athletics at the conclusion of each marking period immediately preceding the beginning of a
sport season, and continue to maintain athletic eligibility throughout the season.
Parent Signature____________________________
Student Signature___________________________
Date________________
North Arlington High School Athletic Code of Conduct for Parents
The essential elements of character building and ethics in sports are embodied in the concept of sportsmanship and
six core principals: trustworthiness, respect, responsibility, fairness, caring, and good citizenship. The highest
potential of sports is achieved when the competition reflects these “six pillars of character”!
Therefore I agree:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
I will not force my child to participate in sports. I will remember that the game is for the student‐athlete not the adults. I will learn the rules of the game and the policies of the NJIC. I (and my guests) will not engage in any kind of unsportsman like conduct with official, coach, player, or parent such as booing and taunting; refusing to shake hands; or using profane language or gestures. I (and my guests) will be a positive support for all players, coaches, officials, and spectators at every game, practice or other sporting event. I will not encourage any behaviors or practices that would endanger the health or well‐being of the athletes. I will teach my child to play by the rules and resolve conflicts without resorting to hostility or violence. I will demand that my child treat other players, coaches, officials and spectators with respect regardless of race, creed, color, sex or ability. I will teach my child that doing one’s best is more important than winning, so that my child will never feel defeated by the outcome of a game or his/her performance. I will never ridicule or yell at my child or other participants for making a mistake or losing a competition. I will promote the emotional and physical well‐being of the athletes ahead of any personal desire I may have for my child to win. I will respect the officials and their authority during games and will never question, discuss, or confront, coaches at the game field. I will demand a sports environment for my child that is free from drugs, tobacco, alcohol and I will refrain from their use at all sports events. I also agree that if I fail to abide by the aforementioned rules and guidelines, I will be subject to disciplinary action that could include, but is not limited to the following: Verbal Warning Parental game suspension with written documentation of incident on file at NAHS Game forfeit through the official or coach Parental season suspension Parent/Guardian Print Name Student Athlete Print Name ________________________________ ____________________________ Parental/Guardian Signature ________________________________ Student Athlete Signature ____________________________ Emergency Information Card I. Athlete’s Name: _________________________________Age: __________ Address: _______________________________________Sport: ____________________ North Arlington, NJ 07031 Home Phone: ______________________ II. Medical Information: 1) Allergies: ______________________________________________________________________ 2) Asthma: _______________________________________________________________________ 3) Orthopedic Problems: ____________________________________________________________ _________________________________________________________________ _________________________________________________________________ 4) General Medical Conditions: _______________________________________________________ __________________________________________________________________ 5) Medications: _____________________________________________________________________ 6) Other: __________________________________________________________________________ III. Emergency Information: (Please list different numbers than home) 1) Emergency Phone: ___________________________ Relationship: _________________ 2) Emergency Phone: ___________________________ Relationship: _________________ Emergency Email_______________________________________________________________ New Jersey Department of Education
ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM
Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider
Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA
Part A: HEALTH HISTORY QUESTIONNAIRE
Date of Last Sports Physical: __________________________
Today’s Date:_____________________
Student’s Name: __________________________________
Date of Birth: ____/___/_______
Sex: M
F (circle one)
Age: ____
School: _____________________________
Sport(s): _____________________________________________________________________
Grade: ________
District: _______________________
Home Phone: (_____) ___________
Provider Name (Medical Home): _______________________________ Phone: _______________________ Fax: ____________
EMERGENCY CONTACT INFORMATION
Name of parent/guardian: _________________________________
Phone (work): _____________________
Phone (home):______________________________ Phone (cell):
Additional emergency contact: ____________________________
Phone (work): _____________________
Relationship to student: ______________________________
______________
Relationship to student: ______________________________
Phone (home):______________________________ Phone (cell):
Directions: Please answer the following questions about the student’s medical history by
“yes” responses on the lines below the questions. Please respond to all questions.
CIRCLING
______________
the correct response. Explain all
1. Have you ever had, or do you currently have:
a. Restriction from sports for a health related problem?
b. An injury or illness since your last exam?
c. A chronic or ongoing illness (such as diabetes or asthma)?
(1.) An inhaler or other prescription medicine to control asthma?
d. Any prescribed or over the counter medications that you take on a regular basis?
e. Surgery, hospitalization or any emergency room visit(s)?
f. Any allergies to medications?
g. Any allergies to bee stings, pollen, latex or foods?
(1.) If yes, check type of reaction:
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
□ Rash □ Hives □ Breathing or other anaphylactic reaction
(2.) Take any medication/Epipen taken for allergy symptoms? (List below.)
Y / N / Don’t Know
h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Don’t Know
i. A blood relative who died before age 50?
Y / N / Don’t Know
Explain all “yes” answers here (include relevant dates):
List all medications here:
Medication Name
Dosage
Frequency
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2. Have you ever had, or do you currently have, any of the following head-related conditions:
a. Concussion or head injury (including “bell rung” or a “ding”)?
b. Memory loss?
c. Knocked out?
c. A seizure?
d. Frequent or severe headaches (With or without exercise)?
e. Fuzzy or blurry vision
f. Sensitivity to light/noise
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Explain all “yes” answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3. Have you ever had, or do you currently have, any of the following heart-related conditions:
a. Restriction from sports for heart problems?
b. Chest pain or discomfort?
c. Heart murmur?
d. High blood pressure?
e. Elevated cholesterol level?
f. Heart infection?
g. Dizziness or passing out during or after exercise without known cause?
h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)?
i. Racing or skipped heartbeats?
j. Unexplained difficulty breathing or fatigue during exercise?
k. Any family member (blood relative):
(1.) Under age 50 with a heart condition?
(2.) With Marfan Syndrome?
(3.) Died of a heart problem before age 50? If yes, at what age? _____________________
(4.) Died with no known reason?
(5.) Died while exercising? If yes, was it during or after? (Circle one.)
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Explain all “yes” answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
4.
Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions:
a. Vision problems?
Y / N / Don’t Know
(1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.)
Y / N / Don’t Know
b. Hearing loss or problems?
Y / N / Don’t Know
(1.) Wear hearing aides or implants?
Y / N / Don’t Know
c. Nasal fractures or frequent nose bleeds?
Y / N / Don’t Know
d. Wear braces, retainer or protective mouth gear?
Y / N / Don’t Know
e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)?
Y / N / Don’t Know
Explain all “yes” answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions:
a. Numbness, a “burner”, “stinger” or pinched nerve?
b. A sprain?
c. A strain?
d. Swelling or pain in muscles, tendons, bones or joints?
e. Dislocated joint(s)?
f. Upper or lower back pain?
g. Fracture(s), stress fracture(s), or broken bone(s)?
h. Do you wear any protective braces or equipment?
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Explain all (yes) answers here (include relevant dates):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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6. Have you ever had or do you currently have any of the following general or exercise related conditions:
a. Difficulty breathing?
(1.) During exercise?
(2.) After running one mile?
(3.) Coughing, wheezing or shortness of breath in weather changes?
(4.) Exercise-induced asthma?
i. Controlled with medication? (specify __________________________)
ii. Experience dizziness, passing out or fainting?
b. Viral infections (e.g. mono, hepatitis, coxsackie virus)?
c. Become tired more quickly than others?
d. Any of the following skin conditions:
(1.) Cold sores/herpes, impetigo, MRSA, ringworm, warts?
(2.) Sun sensitivity?
e. Weight gain/loss (of 10 pounds or more)?
(1.) Do you want to weigh more or less than you do now?
f. Ever had feelings of depression?
g. Heat-related problems (dehydration, dizziness, fatigue, headache)?
(1.) Heat exhaustion (cool, clammy, damp skin)?
(2.) Heat stroke (hot, red, dry skin)?
(3.) Muscle cramps?
h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)?
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Explain all “yes” answers here (include relevant dates):
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
7. Females only:
Age of onset of menstruation:______
How many menstrual periods in the last twelve (12) months?
________
How many periods missed in the last twelve (12) months?
________
8. Males only:
Have you had any swelling or pain in your testicles or groin?
Y / N / Don’t Know
PARENT/GUARDIAN SIGNATURE
I certify that the information provided herein is accurate to the best of my knowledge as of the date of my
signature.
_______________________________________
Signature, Parent/Guardian or Student Age 18
_________________
Date of Signature:
THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE
EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.
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ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM
Part B: Physical Evaluation Form
(Completed by the examining licensed provider MD, DO, APN or PA)
-STUDENT INFORMATIONStudent’s Name: __________________________________ Sport(s): _____________________________________________________
Age: ________ Grade: _____________
Date of Birth: _________________________________________
Sex: M F (circle one)
Address: ___________________________________________________________________________________________________________
City/State/Zip:________________________________________________ Home Phone: _________________________________________
School: _____________________________________________________ District: _____________________________________________
Parent/Guardian’s Full Name: __________________________________________________________________________________________
- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATIONIf conducted by school physician check here
□
Name: _______________________________
Phone: __________________________
Fax: _________________
Address: ______________________________
City/State/Zip:_____________________________________________
- FINDINGS OF PHYSICAL EVALUATION Height: _________
Weight: _________
Vision: R 20/____ L 20/ ____
INDICATORS
General Appearance
Head/Neck
Eyes/Sclera/Pupils
Ears
Gross Hearing
Nose/Mouth/Throat
Lymph Glands
Cardiovascular
Heart Rate
Rhythm
Murmur
If murmur present
Femoral Pulses
Lungs: Auscultation/Percussion
Chest Contour
Skin
Abdomen (liver, spleen, masses)
Assessment of physical maturation or
Tanner Scale
Testicular Exam (Males Only)
Neck/Back/Spine:
Range of Motion
Scoliosis
Upper Extremities: (ROM, Strength,
Stability)
Lower Extremities: (ROM, Strength,
Stability)
Neurological: Balance & Coordination
Hernia
Evidence of Marfan Syndrome
Blood Pressure: ______/_______ Pulse: _____bpm.
Corrected: Y / N
NORMAL?
Contacts: Y / N
Glasses: Y / N
ABNORMAL FINDINGS/COMMENTS
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
ABSENT
Standing makes it:
Squatting makes it:
Valsalva makes it:
Louder
Louder
Louder
Softer
Softer
Softer
No Change
No Change
No Change
YES
YES
YES
YES
YES
YES
YES
YES
YES
ABSENT
YES
YES
YES
ABSENT
ABSENT
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Most recent immunizations and dates administered:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medications currently prescribed, with dose and frequency:
Medication Name
Dosage
Frequency
Additional observations:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
General Diagnosis: ____________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
General Recommendations:
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY
THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.
Part B Page 2 of 4
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CLEARANCES: This section is completed by the examining healthcare provider.
After examining the student and reviewing the medical history the student is:

A.
Cleared for participation in all sports without restrictions.

B.
Not cleared for participation in any sport until evaluation/treatment of:
___________________________________________________________________________________

C.
Cleared for limited participation in the following types of sports only. Please see below for sport
classifications. CHECK ALL THAT APPLY
___ CONTACT/COLLISION
___ LIMITED CONTACT
___ NON-CONTACT/STRENUOUS
___ NON-CONTACT/NON-STRENUOUS
Limitations due to: ___________________________________________________________________
________________________________________________
NOTES TO THE EXAMINING PROVIDER
Conditions requiring clearance before sports participation include, but are not limited to the following:
Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension; Congenital heart disease; Dysrhythmia; Mitral valve prolapse;
Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly,
Splenomegaly; Malignancy; Seizure Disorder; Marfan’s Syndrome; History of repeated concussion; Organ transplant recipient; Cystic
fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye.
Contact/Collision
Basketball
Diving
Field Hockey
Football
Ice Hockey
Lacrosse
Soccer
Wrestling
SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT
Limited Contact
Non-Contact
Strenuous
Baseball
Discus
Cheerleading
Javelin
Fencing
Shot put
High Jump
Rowing
Pole vault
Running/Cross Country
Gymnastics
Strength Training
Skiing
Swimming
Softball
Tennis
Volleyball
Track
Effects of physiologic maneuvers on heart sounds
Standing
Increases murmur of HCM
Decreases murmur of AS, MR
MVP click occurs earlier in systole
Squatting
Increases murmur of AS, MR, AI
Decreases murmur of MCH
MVP click delayed
Valsalva
Increases murmur of HCM
Decreases murmur of AS, MR
MVP click occurs earlier in systole
HCM:
AS:
AI:
MR:
MVP:
Non-strenuous
Bowling
Golf
Physical Stigmata of Marfan’s Syndrome
Kyphosis
High arched palate
Pectus excavatum
Arachnodactyly
Arm span > height 1.05:1 or greater
Mitral Valve Prolapse
Aortic Insufficiency
Myopia
Lenticular dislocation
Hypertrophic Cardio Myopathy
Aortic Stenosis
Aortic Insufficiency
Mitral Regugitation
Mitral Valve Prolapse
Part B Page 3 of 4
NJDOE/APPEF Revised 3/10
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
HISTORY REVIEWED AND STUDENT EXAMINED BY:
Physician’s/Provider’s Stamp:
Primary Care Provider
School Physician Provider
License Type:
MD/DO
APN
PA
PHYSICIAN’S/PROVIDER’S SIGNATURE: __________________________________________________
Today’s Date: ______________
Date of Exam: ______________
RESERVED FOR SCHOOL DISTRICT USE
NOTE: N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating
approval or disapproval of the student’s participation in athletics based on this physical evaluation. This evaluation and
the notification letter become part of the student’s school health record.
History and Physical Reviewed By:
__________________________ ________
Title of Reviewer (please check one):
School Nurse
Medical Eligibility Notification Sent to Parent/Guardian by School Physician
Date: _______________
School Physician
______________________
Date
Letter of notification is attached.
OR
Parent notification indicates that:
Participation Approved without limitations.
Participation Approved with limitations pending evaluation.
Participation NOT Approved
Reason(s) for Disapproval:
____________________________________________________________
_____________________________________________________________________________________
Part B Page 4 of 4
NJDOE/APPEF Revised 3/10
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
Parents/Guardians should read and keep the documents following this page as a reference NJSIAA Banned-Drug Classes
2010 - 2011
The term “related compounds” comprises substances that are included in the class by their pharmacological action
and/or chemical structure. No substance belonging to the prohibited class may be used, regardless of whether it is
specifically listed as an example.
Many nutritional/dietary supplements contain NJSIAA banned substances. In addition, the U. S. Food and Drug
Administration (FDA) does not strictly regulate the supplement industry; therefore purity and safety of nutritional
dietary supplements cannot be guaranteed. Impure supplements may lead to a positive NJSIAA drug test. The use
of supplements is at the student-athlete’s own risk. Student-athletes should contact their physician or athletic
trainer for further information.
The following is a list of banned-drug classes, with examples of banned substances under each class:
(a) Stimulants
amiphenazole
amphetamine
bemigride
benzphetamine
bromantan
caffeine1 (guorana)
chlorphentermine
cocaine
cropropamide
crothetamide
diethylpropion
dimethylamphetamine
doxapram
ephedrine
(ephedra, ma huang)
ethamivan
ethylamphetamine
fencamfamine
meclofenoxate
methamphetamine
methylenedioxymethamphetamine
(MDMA, ecstasy)
Methylphenidate
nikethamide
pemoline
pentetrazol
phendimetrazine
phenmetrazine
phentermine
phenylpropanolamine (ppa)
picrotoxine
pipradol
prolintane
strychnine
synephrine
(citrus aurantium, zhi shi, bitter
(b) Anabolic Agents
anabolic steroids
androstenediol
androstenedione
boldenone
clostebol
dehydrochlormethyltestosterone
dehydroepiandrosterone (DHEA)
dihydrotestosterone (DHT)
dromostanolone
epitrenbolone
fluoxymesterone
gestrinone
mesterolone
methandienone
methenolone
(c) Diuretics
acetazolamide
bendroflumethiazide
benzhiazide
bumetanide
chlorothiazide
chlorthalidone
ethacrynic acid
flumethiazide
furosemide
hydrochlorothiazide
hydroflumenthiazide
methyclothiazide
metolazone
polythiazide
quinethazone
spironolactone
triamterene
trichlormethiazide
and related compounds
(d) Peptide Hormones & Analogues:
corticotrophin (ACTH)
human chorionic gonadotrophin (hCG)
leutenizing hormone (LH)
growth hormone (HGH, somatotrophin)
insulin like growth hormone (IGF-1)
All the respective releasing factors
of the above-mentioned substances
also are banned:
erythropoietin (EPO)
darbypoetin
sermorelin
methyltestosterone
nandrolone
norandrostenediol
norandrostenedione
norethandrolone
oxandrolone
oxymesterone
oxymetholone
pregnelone
stanozolol
testosterone2
tetrahydrogestrinone
(THG)
trenbolone
and related compounds
other anabolic agents
clenbutero
orange)
and related compounds
May 7, 2008 Definitions of positive depends on the following:
1 for caffeine – if the concentration in urine exceeds 15 micrograms/ml 2 for testosterone – if administration of testosterone or use of any other manipulation has the result of increasing the ratio of the total
concentration of testosterone to that of epitestosterone in the urine of greater than 6:1, unless there is evidence that this ratio is due
to aphysiological or pathological condition.
NEW JERSEY STATE INTERSCHOLASTIC
ATHLETIC ASSOCIATION
The Responsibilities of Sportsmanship THE COACH….. 1.
2.
3.
4.
5.
6.
Treats own players and opponents with respect. Inspires in the athletes a love for the game and desire to compete fairly. Is the type of person he/she wants the athletes to be. Disciplines those on the team who display unsportsmanlike behavior. Respects the judgment and interpretation of the rules by the officials. Knows he/she is a teacher and understands the athletic area is a classroom. THE OFFICIAL….. 1.
2.
3.
4.
5.
6.
Knows the rules and their interpretations. Places welfare of the participants above all other considerations. Treats players and coaches courteously and demands the same from them. Works cooperatively with fellow officials, timers and/or scorers for and efficient contest. Is fair and firm in all decisions, never compensating for a previous mistake. Maintains confidence, poise and self control from start to finish. THE PLAYER….. 1.
2.
3.
4.
5.
6.
Treats opponents with respect. Plays hard, but plays within the rules. Exercises self‐control at all times, setting an example for others to follow. Respects officials and accepts their decision without gesture or argument. Wins without boasting, loses without excuses, and never quits. Always remembers that it is a privilege to represent the school and community. THE SPECTATOR….. 1.
2.
3.
4.
5.
6.
Attempts to understand and be informed of the playing rules. Appreciates a good play no matter who makes it. Cooperates with and responds enthusiastically to cheerleaders. Shows compassion for an injured player; applauds positive performances; does not heckle, jeer or distract players; and avoids use of profane and obnoxious language and behavior. Respects the judgment and strategy of the coach, and does not criticize players or coaches for a loss of a game. Respects property of others and authority of those who administer the competition. 7. Censures those whose behavior is unbecoming. North Arlington HIGH SCHOOL
ATHLETIC DEPARTMENT
SUBSTANCE USE – RULES, REGULATIONS & PENALTIES Participation in the Athletic Program at North Arlington High School is intended to provide an opportunity for students to have challenging and meaningful experiences beyond the other available academic and activities programs. Eligibility to participate in the interscholastic athletic program at North Arlington High School is an earned privilege. Students seeking to become members of an athletic team(s) must meet all NJSIAA requirements (i.e., number of credits, age, etc.) and all North Arlington Board of Education rules and regulations. The North Arlington High School Student Handbook provides information about the North Arlington Board of Education Policy on Substance Abuse .Student‐Athletes are held responsible for knowing and following those rules and regulations The use or possession of alcoholic beverages, illegal drugs, drug paraphernalia, narcotics and tobacco in any form is UNACCEPTABLE for any member of any athletic team during the season either on or off the school premises. If it is reported and determined that a student‐athlete has violated the “non‐use” rules, the following penalties may be imposed and will be cumulative beginning with participants in the ninth grade. North Arlington High School/NJSIAA Athletic Eligibility Policy In order to maintain eligibility for participation in athletic activities during the first
semester (September 1 to January 31) in North Arlington High School, a student must complete
27.5 credits in the previous school year. For participation in the second semester (February 1 to
June 30), a student athlete must complete 13.75 credits in the first half of the current school year.
Starting with the class of 2014 a student must complete 30 credits in the previous school year to
participate in the first semester (September 1 to January 31) sports and 15 credits in the first half
of the current school year to participate in second semester (February 1 to June 30) sports.
Also, a student will become ineligible for the next sports season after any marking period
in which they receive two failing grades, or two incompletes, or any combination of a failing
grade and an incomplete. Adherence to this requirement will be monitored by the Director of
Athletics at the conclusion of each marking period immediately preceding the beginning of a
sport season, and continue to maintain athletic eligibility throughout the season.