Huntsville High School Swim and Dive Check List. Name:

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1 Huntsville High School Swim and Dive Check List Name: Code of Conduct Physical Signed by Doctor Athletics Permission Form Liability Release Form 7 th Period Release Form Travel Form Medical Form Copy of Birth Certificate

2 ALABAMA HIGH SCHOOL ATHLETIC ASSOCIATION Preparticipation Physical Evaluation Form History Date Name Sex Age Date of birth Address Phone School Grade Sport Explain Yes answers below: Yes No 1. Has a doctor ever restricted/denied your participation in sports? 2. Have you ever been hospitalized or spent a night in a hospital? Have ever had surgery? 3. Do you have any ongoing medical conditions (like Diabetes or Asthma)? 4. Are you presently taking any medications or pills (prescription or over the counter? 5. Do you have any allergies (medicine, pollens, foods, bees or other stinging insects)? 6. Have you ever passed out during or after exercise? Have you ever been dizzy during or after exercise? Have you ever had chest pain or discomfort in your chest during or after exercise? Do you tire more quickly than your friends during exercise? Have you ever had high blood pressure? Have you ever been told that you have a heart murmur, high cholesterol, or heart infection? Have you ever had racing of your heart or skipped heartbeats? Has anyone in your family died of heart problems or a sudden death before age 50? Does anyone in your family have a heart condition? Has a doctor ever ordered a test on your heart (EKG, echocardiogram)? 7. Do you have any skin problems (itching, rashes, staph, MRSA, acne)? 8. Have you ever had a head injury or concussion? Have you ever been knocked out or unconscious? Have you ever had a seizure? Have you ever had a stinger, burner, pinched nerve, or loss of feeling or weakness in your arms or legs? 9. Have you ever had heat or muscle cramps? Have you ever been dizzy or passed out in the heat? 10. Do you have trouble breathing or do you cough during or after activity? Do you take any medications for asthma (for instance, inhalers)? 11. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)? 12. Have you had any problems with your eyes or vision? Do you wear glasses or contacts or protective eye wear? 13. Have you had any other medical problems (infectious mononucleosis, diabetes, infectious diseases, etc.)? 14. Have you had a medical problem or injury since your last evaluation? 15. Have you ever been told you have sickle cell trait? Has anyone in your family had sickle cell disease or sickle cell trait? 16. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any bones or joints? Head Back Shoulder Forearm Hand Hip Knee Ankle Neck Chest Elbow Wrist Finger Thigh Shin Foot 17. When was your first menstrual period? When was your last menstrual period? What was the longest time between your periods last year? Explain Yes answers: I hereby state that, to the best of my knowledge, my answers to the above questions are correct. Signature of athlete Date Signature of parent/guardian DUPLICATE AS NEEDED Rev FORM 5 Page 1 of 2

3 Preparticipation Physical Evaluation Physical Examination Rule 1, Sec. 14 In order for a student to be eligible for interscholastic athletics, there must be on file in the Superintendent s or Principal s office a current physician s statement certifying that the student has passed a physical exam, and that in the opinion of the examining physician (M.D. or D.O.) the student is fully able to participate in interscholastic athletics (Grade s 7 12). The AHSAA Physicians Certificate (Form 5) must be used. A physical exam will satisfy the requirement for one calendar year from the date of the exam. Height Weight BP / Pulse Vision R 20 / L 20 / Corrected: Y N LIMITED Cardiovascular Pulses Normal Abnormal Findings Heart Lungs Skin E.N.T. Abdominal Genitalia (males) Musculoskeletal Neck Shoulder Elbow Wrist Hand Back Knee Ankle Foot Other Clearance: A. Cleared B. Cleared after completing evaluation/rehabilitation for: C. Not cleared for: Collision Contact Noncontact Strenuous Moderately strenuous Nonstrenuous Due to: Recommendation: Name of physician Date Address Phone. Signature of physician, M.D. or D.O.

4 Huntsville High School Swim Team Code of Conduct Any of the following CAN result in your suspension from the team: 1. Any school suspension or improper conduct in school. 2. Any conduct that the coaches feel is unbecoming of an athlete. 3. Causing poor team morale or injuring team unity. 4. Theft of, or intentional damage of, any school equipment either from our school or others we might meet. 5. Absence from any practice session or meet without prior APPROVAL from the coaching staff. 6. Being late constantly 7. Poor grades or lack of effort in the classroom. 8. Swearing, or any foul language or gesture, or any show of disrespect to a teacher, coach, school or meet official. 9. Any use or possession of drugs or alcohol. 10. All cases involving the violation of an above mention rule will be dealt with on an individual basis. The head coach will determine the action to be taken. To the athlete: I have carefully read the code of conduct and understand what it means. I am signing this to give you my word that I will live by them. Athlete Signature To the parents: I have also read and understand the code of conduct. I will do all possible to support them and to see that my son or daughter lives by them. Parental Signature

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9 Huntsville High Swim & Dive Gear Size Price Hooded Sweatshirt (grey) with 2 color logo $25.00 XS, S, M, L, XL, (2XL + $2.50, 3XL + $5.00) Sweatshirt (grey) with 2 color logo $20.00 XS, S, M, L, XL, (2XL + $2.50, 3XL + $5.00) Sweatpant (grey) with 2 color logo $20.00 XS, S, M, L, XL, (2XL + $2.50, 3XL + $5.00) Polo Shirt (white) with embroidered logo $22.00 XS, S, M, L, XL, (2XL + $2.50, 3XL + $5.00) TOTAL Name: Phone: Please make checks payable to HHS Swim & Dive Booster Club. Due by August 27, 2010 to Ms. Brennan

10 Huntsville High Swim and Dive Team Warm-Up Order Form Swimmer/Diver s Name: Grade: Parent s Name: Phone#: Speedo Digital Evolution Female Sizes (26-40) $55.00 Size Ordered x suits Total Speedo Digital Evolution Male Jammer Sizes (22-38) $33.00 Size Ordered x suits Total Speedo Velocity Warm-Up Jacket: $36.00 Adult $30.00 Youth YL AS AM AL AXL Monogram of Name: Add $5.00. Will be placed on right breast of jacket. Name desired for monogram: Speedo Velocity Warm-Up Pants: $31.00 Adult $25.00 Youth YL AS AM AL AXL Payment must be made at time of order to Huntsville High Swim and Dive Team. Order Deadline is Friday, August 27, Delivery will take 3-4 weeks.