CSU Tryout Checklist

Transcription

1 CSU Tryout Checklist Pre-participation exam (Physical) no more than 6 months old Sickle Cell Test Results and form CSU release form CSU tryout waiver form Concussion form Proof of Insurance You must have completed all of the above items and return them to the CSU Athletic Training Department to be cleared for participation in any athletic tryout. Page 1 of 6

2 Central State University Athletics Participation Tryout Waiver Explanation The purpose of this form is to give prospective student-athletes (PSA) trying out for an athletic team guidelines for conduct at Central State University. Please read this document thoroughly before signing. If any questions may arise please contact the following individuals: Head Coach of the respective athletic team Assistant Compliance office at Associate Athletic Director at A member institution may conduct a tryout of a PSA only on its campus or at a site which it normally conducts practice or competition beginning June 15 immediately preceding the PSA s junior year in HS and only under the following conditions (NCAA Bylaw ): a. Not more than one tryout per PSA per institution per sport shall be permitted. b. The tryout may be conducted only for a HS or preparatory school PSA outside his/her HS traditional season in the sport; for a two year college student at the conclusion of the sport season or anytime provided eligibility has been exhausted in the sport, and a four year college student, after the conclusion of the sport season, provided written permission to contact the PSA has been obtained. c. Prior to participation in a tryout, a PSA is required to undergo a medical examination or evaluation by the institution s regular or designated team physician. The exam must contain the sickle cell solubility (SST), unless documentation of results are provided or PSA declines the test and signs a written release. The exam must have been administered six (6) months prior to tryout. d. The tryout may include test to evaluate the PSA s strength, speed, agility and sport skills. In football, ice hockey, men s lacrosse and wrestling, the tryout may include competition. e. Competition against the member institution s team is permissible, provided the competition is considered a countable athletically related activity. f. The time of the tryout activity (other than the PPE) shall be limited to the length of the institution s normal practice period in the sport but in no event shall it be longer than two hours. g. The institution may provide equipment and clothing on an issuance-and-retrieval basis to a PSA during the period of the tryout. Central State University does not provide accident insurance coverage to any PSA while trying out for a respective intercollegiate athletics team on its campus site. All PSAs must provide proof of insurance upon tryout. Page 2 of 6

3 ATHLETIC PARTICIPATION TYROUT WAIVER & FORM Name _ (PSA/walk-on) Print I, the undersigned, hereby acknowledge the following: A. Is aware that participation in any sport can be a dangerous activity involving MANY RISK OF INJURY. B. Understands their participation is granted based upon having passed a medical examination or evaluation administered or supervised by a physician (e.g. team physician, family physician) and that the examination or evaluation was administered within six months prior to participating in the tryout. C. Understands that the dangers and risks of participating or training to participate in athletics include, but are not limited to, possible permanent disability or death, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all bones, ligaments, muscles, tendons and other aspects of the muscular skeletal system and serious injury or impairment to other aspects of said student-athlete s body, general health and well-being. D. Understands that the dangers and risks of participating or training to participate in athletics may result not only in serious injury, but in serious impairment of said student-athletes future abilities to earn a living, to engage in other business, social and recreational activities and generally to enjoy life. E. Comprehends the dangers of participating in athletics and recognizes the importance of following the instructions of the Athletic Staff regarding play/performance techniques, training and other team rules, etc. and agrees to obey such instructions. F. Understands that if participating in CONTACT/COLLISION SPORT(S) (e.g., football, basketball) the risks of injury are even greater than for other sports. Therefore, in consideration of the opportunity to participate in this tryout activity, the undersigned, voluntarily and freely assumes all risks of loss, damage, illness, injury or death that may be sustained from participation in University or Department of Intercollegiate Athletic activities. I agree to hold Central State University, its employees, agents, representatives, coaches, and volunteers harmless from any and all liability, actions, cause of action, debts, claims or demands of any kind and nature whatsoever which may arise by or in the connection with my participation in any activities related to the sport. The terms hereof shall serve as a release against Central State University, its employees, agents, representatives, coaches and volunteers by me, my heirs, estate, executor, administrator, assignees and all members of my family. Signature of Prospective Student/Walk-On Signature of Parent/Guardian if under the age of 18 Signature of Head Coach/Witness Page 3 of 6

4 MEDICAL AUTHORIZATION FORM PROOF OF INSURANCE Medical Authorization I,, (PSA name) understand that an injury may occur as a result from participation in the CSU tryout. I give permission to the CSU Athletic Training Medical Staff to provide any emergency medical care or treatment that may be required, including transportation and accept responsibility for the costs that may be incurred for such medical services. Signature Parent/Guardian: _ PSA: : : Insurance Information All PSAs are REQUIRED to have MEDICAL INSURANCE COVERAGE for accidental injury. Please provide information below: Insurance Company Subscriber name Policy Number _ Group Number Effective Page 4 of 6

5 Central State University Marauders Athletic Training Office 1400 Brush Row Rd., Wilberforce, OH McPherson Stadium Beacom-Lewis Gymnasium Student-Athlete Concussion Reporting Agreement I,, hereby acknowledge that I have received and read the concussion fact sheet for student-athletes. I understand that it is my responsibility to report any and all concussive events and concussion like symptoms to a member of the CSU Athletic Training Staff. The symptoms could include but are not limited to the following: HEADACHE NECK PAIN NAUSEA VOMITING LOSS OF APPETITE BALANCE PROBLEMS/DIZZINESS DROWSINESS/FATIGUE DIFFICULTY SLEEPING NERVOUSNESS/ANXIETY RINGING IN THE EARS FEELING SLOWED DOWN FEELING IN A FOG DIFFICULTY CONCENTRATING OR REMEMBERING CONFUSION/DISORIENTATION BLURRED VISION SADNESS/ALTERED EMOTIONS SENSITIVITY TO LIGHT/NOISE CONTINUED DOUBLE VISION I understand that concussions and head injuries have the potential to be life-threatening or can lead to Second Impact Syndrome. Concussions that are unreported and/or unmanaged carry a greater risk of traumatic brain injury (TBI). All head/neck related injuries must be reported to a member of the Athletic Training Staff immediately upon occurrence. _ Name (print) _ Signature _ CSU ID# _ Signature of Parent/Guardian if under the age of 18 Sport of Birth Page 5 of 6

6 Central State University Athletic Training Sickle Cell Trait Testing To insure a healthier athletic experience for each of our student athletes, the NCAA is requiring that sickle cell trait testing is offered to all student athletes. Sickle cell trait is a hereditary condition that can affect the shape of red blood cells during intense exercise. These deformed red blood cells can accumulate in the bloodstream, blocking normal blood flow to muscles and tissue. During intense exercise, athletes with sickle cell trait can experience significant physical distress, collapse and even die. In order to provide better medical care for athletes that have sickle cell trait, the NCAA recommends that all athletes know their sickle cell trait status. A quick fact sheet from the NCAA regarding sickle cell trait is provided below for your reference. Screening for sickle cell trait is required by the NCAA Div. II Institutions as a part of the medical examination, unless you confirm your sickle cell status by providing documentation of results from prior testing or by declining the test and signing a written release. SCT testing is highly encouraged for all prospective student-athletes. Please take time to review the fact sheet and check the option below that best fits your needs. Please print your name on the line provided by your choice. I, have provided proof of sickle cell trait testing, with results, to be added to my medical file at Central State University. I, have elected not to proceed with testing for sickle cell trait. I have read the literature provided by the NCAA and Central State University. Recognizing that my true physical condition is dependent upon an accurate medical history and full disclosure of any symptoms, complaints, prior injuries, ailments, and/or other disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to the CSU Athletic Training Staff and team physicians. By signing this waiver, I voluntarily release the NCAA, Central State University, and all employees of CSU of any responsibility or liability involving negative outcomes which may result from this decision. Student Athlete s Signature Parent/Guardian Signature (if under 18yrs of age) CSU ATC Signature Sickle Cell Trait Status of Test Results (+/-) Physician Signature _ Printed Information or Physician Stamp Page 6 of 6

7 A Fact Sheet for Student-athletes SICKLE CELL TRAIT What is sickle cell trait? Sickle cell trait is not a disease. Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Sickle cell trait will not turn into the disease. Sickle cell trait is a life-long condition that will not change over time. u During intense exercise, red blood cells containing the sickle hemoglobin can change shape from round to quarter-moon, or sickle. u Sickled red cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to the tissues and muscles. u During intense exercise, athletes with sickle cell trait have experienced significant physical distress, collapsed and even died. u Heat, dehydration, altitude and asthma can increase the risk for and worsen complications associated with sickle cell trait, even when exercise is not intense. u Athletes with sickle cell trait should not be excluded from participation as precautions can be put into place. Do you know if you have sickle cell trait? People at high risk for having sickle cell trait are those whose ancestors come from Africa, South or Central America, India, Saudi Arabia and Caribbean and Mediterranean countries. u Sickle cell trait occurs in about 8 percent of the U.S. African-American population, and between one in 2,000 to one in 10,000 in the Caucasian population. u Most U.S. states test at birth, but most athletes with sickle cell trait don t know they have it. u The NCAA recommends that athletics departments confirm the sickle cell trait status in all student-athletes. u Knowledge of sickle cell trait status can be a gateway to education and simple precautions that may prevent collapse among athletes with sickle cell trait, allowing you to thrive in your sport. how can i prevent a collapse? u Know your sickle cell trait status. u Engage in a slow and gradual preseason conditioning regimen. u Build up your intensity slowly while training. u Set your own pace. Use adequate rest and recovery between repetitions, especially during gassers and intense station or mat drills. u Avoid pushing with all-out exertion longer than two to three minutes without a rest interval or a breather. u If you experience symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness, stop the activity immediately and notify your athletic trainer and/or coach. u Stay well hydrated at all times, especially in hot and u Maintain proper asthma management. u Refrain from extreme exercise during acute illness, if feeling ill, or while experiencing a fever. u Beware when adjusting to a change in altitude, e.g., a rise in altitude of as little as 2,000 feet. Modify your training and request that supplemental oxygen be available to you. u Seek prompt medical care when experiencing unusual physical distress. humid conditions. u Avoid using high-caffeine energy drinks or supplements, or other stimulants, as they may contribute to dehydration. For more information and resources, visit

8 CONCUSSION A fact sheet for student-athletes What is a concussion? A concussion is a brain injury that: Is caused by a blow to the head or body. From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. Can change the way your brain normally works. Can range from mild to severe. Presents itself differently for each athlete. Can occur during practice or competition in ANY sport. Can happen even if you do not lose consciousness. How can I prevent a concussion? Basic steps you can take to protect yourself from concussion: Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. Follow your athletics department s rules for safety and the rules of the sport. Practice good sportsmanship at all times. Practice and perfect the skills of the sport. What are the symptoms of a concussion? You can t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: Amnesia. Confusion. Headache. Loss of consciousness. Balance problems or dizziness. Double or fuzzy vision. Sensitivity to light or noise. Nausea (feeling that you might vomit). Feeling sluggish, foggy or groggy. Feeling unusually irritable. Concentration or memory problems (forgetting game plays, facts, meeting times). Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse. What should I do if I think I have a concussion? Don t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. It s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit and Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services.

9 Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM Name 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 a Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. b Consider GU exam if in private setting. Having third party present is recommended. c Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion. Cleared for all sports without restriction Cleared for all sports without restriction with recommendations for further evaluation or treatment for Not cleared Pending further evaluation For any sports For certain sports Reason Recommendations I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If 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) 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. HE /0410

10 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.) of Exam _ Name of birth Sex Age _ Grade School Sport(s) Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects Explain Yes answers below. Circle questions you don t know the answers to. GENERAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes Infections Other: 3. Have you ever spent the night in the hospital? 4. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU Yes No 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 7. Does your heart ever race or skip beats (irregular beats) during exercise? 8. Has a doctor ever told you that you have any heart problems? If so, check all that apply: High blood pressure A heart murmur High cholesterol A heart infection Kawasaki disease Other: 9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) 10. Do you get lightheaded or feel more short of breath than expected during exercise? 11. Have you ever had an unexplained seizure? 12. Do you get more tired or short of breath more quickly than your friends during exercise? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)? 14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? 15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? BONE AND JOINT QUESTIONS Yes No 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? 18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? 20. Have you ever had a stress fracture? 21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism) 22. Do you regularly use a brace, orthotics, or other assistive device? 23. Do you have a bone, muscle, or joint injury that bothers you? 24. Do any of your joints become painful, swollen, feel warm, or look red? 25. Do you have any history of juvenile arthritis or connective tissue disease? MEDICAL QUESTIONS Yes No 26. Do you cough, wheeze, or have difficulty breathing during or after exercise? 27. Have you ever used an inhaler or taken asthma medicine? 28. Is there anyone in your family who has asthma? 29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? 30. Do you have groin pain or a painful bulge or hernia in the groin area? 31. Have you had infectious mononucleosis (mono) within the last month? 32. Do you have any rashes, pressure sores, or other skin problems? 33. Have you had a herpes or MRSA skin infection? 34. Have you ever had a head injury or concussion? 35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? 36. Do you have a history of seizure disorder? 37. Do you have headaches with exercise? 38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? 39. Have you ever been unable to move your arms or legs after being hit or falling? 40. Have you ever become ill while exercising in the heat? 41. Do you get frequent muscle cramps when exercising? 42. Do you or someone in your family have sickle cell trait or disease? 43. Have you had any problems with your eyes or vision? 44. Have you had any eye injuries? 45. Do you wear glasses or contact lenses? 46. Do you wear protective eyewear, such as goggles or a face shield? 47. Do you worry about your weight? 48. Are you trying to or has anyone recommended that you gain or lose weight? 49. Are you on a special diet or do you avoid certain types of foods? 50. Have you ever had an eating disorder? 51. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY 52. Have you ever had a menstrual period? 53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months? Explain yes answers here I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete Signature of parent/guardian 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. HE /0410