Caroline County Public Schools Athletic Eligibility Form

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Kerry Pierce
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1 Caroline County Public Schools Athletic Eligibility Form Name: Birthdate: Age: Address: Grade: School: In order for a student to participate in high school athletics, the following items within this packet MUST be completed and returned prior to practice or play. 1. Health Insurance Verification 2. Parent Verification 3. Pre-Participation Head Injury/Concussion Reporting Form 4. Clearance Form completed by Physician The attached medical history form may be requested by your physician but is not needed by the school. I. Health Insurance Verification: All students MUST have one of the following: (Please check) School Health Insurance Plan Private Health Insurance Plan Insurance Provider: Policy Number: In addition, all football players who do not have private insurance plan MUST have the special Football Insurance Plan through the school. II. Concussion Information and Parent Verification: What is a concussion? According to the US Department of Health and Human Services Centers for Disease Control and Prevention (CDC): A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth. Even a ding, getting your bell rung, or what seems to be a mild bump or blow to the head can be serious. Concussions can occur in any sport or recreation activity. So, all coaches, parents, and athletes need to learn concussion signs and symptoms and what to do if a concussion occurs. The following are a list of symptoms that may suggest a concussion has occurred. Signs observed by parents/guardians Appears dazed or stunned Is confused about assignment or position Forgets sports plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness (even briefly) Shows behavior/personality changes Can t recall events prior to hit or fall Can t recall events after hit or fall Signs reported by athlete 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 Does not feel right What should you do if you think a concussion has occurred?

2 1. Seek medical attention right away. A health care professional will be able to decide how serious the concussion is and when it is safe to return to play. 2. Do not return to play until medically cleared. Concussions take time to heal. Don t return to play until a health care professional says it is OK. Children who return to play too soon while their brain is still healing risk a greater chance of having a second concussion. Second or later concussions can be very serious. They can cause permanent brain damage, affecting the injured student-athlete for a lifetime. 3. Inform all coaches about any recent concussions. Coaches should know if an athlete has had a recent concussion. The coach may not know about a concussion in another sport or activity if he or she is not informed by the parent/guardian, or athlete. Parent/Guardian: I have read the information about concussions contained in this packet. I grant permission for my son/daughter to participate in interscholastic athletics. In addition, all information contained in this packet is correct. If medical coverage or medical assistance is revoked or elapsed, the parent assumes full responsibility for medical bills. Parent/Guardian Signature: Date:

3 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 the season a student plans to participate in an extracurricular athletic activity. The form must be updated if medical history changes during the school year. Name: Grade: Sport(s): Home Address: Student Information 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 If yes, when? Dates (month/year): If yes, please describe the circumstances: No 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

Ei PR EPA RTICIPATION PHYSICA L EVA LUA TION HISTORY FORM (Note: This form is to be filled out by the patient and parent prior to seeing the physician. Thephysician should keep this form in the chart.

Circle questions you don't know the answers to. O O Explain"yes" answers here,, t'; : >. Ihereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

5 Ei PR EPA RTICIPATION PHYSICA L EVA LUA TION HISTORY FORM (Note: This form is to be filled out by the patient and parent prior to seeing the physician. Thephysician should keep this form in the chart.) Date of Exam Name Sex Date of birth Grade Age _ School Sport(S) Explain 11Yes11 answers below. Circle questions you don't know the answers to. O O Explain"yes" answers here,, t'; : >. Ihereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature o1 athlete Signatureo1parenVguardian Date _ <02010 American Academy of Family Physicians, American Academy of Pediatrics. AmeriC811 College of Sports Medicine. American Medical Society far Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission ls granted to reprint for noncommercial. educational purposes withacknowledgment Hf0503 &-26&1/0410

6 PR EPA RTICIPA TION PHYSICA L EVA LUATION THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM Date of Exam Name Date of birth Sex Age Grade _ School Sport(s) Type of disability 2. Dato of disability 3. Classification Of avallable) 4. cause of disability (birth, disease. accident/trauma, other) 5. list the sports you are Interested in playing 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 dysreflexla? 14. Have you ever been diagnosed with a heat-related {hyperthermla) or cold-related (hypothermia) fllness? 15. Do you have muscle spaslicity? 16. Do you have frequent seizures that cannot be controlled by medication? Explain "yes" answers here Yes No Pl easo Indlcate If you have ever had any of the following 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 alh!eto Slgnatute of parcnvguardlan Date,.. _ 201OAmerican Academy of Family Physicians, American Academy of Pediatrics, American College of Sf)OftS Medic/ne, American Medical Society for Sports Medicine. American Orthopaedic Society tor Sports Medicine. and American Ostsopath,c Academy of Sports Medicine. Permission is granted to reprint tor noncommercial, educational purposes with acknowledgment.

7 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 ( Parent Heart Watch ( and the Sudden Cardiac Arrest Foundation ( Visit these sites for more information.

8 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 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.

9 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

CONCUSSION. It s better to miss one game than the whole season. IN HIGH SCHOOL SPORTS A FACT SHEET FOR PARENTS. What is a concussion?

CONCUSSION. It s better to miss one game than the whole season. IN HIGH SCHOOL SPORTS A FACT SHEET FOR PARENTS. What is a concussion? HEADS UP CONCUSSION IN HIGH SCHOOL SPORTS A FACT SHEET FOR PARENTS 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,