S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class

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1 Student Last Name Student First Name Middle Initial S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class Student ID Number Sport(s) of Interest (please list all) Athletic Eligibility Packet Congratulations on your choice to participate in athletics at East Ridge High School. ERHS is a proud member of Florida High School Athletics Association (FHSAA), and as such must operate under the rules and regulations established for governing all member schools. The administrators, athletic directors, athletic trainer and coaches are responsible for strict adherence to these policies, as well as county established policies. This is to assure the safety of all student-athletes and to protect the integrity of the athletic programs. Below is a checklist of the forms and documents that are required for participation in all high school athletics. Additional eligibility requirements must be met in order to participate (i.e. minimum GPA, establishing residency, etc.). Please be sure to complete the following steps correctly to ensure your clearance for participation in athletics at ERHS. Missing information will result in a denial to participate and will create unnecessary delays. Required forms and documents: Athletic clearance account pg 2 FHSAA El2 Preparticipation physical evaluation (Uploaded) pg 3-5 Copy of original birth certificate (Uploaded) pg 6 Copy of current health insurance card (Uploaded) pg 7 o School insurance of Florida maybe be purchased if necessary o Available for online purchase at **Football athletes must have special policy if purchasing insurance through school insurance of Florida 1

2 Instructions on how to complete athletic clearance After a physical exam is performed by the appropriate health care provider this information along with other documents must be uploaded to AthleticClearance.com 1. Go to AthleticClearance.com 2. Select Florida 3. If you already have an account login. If you don t have an account please register then login. 4. Select start clearances a. Select under year b. Select East Ridge High school for school c. Select which sport you are trying out for i. If you are playing multiple sports you can add them all at the end 5. Fill out student information 6. Upload the required documents under the following sections a. Page 1 of El2 physical form physical form b. Page 2 of El2 form concussion/ baseline certification c. Birth certificate additional form d. Insurance card proof of insurance **Uploading the documents can be done in a variety of ways. A couple examples are taking pictures with a cell phone, using a scanning application on a cell phone or using a scanner. ** Not knowing how is not an excuse for not doing this step. Please ask questions if you need help. 7. Fill out medical history 8. Fill out parent/guardian 9. Fill out signatures a. Make sure to place the correct signatures in the appropriate boxes b. Place parents name where it says parent signature c. Place students name where it says student signature 10. Select all sports that you intend on trying out for!!!! 2

3 Florida High School Athletic Association Preparticipation Physical Evaluation (Page 1 of 3) EL2 Revised 03/16 This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2. This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted. Part 1. Student Information (to be completed by student or parent) Student s Name: Sex: Age: Date of Birth: / / School: Grade in School: Sport(s): Home Address: Home Phone: ( ) Name of Parent/Guardian: Person to Contact in Case of Emergency: Relationship to Student: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Personal/Family Physician: City/State: Office Phone: ( ) Part 2. Medical History (to be completed by student or parent). Explain yes answers below. Circle questions you don t know answers to. Yes No 1. Have you had a medical illness or injury since your last check up or sports physical? 2. Do you have an ongoing chronic illness? 3. Have you ever been hospitalized overnight? 4. Have you ever had surgery? 5. Are you currently taking any prescription or non- prescription (over-the-counter) medications or pills or using an inhaler? 6. Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance? 7. Do you have any allergies (for example, pollen, latex, medicine, food or stinging insects)? 8. Have you ever had a rash or hives develop during or after exercise? 9. Have you ever passed out during or after exercise? 10. Have you ever been dizzy during or after exercise? 11. Have you ever had chest pain during or after exercise? 12. Do you get tired more quickly than your friends do during exercise? 13. Have you ever had racing of your heart or skipped heartbeats? 14. Have you had high blood pressure or high cholesterol? 15. Have you ever been told you have a heart murmur? 16. Has any family member or relative died of heart problems or sudden death before age 50? 17. Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month? 18. Has a physician ever denied or restricted your participation in sports for any heart problems? 19. Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, blisters or pressure sores)? 20. Have you ever had a head injury or concussion? 21. Have you ever been knocked out, become unconscious or lost your memory? 22. Have you ever had a seizure? 23. Do you have frequent or severe headaches? 24. Have you ever had numbness or tingling in your arms, hands, legs or feet? 25. Have you ever had a stinger, burner or pinched nerve? Yes No 26. Have you ever become ill from exercising in the heat? 27. Do you cough, wheeze or have trouble breathing during or after activity? 28. Do you have asthma? 29. Do you have seasonal allergies that require medical treatment? 30. Do you use any special protective or corrective equipment or medical devices that aren t usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, shunt, retainer on your teeth or hearing aid)? 31. Have you had any problems with your eyes or vision? 32. Do you wear glasses, contacts or protective eyewear? 33. Have you ever had a sprain, strain or swelling after injury? 34. Have you broken or fractured any bones or dislocated any joints? 35. Have you had any other problems with pain or swelling in muscles, tendons, bones or joints? If yes, check appropriate blank and explain below: Head Elbow Hip Neck Forearm Thigh Back Wrist Knee Chest Hand Shin/Calf Shoulder Finger Ankle Upper Arm Foot 36. Do you want to weigh more or less than you do now? 37. Do you lose weight regularly to meet weight requirements for your sport? 38. Do you feel stressed out? 39. Have you ever been diagnosed with sickle cell anemia? 40. Have you ever been diagnosed with having the sickle cell trait? 41. Record the dates of your most recent immunizations (shots) for: Tetanus: Measles: Hepatitus B: Chickenpox: FEMALES ONLY (optional) 42. When was your first menstrual period? 43. When was your most recent menstrual period? 44. How much time do you usually have from the start of one period to the start of another? 45. How many periods have you had in the last year? 46. What was the longest time between periods in the last year? Explain Yes answers here: We hereby state, to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s , Florida Statutes, and FHSAA Bylaw 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test. Signature of Student: Date: / / Signature of Parent/Guardian: Date: / / 1

4 EL2 Florida High School Athletic Association Preparticipation Physical Evaluation (Page 2 of 3) Revised 03/16 Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed physician assistant or certified advanced registered nurse practitioner). Student s Name: Date of Birth: / / Height: Weight: % Body Fat (optional): Pulse: Blood Pressure: / ( /, / ) Temperature: Hearing: right: P F left: P F Visual Acuity: Right 20/ Left 20/ Corrected: Yes No Pupils: Equal Unequal FINDINGS NORMAL ABNORMAL FINDINGS INITIALS* MEDICAL 1. Appearance 2. Eyes/Ears/Nose/Throat 3. Lymph Nodes 4. Heart 5. Pulses 6. Lungs 7. Abdomen 8. Genitalia (males only) 9. Skin MUSCULOSKELETAL 10. Neck 11. Back 12. Shoulder/Arm 13. Elbow/Forearm 14. Wrist/Hand 15. Hip/Thigh 16. Knee 17. Leg/Ankle 18. Foot * station-based examination only This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2. This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted. ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s): Cleared without limitation Disability: Diagnosis: Precautions: Not cleared for: Reason: Cleared after completing evaluation/rehabilitation for: Referred to For: Recommendations: Name of Physician/Physician Assistant/Nurse Practitioner (print): Date: / / Address: Signature of Physician/Physician Assistant/Nurse Practitioner: 2

5 EL2 Florida High School Athletic Association Preparticipation Physical Evaluation (Page 3 of 3) Revised 03/16 This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2. This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted. Student s Name: ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable) I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s): Cleared without limitation Disability: Diagnosis: Precautions: Not cleared for: Reason: Cleared after completing evaluation/rehabilitation for: Recommendations: Name of Physician (print): Date: / / Address: Signature of Physician: Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine. 3

6 A Copy of an Original Certified Birth Certificate is required by the Florida High School Athletic Association for eligibility. All incoming freshmen, transfer students, and newly enrolled student athletes must upload a copy on athletic clearance under additional forms. 6

7 PROOF OF HEALTH INSURANCE COVERAGE Please upload copy of insurance card under proof of insurance on athletic clearance 7

8 Please take a moment and check that all paperwork in this eligibility packet is filled out COMPLETELY with all student and parent/guardian signatures before submission to East Ridge Athletics. The list of required forms is on the bottom of the cover page. Note: If you have not clicked all the sports you want to play you will have to go back into athletic clearance and do it again. Also if the signatures are done incorrectly they will be reset for you to do them again. A copy of a current health insurance card (front and back) is required. New student-athletes must also include a copy of their Birth Certificate with this sports eligibility packet. No exceptions. Incomplete accounts will NOT be accepted and will result in a denial status on athletic clearance. To avoid any delay in their participation eligibility please be sure the packet is 100% COMPLETE. Thank You, Athletic Department Any questions please contact the Athletic Trainer Gabrielle Sombelon at SombelonG@lake.k12.fl.us or the Athletic Director Rick Everett at EverettR@lake.k12.fl.us or the Assistant Athletic Director Ty Ensor at EnsorT@lake.k12.fl.us 8