Microsoft Word - CMS MS Athletic Pre-Participation Form

Page 1 of 3 • CMS MS Athletic Participation Form • 5/31/13

Charlotte-Mecklenburg Schools

Middle School Student-Athlete Pre-Participation Form

TAB THROUGH FORM & TYPE INFORMATION

OR PRINT FORM AND WRITE INFORMATION

PERSONAL & EMERGENCY CONTACT INFORMATION

Student-Athlete’s Name (First, MI, Last): CMS Student ID #

Gender: M F Date of Birth: Age: Home Phone:

Resides At Street Address: City: State: Zip Code: County:

Father’s Name: Daytime Phone: Cell Phone:

Street Address: City: State: Zip Code: County:

Mother’s Name: Daytime Phone: Cell Phone:

Street Address: City: State: Zip Code: County:

If applicable… Guardian’s

Name:

Daytime Phone: Cell Phone:

Street Address: City: State: Zip Code: County:

• If student-athlete resides with other than parent(s), attach legal documentation of custody (guardianship or affidavit provided by Student Placement)

Failure to provide accurate and up-to-date residence information may be grounds for loss of athletic eligibility

SPORT (check all sports you are considering to participate in)

Fall Winter Spring

Cheerleading Basketball - Boy’s Baseball

Football Basketball - Girl's Soccer - Boy's

Golf - Boy's Cheerleading Soccer - Girl's

Golf - Girl's Track - Boy's

Softball Track - Girl's

Volleyball - Girl's

INSURANCE

School Board Policy JLA requires that all students who participate in athletics be adequately covered by medical or accident insurance.

We acknowledge that it is the signed responsibility to notify CMS of any changes that occur to the personal insurance policy below and affect the procedures in

which the above-named individual may receive treatment; this includes loss of coverage. We certify that we have purchased and will maintain in full force and effect

during student-athlete’s participation in athletics the following insurance policy:

Check One: School Accident Insurance Personal Insurance Company

Name of Insurance Company Policy Number Group Number

Insurance Phone for Authorization Policy Holder

RELEASE

In consideration of CMS allowing the above-named individual to participate in athletics, we agree to release and hold CMS, its athletic coaches, and other

employees free, harmless and indemnified from and against any and all claims, suits, or causes of action arising from or out of injury that the student-athlete may

suffer from participation in athletics other than an injury from gross or willful negligence.

ASSUMPTION OF RISK

We acknowledge and understand that there is a risk of injury involved in athletic participation. We understand that the student-athlete will be under the supervision

and the instructions of the coach in order to reduce the risk of injury to the student-athlete and other athletes. However, we acknowledge and understand that neither

the coach nor CMS can eliminate the risk of injury in sports. Injuries may and do occur. Sports injuries can be severe and in some cases may result in permanent

disability or even death. We freely, knowingly, and willfully accept and assume the risk of injury that might occur from participation in athletics.

HIPAA / FERPA RELEASE

The above named student-athlete has opted his/her rights under the US Department of Health and Human Resources guidelines. By signing this release, the

student-athlete allows sharing of medical information between the Sports Medicine Staff (team physicians and medical staff, athletic trainers, and student

assistants), the CMS Athletics Staff (Athletic Director and Coaches), CMS Administration and his/her medical provider(s). In the event of an emergency situation,

information may be shared with emergency medical personnel. Every reasonable effort will be made to protect this information. It is understood that once this

medical information is disclosed, it is no longer protected under the HIPAA/FERPA guidelines.

SEVENTH GRADE ENTRY

• This is my consecutive semester at Middle School

• I initially entered the seventh grade in the fall of (yr.)

• Last semester I attended School in City State

Parent/Guardian Initials: ______________ Student-Athlete Initials: ______________

Page 2 of 3 • CMS MS Athletic Participation Form • 5/31/13

MEDICAL HISTORY

* Please take the time, read through the questions, and answer to the best of your knowledge.*

The following questions should be answered by the student-athlete with the assistance of a parent/guardian. Explain any “Yes” answers below.

If additional space is needed, please attach to this form.

General Medical History

YES NO Cardiovascular History YES NO

1. Does the athlete have a chronic illness or see a doctor regularly for any

particular problem? --------------------------------------------------------------------------

1. Do you cough, wheeze or have extreme trouble breathing with exercise? -------

2. Has the athlete had surgery other than a tonsillectomy? ---------------------------

2. Do you use an inhaler? ------------------------------------------------------------------------

3. Has the athlete ever been hospitalized? -----------------------------------------------

3. Ever passed out/nearly passed out during/after exercise? ---------------------------

4. Does the athlete have sickle cell trait? --------------------------------------------------

4. Ever been dizzy during or after exercise? ------------------------------------------------

5. Does the athlete have history of seizures? --------------------------------------------

5. Ever had chest pain/discomfort during or after exercise? ----------------------------

6. Does the athlete have only one of any paired organ (eyes, ears, kidneys,

testicles, ovaries, etc.)? --------------------------------------------------------------------

6. Do you tire more easily or more quickly than your friends during exercise? -----

7. Do you have any skin problems other than acne? -----------------------------------

7. Ever had a racing of your heart or skipped heartbeats? ------------------------------

8. Has the athlete ever suffered a heat-related illness (heat exhaustion or heat

stroke)? ----------------------------------------------------------------------------------------

8. Ever been told you had a heart murmur? ------------------------------------------------

9. Have you ever had a head injury, been knocked out, lost your memory, had

your ‘bell rung’, or concussion? ----------------------------------------------------------

9. Ever been told you have high blood pressure? -----------------------------------------

10. Have you had mononucleosis or any significant illness in the last 60 days?--

10. Has any member of your family:

• Died of heart problems or sudden death before age 50? -----------------------

• Been told they had a serious heart problem before age 50? ------------------

• Been told they had Marfan’s syndrome? -------------------------------------------

Hypertrophic or dilated cardiomyopathy? ------------------------------

Heart rhythm abnormality? ------------------------------------------------

11. Do you wear glasses or contacts? ------------------------------------------------------

12. Does athlete have trouble with hearing/wear hearing aid(s)? --------------------

13. Are you currently taking any medicines or do you take any medicines on a

regular basis (prescription or over-the-counter)? -----------------------------------

14. Have you ever taken any supplements or vitamins to help with weight

loss/gain or improve performance? ----------------------------------------------------

Orthopedic History YES NO

15. Do you have any allergies (seasonal/insects/food/medicines)? ----------------

1. Has the athlete ever broken or fractured any bones? ---------------------------------

16. Do you want to weigh more or less than you do now? ----------------------------

2. Has the athlete ever subluxed or dislocated any joint? -------------------------------

17. Do you lose weight regularly to meet weight requirements for you sport or

other reasons? ------------------------------------------------------------------------------

3. Have you ever had a stinger, burner, or pinched nerve? ----------------------------

18. Do you feel stressed out, tired, or depressed? --------------------------------------

4. Have you had any other problems related to your:

• Neck, spine, or back? -------------------------------------------------------------------

• Shoulders? --------------------------------------------------------------------------------

• Elbows? ------------------------------------------------------------------------------------

• Wrists, hands, fingers? -----------------------------------------------------------------

• Hips? ----------------------------------------------------------------------------------------

• Knees? --------------------------------------------------------------------------------------

• Ankles, feet, or toes? --------------------------------------------------------------------

• Other? ---------------------------------------------------------------------------------------

19. Have you ever been denied or restricted from participation in sports? --------

20. Are there any other issues you would like to discuss with a healthcare

professional? ---------------------------------------------------------------------------------

FEMALES ONLY

YES NO

21. Are your periods irregular (not every month)? ---------------------------------------

22. Are your periods heavy? ------------------------------------------------------------------

Please explain “Yes” answers in the space below. Please put date(s) of any injuries along with explanation:

CERTIFICATION / MEDICAL AUTHORIZATION

We certify that all of the information provided by us on this form is correct. We agree by the rules of the NCDPI and CMS. We give our consent for the student-athlete

to receive a medical screening prior to participation in athletics and acknowledge that this is simply a screening evaluation and not suitable for regular health

care. If the student-athlete is injured while participating in athletics and CMS is unable to contact the parent, we grant CMS permission and the authority to obtain

necessary medical care and/or treatment for the student’s injury including first aid, CPR, medical or surgical treatment recommended by a physician and we accept

the financial responsibility for such medical care or treatment.

We (student and parents) certify that the home address shown in this document is the student’s sole bona fide residence, and we will notify the school principal

immediately of any change in residence, since such a move may alter the eligibility status of the student athlete.

All information contained in this form is accurate and correct.

Student-Athlete: ___________________________________________________ Date: _____________________________

(Signature)

Parent/Guardian: ___________________________________________________ Date: _____________________________

(Please Print Name)

Parent/Guardian: ___________________________________________________ Date: _____________________________

(Signature)

Page 3 of this document must be completed by a

Physician, Physician’s Assistant or Nurse Practitioner

Page 3 of 3 • CMS MS Athletic Participation Form • 5/31/13

Name (First, MI, Last): ________________________________________________________ CMS Student ID # ____________________________

PHYSICAL EXAMINATION: To be completed by a Physician, Physician’s Assistant or Nurse Practitioner ONLY

Height: _______________ Weight: _______________ Pulse: _______________ Blood Pressure (sitting): (arm) __________ (leg) ___________

Vision: Right 20 / _________ Left 20 / _________ Corrected: Y N Body Fat% (opt.): ___________ UA (opt.): ___________

Normal Abnormal Findings Initials

General

edica

earance/Emotional Affect

Head/E

es/Ears/Nose/Throat

h Nodes

Heart

(

standin

/su

ine

)

Pulses

(

include femoral

)

Lun

Abdomen

(

include liver, s

leen

)

Skin

Neurolo

(

Balance, Coordination

)

Genitalia

(

males onl

Orthopedic Record if any laxity,

weakness, instability, decreased ROM

Cervical/Spine

Shoulder/Arm

Elbow/Forearm

Wrist/Hand

Hip/Thigh

Knee

Leg/Ankle

Foot

Cardiologic (optional)

EKG

Echocardiogram

Neurologic (optional)

Baseline Neuropsychological Testing

CLEARANCE

I, the undersigned, certify that I have examined this student-athlete and find him/her medically:

 Cleared

 Deferred until: (e.g. Rehab, consultation, lab, referral, etc.) ____________________________________________________________

 May participate in the following sport(s) ONLY: (CHECK ALL THAT APPLY)

______ Contact/Collision ______ Limited Contact ______ Non-Contact/Strenuous ______ Non-Contact/Non-Strenuous

Classification of Sports by Contact

Contact/Collision Limited Contact Non-Contact

Strenuous Non-Strenuous

 Football  Baseball/Softball  Discus, Javelin, Shot Put Golf

 Soccer  Basketball  Running/Cross Country

 Cheerleading  Swimming

 Volleyball  Tennis

 High Jump, Pole Vault  Strength Training

Please specify each condition requiring clearance before participating in a sport in the classification checked above:

_______________________________________________________________________________________________________________________________

 Not cleared Due to: ______________________________________________________________________________________________

The following are considered disqualifying, but not limited to, until medical and parental releases are obtained: Atlantoaxial instability; Bleeding disorder; Hypertension; Dysrhythmia; Mitral valve

prolapse; Acute infections; Obvious growth retardation; Diabetes mellitus; Jaundice; Severe visual or auditory impairment; Pulmonary insufficiency; Organ transplant recipient; Enlarged liver or

spleen; Hernia; Musculoskeletal deformity associated with functional loss; History of convulsions or repeated concussions; Absence of one kidney, eye, testicle, ovary, etc.

Physician’s Name: _________________________________________

Address: _________________________________________________

_________________________________________________

Phone: ___________________________________________________

Physician Office Stamp:

Signature _________________________________________________ MD PA NP Date of exam: __________________________