santan jhs physical packet

8/14/2019 Santan JHS Physical Packet

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Santan Junior High Athletics2011 - 2012

Dear Parent and Athlete,

The following information is provided for both parent and athlete in order that we maintain a

clear understanding of what is needed and expected from your son or daughter in meetingeligibility for participation in the Chandler Unified School District programs. The packet mustbe completed in its entirety and returned to Mrs. Bell at the Student Services Desk prior tothe student attending tryouts or participating in the sport. Incomplete packets will be returnedto the student.

1. Physical ClearanceAll students participating in sports and/or cheer must have a physical. Thephysical packet must be completed, signed, and dated after March 1, 2011 to bevalid. Doctor’s clearance must be on the Arizona Interscholastic AssociationPhysical Evaluation form. Other forms will not be accepted.

2. InsuranceStudents must have insurance. They can be covered under a parent or familypolicy or under a school type plan. Brochures for school insurance are availableupon request. Parent/Family insurance holders must provide company name andpolicy number as requested.

3. Legal Guardian Consent for Emergency CareThis is located on page 3 of the packet and must be completed in its entirety.

4. Coaches Card/Athlete EmergencyThis is located on the page 4 of the packet. The coach will carry this to thepractices/games.

5. Tryout InformationThis needs to be read and signed by both the athlete and parent.

6. AIA/Chandler Unified School District Code of ConductThis is to be read and signed by both the student and parent.

7. AIA Concussion/MTBI Acknowledgement Form This is to be read and signed by both the student and parent. The attached Factsheet is for your reference. Please detach and keep.

Students must pass all classes. An F grade will not be accepted from any class.

If you have any questions, please do not hesitate to call Tamara Bell, Student ServicesAssistant, at (480) 883-4610 or at [email protected]. We appreciate yoursupport.



Exam Date

ARIZONA INTERSCHOLASTIC ASSOCIATION

7007 North 18th Street, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

2011-2012 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

(The Parent or Guardian should fill out this form with assistance from the student athlete.)

Name _______________________ Sex _______ Age ______ Date of Birth ______________ Grade ____________

School ___________________________________ Sport(s) _______________________________________________________

Address ______________________________________________________ Phone _________________________________

Personal Physician __________________________________ Hospital Preference _________________________________

In case of emergency, contact:

Name _____________________ Relationship ________________ Phone (H): __________ (W): __________ (C) ___________

Name _____________________ Relationship ________________ Phone (H): __________ (W): __________ (C) ___________

Explain "Yes" answers below.

Circle questions you don't know the answers to.

YES NO

1. Has a doctor ever denied or restricted your participation in sports YES NO 24. Do you cough, wheeze, or have difficulty breathing during

for any reason? □ □ or after exercise? □ □

2. Do you have an ongoing medical condition (like diabetes or 25. Is there anyone inyour family who has asthma? □ □

asthma)? □ □ 26. Have you ever used an i nhaler or taken asthma medicine? □ □

3. Are you currently taking any prescription or nonprescription (over- 27. Were you born without, are you missing. Or do you have a

the-counter) medicines or supplements? (Please specify): nonfunctioning kidney, eye, testicle or any other organ? □ □

□ □ 28. Have you had infectious mononucleosis (mono) within the

4. Do you have allergies to medicines, pollens, foods, or stinging last month? □ □

insects? (Please speciy): 29. Do you have any rashes, pressure sores, or other skin problems? □ □

□ □ 30. Have you had a herpes skin infection? □ □

31. Have you ever had an injury to your face, head, skull or brain

5. Have you ever passed out or nearly passed our DURING exercise? □ □ (including a concussion, confusion, memory loss or headache from □ □

6. Have you ever passed out or nearly passed out AFTER exercise? □ □ a hit to your head, having your "bell rung" or getting "dinged")?

7. Have you ever had di scomfort , pain, or pressure i n your chest during 32. Have you ever had a sei zure? □ □

exercise? □ □ 33. Doyou have headaches with exercise? □ □

8. Does your heart race or skip beats during exercise? □ □ 34. Have you ever had numbness, tingling, or weakness in your arms

9. Has a doctor ever told you that you have (check all that apply): or legs after being hit, falling, stingers or burners? □ □

□ High blood pressure □ A heart murmur □ □35. When exercising in the heat, do you have severe muscle cramps

□ High cholesterol □ A heart infection or become ill? □ □

10. Has a doctor ever ordered a test for your heart? (ex: ECG, 36. Has a doctor told you that you or someone in your family has

echocardiogram) □ □ sickle cell trait or sickle cell disease? □ □

11. Has anyone in your family died for no apparent reason? □ □ 37. Have you ever been tested for sickle cell trait? □ □

12. Does anyone in your family have a heart problem? □ □ 38. Have you had any problems with your eyes or vision? □ □

13. Has any family member or relative died of heart problems or of 39. Do you wear glasses or contact lenses? □ □

sudden death before age 50? □ □ 40. Do you wear protective eyewear, such as goggles or a face shield? □ □

14. Does anyone in your family have Marfan syndrome? □ □ 41. Are you happy with your weight? □ □

15. Have you ever spent the night in the hospital? □ □ 42. Are you trying to gain or lose weight? □ □

16. Have you ever had surgery? □ □ 43. Has anyone recommended you change your weight or eating

* 17. Have you ever had an injury (sprain, muscle/ligament tear, habits? □ □

tendinitis, etc.) that caused you to miss a practice or game? If yes, □ □ 44. Do you limit or carefully control what you eat? □ □

circle affected area in the boxes below: 45. Do you have any concerns that you would like to discuss with a

* 18. Have you had any broken/fractured bones or dislocated joints? doctor? □ □

If yes, circle affected area in the boxes below: □ □

* 19. Have you had a bone/joint injury that required x-rays, MRI, CT,FEMALES ONLY

surgery, injections, rehabilitation, physical therapy, a brace, a cast, or □ □

crutches? If yes, circle affected area in the boxes below: 46. Have you ever had a menstrual period? □ □

* □ Head □ Neck □ Shoulder □ Upper Arm □ Elbow □ Forearm 47. How old were you when you had your fi rst menstrual period?

□ Hand/Fingers □ Chest □ Upper Back □ Low Back □ Hip □ Thigh 48. How many periods have you had in the last year?

□ Knee □ Calf/Shin □ Ankle □ Foot/Toes

20. Have you ever had a stress fracture? □ □

21. Have you been told that you have or have you had an x-ray for Explain "Yes" answers here:

atlantoaxial (neck) instability? □ □

22. Do you regularly use a brace or assistive device? □ □

23. Has a doctor told you that you have asthma or allergies? □ □

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Furthermore, I acknowledge and understand that my eligibility

may be revoked if I have not given truthful and accurate information in response to the above questions.

Signature of athlete Signature of parent/guardian DateFORM 15.7-A 02/11



2011-2012 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

Name __________________________________ Date of birth ______________ Age ________ Sex _______

Height _________ Weight _________ % Body fat (optional) ___________ Pulse ______ BP ____ / ____ (____ / ____, ____ / ____)

Vision R 20 / _____ L 20 / _____ Corrected: Y N Pupils: Equal _____ Unequal _____

NORMAL ABNORMAL FINDINGS INITIALS *

MEDICAL

Appearance

Eyes/Ears/Nose/Throat

Hearing

Lymph Nodes

Heart

Murmurs

Pulses

Lungs

Abdomen

Genitourinary †

SkinMUSCULOSKELETAL

Neck

Back

Shoulder/Arm

Elbow/Forearm

Wrist/Hand/Fingers

Hip/Thigh

Knee

Leg/Ankle

Foot/Toes

* Multi-examiner set-up only.

† Having a third party present is recommended for the genitourinary examination.

Notes:

□ Cleared without restriction

□ Not cleared for: □ All sports □ Certain sports: ___________________________ Reason: _________________________

Recommendations: ____________________________________________________________________________________________

Name of physician (print/type) _____________________________________________________________ Date ________________

Address ________________________________________________________________________ Phone ______________________

Signature of physician _________________________________________________________, MD / DO / NP / PA-C

FORM 15.7-B 02/11



Legal Guardian Consent

I / we give our consent forto participate in organized interscholastic athletics, realizing that such activity involves the potential for injurywhich is inherent in all sports. I / we acknowledge that even the best coaching, use of the most advanced

protective equipment and strict observance of rules, injuries are still a possibility. On rare occasions, these injuriescan be so severe as to result in total disability, paralysis, quadriplegia or even death.

I / we acknowledge that I / we have read and understand this warning.

My signature verifies also that I am the legal guardian of the above named student.

Parent / Guardian

Student Athlete

INSURANCE INFORMATION CARDCHANDLER UNIFIED SCHOOLS

Name

Grade

For a student to participate in an athletic program,

accident insurance in required.NAME OF COMPANY STUDENT IS COVERED BY:

Policy No.:

I do want school insurance: Yes No

At school protection 24 hour

(Parent / Guardian Signature)

Address

Phone

ATHLETICS EMERGENCY CARD

Student’s Name

I,give the coach permission to seek medical aid as deemed

necessary for my son / daughter in the event I cannot becontacted.

(Parent / Guardian Signature)

Address

Phone

Doctor

Doctor Phone

33-4016

3



Santan Jr. High Coaches Card

Athletic Emergency CardChandler Unified School District

Student’s Name:

Gender: Male Female Grade:

I, , give the coach permission toseek medical aid as deemed necessary for my son / daughter in the event Icannot be contacted.

Parent/Guardian Signature Date

Address:

Phone: Alt. Phone:

Doctor: Phone:

Insurance Co.

Policy # Exp.

1st Season Sport 2nd Season Sport

3rd

Season Sport 4th

Season Sport

4



2011-12 Santan JHS Tryout Information

Parents and Athletes,

1. Students need to be picked up after tryouts as we do not have late buses.Parents should be here by 5:30pm, tryouts should not last much past thiseach day.

2. Per school guidelines, all tryouts are closed to parents and/or spectators.In the past, we have had many people attend tryouts, placing undopressure on athletes and in some cases, trying to provide instruction tothose participating during the tryout. The idea of the tryout is to assess

the skill and attitudes of the student athletes at their current level. Foroutside sports, such as flag football, baseball, softball, and soccer, werequire that parents refrain from approaching the tryout area until after thetryout has completed.

3. During tryouts students need to wear a plain t-shirt. Jerseys, shirts or hatsshowing affiliation with any organization or club team are not allowed.

4. We expect all athletes to be role models both in and out of the classroom.Our athletes represent Santan as they travel to various schools around thedistrict. Grades, classroom behavior, and talent are all taken into

consideration before the final team is chosen.

Athlete Signature Date

Parent Signature Date

5



AIA-CHANDLER UNIFIED SCHOOL DISTRICT

Code of Conduct for Interscholastic Student-Athletes/Parents

Interscholastic athletic competition should demonstrate high standards of ethics and sportsmanship and promote the development of good character and important life skills. The highest potential of sports is achieved when participants are committed to pursuing victory with honor according to the six principals: trustworthiness, respect, responsibility, fairness, caring, and good citizenship (The Six Pillars of Character). The code applies to all student-athletes involved in interscholastic sports in Arizona. I understand in order to participate in high school athletics; I must act in accord with the following:

TRUSTWORTHINESS

1. Trustworthiness – be worthy of trust in all I do.

• Integrity – live up to the high ideals of esthetics andsportsmanship and always pursue victory with honors;do what’s right even when it’s unpopular or personallycostly.

• Honest – live and compete honorably, don’t lie, cheat,steal, or engage in any other dishonest orunsportsmanlike conduct.

• Reliability – fulfill commitments; do what I say I will do;

be on time to practices and games.• Loyalty – be loyal to my school and team; put the team

above personal glory.

RESPECT

2. Respect – treat all people with respect all the time andrequire the same of other student-athletes.

3. Class – live and play with class; be a good sport; begracious in victory and accept defeat with dignity; givefallen opponents help; compliment extraordinaryperformance, show sincere respect in pre- and post-season rituals.

4. Disrespectful conduct – don’t engage in disrespectfulconduct of any sort including profanity, obscene gestures,offensive remarks of a sexual or racial nature, trash-talking, taunting boastful celebrations, or other actions thatdemean individuals or the sport.

5. Respect officials – treat contest officials with respect; don’tcomplain about or argue with official calls or decisionsduring or after an athletic event.

RESPONSIBILITY

6. Importance of education – be a student first and commit togetting the best education I can. Be honest with myself

about the likelihood of getting an athletic scholarship orplaying on a professional level and remember that manyuniversities will not recruit student-athletes that do nothave a serious commitment to their education, the abilityto succeed academically or the character to representtheir institution honorably.

7. Role-Modeling – Remember, participation in sports is aprivilege, not a right and that I am expected to representmy school, coach and teammates with honor, on and offthe field. Consistently exhibit good character and conductmyself as a positive role model. Suspension, terminationof the participation privilege is within the sole discursion ofthe school administration.

8. Self-Control – exercise self-control; don’t fight or showexcessive displays of anger or frustration; have thestrength to overcome the temptation to retaliate.

9. Healthy Lifestyle – safe guard your health; don’t use anyillegal or unhealthy substances including alcohol, tobacco,and drugs or engage in any unhealthy techniques to gain,loose or maintain weight.

10. Integrity of the Game – protect the integrity of the game,don’t gamble. Play game according to the rules.

FAIRNESS

11. Be fair – live up to high standards of fair play; be open-minded; always be willing to listen and learn.

CARING

12. Concern for Others – demonstrate concern for othersnever intentionally injure any player or engage in recklessbehavior that might cause injury to others or myself.

13. Teammates – help promote the well-being of teammatesby positive counseling and encouragement or by reportingany unhealthy or dangerous conduct to coaches.

CITIZENSHIP

14. Play by the Rules – maintain a thorough knowledge andabide by all applicable game and competition rules.

15. Spirit of Rules – honor the spirit and letter of rules; avoidtemptations to gain completive advantage throughimproper gamesmanship techniques that violate thehighest traditions of sportsmanship.

I have read and understand the requirements of the Code ofConduct. I understand that I’m expected to perform according

to this code and understand that there may be sanctions orpenalties if I do not.

Student-Athlete Signature Date

Parent/Guardian Signature Date



Arizona Interscholastic Association, Inc.

Mild Traumatic Brain Injury (MTBI) / Concussion

Statement and Acknowledgement Form

I, _________________________ (student), acknowledge that I have to be an active participant in my own health

and have the direct responsibility for reporting all of my injuries and illnesses to the school staff (e.g., coaches,

team physicians, athletic training staff). I further recognize that my physical condition is dependent upon

providing an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/ordisabilities experienced before, during or after athletic activities.

By signing below, I acknowledge:

My institution has provided me with specific educational materials including the CDC Concussion fact

sheet (http://www.cdc.gov/concussion/HeadsUp/youth.html) on what a concussion is and has given me

an opportunity to ask questions.

I have fully disclosed to the staff any prior medical conditions and will also disclose any future conditions.

There is a possibility that participation in my sport may result in a head injury and/or concussion. In rare

cases, these concussions can cause permanent brain damage, and even death.

A concussion is a brain injury, which I am responsible for reporting to the team physician or athletic

trainer.

A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance,

sleep, and classroom performance.

Some of the symptoms of concussion may be noticed right away while other symptoms can show up

hours or days after the injury.

If I suspect a teammate has a concussion, I am responsible for reporting the injury to the school staff.

I will not return to play in a game or practice if I have received a blow to the head or body that results in

concussion related symptoms.

I will not return to play in a game or practice until my symptoms have resolved AND I have written

clearance to do so by a qualified health care professional.

Following concussion the brain needs time to heal and you are much more likely to have a repeatconcussion or further damage if you return to play before your symptoms resolve.

Based on the incidence of concussion as published by the CDC the following sports have been identified as high risk

for concussion; baseball, basketball, diving, football, pole vaulting, soccer, softball, spiritline and wrestling.

I represent and certify that I and my parent/guardian have read the entirety of this document and fully understand

the contents, consequences and implications of signing this document and that I agree to be bound by this

document.

Student Athlete:

Print Name: _________________________ Signature: __________________________

Date: ___________

Parent or legal guardian must print and sign name below and indicate date signed.

Print Name: _________________________ Signature: __________________________

Date: ___________

FORM 15.7-C 02/11

http://www.cdc.gov/concussion/HeadsUp/youth.html






U.S D E P A R T M E N T OF H E A L T H AND H U M A N S E R V I C E S

C E N T E R S FO R D I S E A S E C O N T R O L A N D P R E V E N T I O N

A Fact Sheet for ATHLETES

WHAT IS A CONCUSSION?

A concussion is a brain injury that :

• Is caused by a bump or blow to the head

• Can change the way your brain normal ly works

• Can occur during practices or games in

any sport • Can happen even if you haven't been

knocked out

• Can be serious even i f you've just been "dinged"

WHATARE THE SYMPTOMS OF

A CONCUSSION?

• Headache or "pressure" in head

• Nausea or vomiting

• Balance problems or dizziness

• Double or blurry vision• Bothered by light

• Bothered by noise

• Feeling sluggish, hazy, foggy, or groggy

• Difficulty paying attention

• Memory problems

• Confusion

• Does not "feel right"

WHATSHOULD I DO IF I THINK

I HAVE A CONCUSSION?

• Tell your coaches and your parents. Never

ignore a bump or blow to the head even if you

feel fine. Also, tell your coach if one of your

teammates might have a concussion.

• Get a medical check up. A doctor or health care

professional can tell you if you have a concussion

and when you are a1< to return to play.

• Give yourself time to get better. 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 second concussion. Second

or later concussions can cause damage to your

brain . It is important to rest until you get

approval from a doctor or health care

professional to return to play.

HOW CAN I PREVENT A CONCUSSION?

Every sport is different, but there are steps you

can take to protect yourself.

• Follow your coach's rules for safety and the

ru les of the sport.

• Practice good sportsmanship at all times .

• Use the proper sports equipment, including

personal protective equipment (such as helmets,

padding, shin guards, and eye and mouth

guards) . In order for equipment to protect you,

it must be:

> The right equipment for the game, position,

or activity

> Worn correctly and fi t well

> Used every time you play

It's better to miss one game than the whole season.

For more information and to orderadditional materials free-of-charge. visit: For more detailed information on concussion and traumatic brain injury, visit:

www.cdc.govjConcussionInYouthSports www.cdc.govjinjury

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