PARADISE

VALLEY

UNIFIED

ATHLETIC

SCHOOL

N O. 6 9_

INFORMATION

CHECK ALL THAT APPLY ___BADMINTON ___X COUNTRY ___FOOTBALL ___GOLF ___SWIM/DIVE

DISTRICT

___SPIRITLINE ___BASEBALL ___VOLLEYBALL ___SOFTBALL ___BASKETBALL ___TENNIS ___SOCCER ___TRACK ___WRESTLING ___UNIFIED

STUDENT ID # _____________________ OFFICE USE ONLY _____ Emergency Card _____ I C Video _____ Brain Book

_____ Clearance Issued _____ Physical _____ Date Completed

***PLEASE READ CAREFULLY AND FULLY COMPLETE ALL PAGES AND SIGNATURE LINES*** STUDENT: __________________________________________________________________ BIRTHDAY: ___________________ SEX: _________ GRADE: _____________ HOME ADDRESS: ________________________________________________________________________ CITY: _____________________________ ZIP: ______________ PARENT (S) NAME: ______________________________________________________ HOME PHONE: _______________________ CELL PHONE: ____________________ If not living with parents, name of Guardian __________________________________________________________________ Relationship? _____________________________ Schools or schools attended last year: _________________________________________________________________________________________________________________ IF PARENT OF GUARDIAN CANNOT BE CONTACTED IN AN EMERGENCY, PLEASE CONTACT: NAME: _________________________________________________________________ HOME PHONE: _______________________ CELL PHONE: ____________________ PHYSICIAN: ___________________________________________________________________ PHYSICIAN’S PHONE: ___________________________________________ PREFERRED HOSPITAL: _________________________________________________ ALLERGIES: ___________________________________________________________ I hereby give consent for coaches, trainers, or a team physician to use their judgment in securing medical aid in emergencies. INSURANCE It is recommended that each student athlete have medical insurance coverage. THE PARADISE VALLEY UNIFIED SCHOOL DISTRICT DOES NOT PROVIDE HEALTH INSURANCE FOR STUDENT ATHLETES. Parents are highly encouraged to obtain insurance, as they are responsible for medical bills incurred as a result of participation in athletics. Parents must provide insurance information to assist coaches, trainers, other athletic staff, and medical people in the event an athlete may require medical assistance as a result of injury. I have purchased school insurance: ( ) YES ( ) NO I have my own insurance: ( ) YES ( ) NO Insurance Co.: ________________________________________________________________ Policy No.: _______________________________________________________ PARENT CONSENT SPORTS INJURY VIDEO In order to participate in District organized athletics, each student together with their parent or guardian must view the online Parent Consent Sports Injury Video prior to participating in their first District organized athletic sport. A link to this video can be found at http://youtu.be/rtTJR9KNVWQ BY MY SIGNATURE BELOW, I CONFIRM THAT MY STUDENT ATHLETE AND I HAVE VIEWED THE ONLINE VIDEO AND UNDERSTAND THE RISKS INVOLVED IN PARTICIPATION IN DISTRICT ATHLETICS. PARENT/GUARDIAN SIGNATURE: _________________________________________________________________ DATE: _______________________________ BRAINBOOK ALL athletes are required by the AIA to complete a concussion education course as well as pass a test at the end of the course with a minimum score of 80% before they are allowed to compete in any sport. A certificate of completion must be printed and turned in. The website for this course is http://aiaacademy.org/users/login/brainbook. This course only needs to be completed one time prior to participating in their first District organized athletic sport. STUDENT ATHLETE DRUG TESTING CONSENT I/WE HAVE READ AND UNDERSTAND The Paradise Valley Unified School District Parent and Athlete Informed Consent and Random Drug Testing Handbook. I will allow my son/daughter to participate in this drug program while participating as a high-school athlete in the Paradise Valley Unified School District and hereby voluntarily agree to be subject to the terms of the prevention program. I accept the method of obtaining urine samples, testing and analysis of such specimens and all other aspects of the program. I agree to cooperate in furnishing urine specimens that may be required from time to time. I further agree and consent to the disclosure of the sampling, testing, and results as provided in the program. This consent is given pursuant to all state and federal privacy statutes and constitutional and common law privacy provisions and is a waiver of right to nondisclosure of such test records and results, only to the extent of the disclosure authorized in the program. PERMISSION TO TRANSPORT I/WE give the District permission for our son/daughter to be transported by District vehicles to away games and off-site practices as required. EQUIPMENT CODE It is the athlete’s responsibility to care for and return all equipment issued by the high school. I/WE understand and agree that all equipment issued to our son/daughter is the property of the high school and must be returned in reasonable condition. Items lost, stolen, or abused must be replaced and the Athletic Department reimbursed for the cost of the equipment. CODE OF CONDUCT/HANDBOOK I/WE have read and understand the information in the Informed Consent Handbook, including the PVUSD statement of understanding and the high school Code of Conduct, and attest the fulfillment of all rules and requirements for athletes, as outlined in the handbook. RELEASE OF NAME AND /OR IMAGE I/WE give the District permission for my/our son/daughter to be photographed while participating in District sporting events, and for such photographs to be used in various media publications and formats, including but not limited to web pages, newspaper articles, district publications, and/or district site newsletters. I/WE also agree to allow such photographs to be captioned from time to time with my/our son’s/daughter’s complete name. PARENT/GUARDIAN SIGNATURE:

ACKNOWLEDGEMENT I/WE have read, understand, and will abide by the statements listed on all pages of this packet. PARENT/GUARDIAN SIGNATURE: _______________________________________________ DATE: _____________________ STUDENT SIGNATURE: _________________________________________________________ DATE: _____________________ ATHPHYS – 3/18/14



ArizonaInterscholasticAssociation,Inc. MildTraumaticBrainInjury(MTBI)/Concussion AnnualStatementandAcknowledgementForm

I,_________________________(student),acknowledgethatIhavetobeanactiveparticipantinmyownhealth andhavethedirectresponsibilityforreportingallofmyinjuriesandillnessestotheschoolstaff(e.g.,coaches, teamphysicians,athletictrainingstaff).Ifurtherrecognizethatmyphysicalconditionisdependentupon providinganaccuratemedicalhistoryandafulldisclosureofanysymptoms,complaints,priorinjuriesand/or disabilitiesexperiencedbefore,duringorafterathleticactivities. Bysigningbelow,Iacknowledge: x

x x x x x x x x x

MyinstitutionhasprovidedmewithspecificeducationalmaterialsincludingtheCDCConcussionfact sheet(http://www.cdc.gov/concussion/HeadsUp/youth.html)onwhataconcussionisandhasgivenme anopportunitytoaskquestions. Ihavefullydisclosedtothestaffanypriormedicalconditionsandwillalsodiscloseanyfutureconditions. Thereisapossibilitythatparticipationinmysportmayresultinaheadinjuryand/orconcussion.Inrare cases,theseconcussionscancausepermanentbraindamage,andevendeath. Aconcussionisabraininjury,whichIamresponsibleforreportingtotheteamphysicianorathletic trainer. Aconcussioncanaffectmyabilitytoperformeverydayactivities,andaffectmyreactiontime,balance, sleep,andclassroomperformance. Someofthesymptomsofconcussionmaybenoticedrightawaywhileothersymptomscanshowup hoursordaysaftertheinjury. IfIsuspectateammatehasaconcussion,Iamresponsibleforreportingtheinjurytotheschoolstaff. IwillnotreturntoplayinagameorpracticeifIhavereceivedablowtotheheadorbodythatresultsin concussionrelatedsymptoms. IwillnotreturntoplayinagameorpracticeuntilmysymptomshaveresolvedANDIhavewritten clearancetodosobyaqualifiedhealthcareprofessional. Followingconcussionthebrainneedstimetohealandyouaremuchmorelikelytohavearepeat concussionorfurtherdamageifyoureturntoplaybeforeyoursymptomsresolve.

BasedontheincidenceofconcussionaspublishedbytheCDCthefollowingsportshavebeenidentifiedashighrisk forconcussion;baseball,basketball,diving,football,polevaulting,soccer,softball,spiritlineandwrestling. IrepresentandcertifythatIandmyparent/guardianhavereadtheentiretyofthisdocumentandfullyunderstand thecontents,consequencesandimplicationsofsigningthisdocumentandthatIagreetobeboundbythis document. StudentAthlete: PrintName:_________________________Signature:__________________________ Date:___________ Parentorlegalguardianmustprintandsignnamebelowandindicatedatesigned.

PrintName:_________________________Signature:__________________________ Date:___________ FORM15.7ͲC06/1ϯ

2

Exam Date ARIZONA INTERSCHOLASTIC ASSOCIATION 7007 North 18th Street, Phoenix, Arizona 85020-5552 Phone: (602) 385-3810

2014-2015 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION (The Parent or Guardian should fill out this form with assistance from the student athlete.) Name _______________________

Sex _________ Age ______

School ___________________________________

Date of Birth ______________

Grade ____________

Sport(s) _______________________________________________________

Address ______________________________________________________ Personal Physician __________________________________

Phone _________________________________

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.

1) Has a doctor ever denied or restricted your participation in sports for any reason? 2) Do you have an ongoing medical condition (like diabetes or asthma)? 3) Are you currently taking any prescription or nonprescription (over-the-counter) medicines or supplements? (Please specify):

YES

4) Do you have allergies to medicines, pollens, foods, or stinging insects? (Please specify):

Head Neck Shoulder Upper Arm Elbow Hand/Fingers Chest Upper Back Low Back Knee Calf /Shin Ankle Foot/Toes

12) Have you ever had a stress fracture? 13) Have you been told that you have or have you had

an x-ray for atlantoaxial (neck) instability? 14) Do you regularly use a brace or assistive device? 15) Has a doctor told you that you have asthma or allergies? 16) Do you cough, wheeze, or have difficulty breathing

during or after exercise?

YES 18) Have you ever used an inhaler or taken asthma medicine? 19) Were you born without, are you missing. Or do you have a nonfunctioning kidney, eye, testicle or any other organ? 20) Have you had infectious mononucleosis (mono) within the last month? 21) Do you have any rashes, pressure sores, or other skin problems? 22) Have you had a herpes skin infection? 23) Hav e y ou ev er had an injury to y our f ace, head, skull or brain

NO

(including a concussion, conf usion, memory loss or headache f rom a hit to y our head, hav ing y our "bell rung" or getting "dinged")?

5) Does your heart race or skip beats during exercise? 6) Has a doctor ev er told y ou that y ou hav e (check all that apply) : High blood pressure A heart murmur High cholesterol A heart infection 7) Have you ever spent the night in the hospital? 8) Have you ever had surgery? * 9) Have you ever had an injury (sprain, muscle/ligament YES tear, tendinitis, etc.) that caused you to miss a practice or game? (If yes, circle affected area in the box below): *10) Have you had any broken/fractured bones or dislocated joints? (If yes, circle affected area in the boxes below): * 11) Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? (If yes, circle affected area in the boxes below): *

NO

24) Have you ever had a seizure? 25) Doyou have headaches with exercise? 26) Hav e y ou ev er had numbness, tingling, or weakness in y our arms or legs af ter being hit, f alling, stingers or burners?

27) When exercising in the heat, do you have severe mucsle cramps or become ill? 28) Has a doctor told you that you or someone in your NO family has sickle cell trait or sickle cell disease? 29) Have you ever been tested for sickle cell trait? 30) Have you had any problems with your eyes or vision? 31) Do you wear glasses or contact lenses? 32) Do you wear protective eyewear, such as goggles or a face shield? 33) Are you happy with your weight? 34) Are you trying to gain or lose weight? 35) Has anyone recommended you change your weight or Forearm eating habits? Hip Thigh 36) Do you limit or carefully control what you eat? 37) Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY YES 38) Have you ever had a menstrual period? 39) How old were y ou when y ou had y our f irst menstrual period? 40) How many periods have you had in the last year?

17) Is there anyone inyour family who has asthma?

Explain "Yes" answers here:

Page 1 of 2

NO

2014-2015 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION (The Physician should fill out this form with assistance from the Parent or Guardian.)

Student Name:

Date of Birth:

Patient History Questions: Please tell me about your child . 1) Has your child fainted or passed out DURING or AFTER exercise, emotion or startle? 2) Has your child ever had extreme shortness of breath during exercise? 3) Has your child had extreme fatigue associated with exercise (different from other children)? 4) Has your child ever had discomfort, pain or pressure in his/her chest during exercise? 5) Has a doctor ever ordered a test for your child's heart? 6) Has your child ever been diagnosed with an unexplained seizure disorder?

YES

NO

YES

NO

7) Has your child ever been diagnosed with exercised -induced asthma not well controlled with medication? Family History Questions: Please tell me about any of the follow ing in your family . 8) Are there any family members who had sudden, unexpected, unexplained death before age 50? (including SIDS, car accidents, drowning, or near drowning) 9) Are there any family members who died suddenly of "heart problems" before age 50? 10) Are there any family members who have unexplained fainting or seizures? 11) Are there any relatives with certain conditions, such as: Enlarged Heart: Hypertrophic Cardiomyopathy (HCM) Dilated Cardiomyopathy (DCM) Heart Rhythm problems: Long QT Syndrome (LQTS) Short QT Syndrome Brugada Syndrome Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) Marfan Syndrome (Aortic Rupture) Heart Attack, age 50 or younger Pacemaker or Implanted Defibrillator Deaf at Birth (Congenital Deafness) Explain "Yes" answers here:

I hereby state that, to the best of my knowledge, my answers to all of 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 MD/DO/NP/PA/ND:

Signature of parent/guardian:

Date:

FORM 15.7-A 02/14

Page 2 of 2

Date:

2012-2013 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION Name __________________________________

Date of birth ______________ Age ________ Sex _______

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

R 20 / _____

L 20 / _____

NORMAL

Corrected:

Y

N

Pupils:

Equal _____ Unequal _____

ABNORMAL FINDINGS

INITIALS *

MEDICAL Appearance Eyes/Ears/Nose/Throat Hearing Lymph Nodes Heart Murmurs Pulses Lungs Abdomen Genitourinary †† Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm W i t/H d/Fi 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:

Ƒ Cleared without restriction Ƒ Not cleared for:

Ƒ All sports

Ƒ Certain sports: ___________________________ Reason: _________________________

Recommendations: ____________________________________________________________________________________________

Name of physician (print/type) _____________________________________________________________

Date ________________

Address ________________________________________________________________________ Phone ______________________ Signature of physician _________________________________________________________, MD / DO / NP / PA-C

FORM 15.7-B

03/12

ATHLETICS CONSENT FOR EMERGENCY CARE

Student name ____________________________________________________ID ___________________ Grade _________ Sport(s) Fall _________________________ Winter ___________________________ Spring_________________________ BE IT KNOWN that I, the undersigned or guardian of the student above named, do hereby give and grant unto any medical doctor or hospital my consent and authorization to rend such aid, treatment or care to said student as in the judgment of said doctor or hospital, may be required, on an emergency basis, in the event said student should be injured or stricken while participating in an interscholastic activity sponsored or sanctioned by Arizona Interscholastic Association, Inc. of which the named high school is a member. IT IS HEREBY understood that the consent and authorization hereby given and granted are continuing, and are intended by me to extend throughout the current school year. IT IS FURTHER understood that any expense incurred will be paid for by insurance or the parent/guardian of the student. Payment of the expense is not a school responsibility. EMERGENCY CARE: If emergency service involving medical action or treatment is required and neither the parents or guardians can be contacted, I hereby consent for the student named above to be given medical care by the doctor selected by the school. _________________________________________________________________ Signature of Parent/Guardian Date

______________________________ Student date of birth

______________________________________________________________________________________________________ Print name of Parent/Guardian name Mailing address Father’s phone numbers _________________________________________________________________________________ Primary Secondary Mother’s phone numbers _________________________________________________________________________________ Primary Secondary IN CASE OF EMERGENCY – if parent/guardian not available – contact: Friend/Relative _______________________________________________________Phone _____________________________ Friend/Relative _______________________________________________________Phone _____________________________ Family physician ______________________________________________________Phone _____________________________ Hospital _______________________________________Insurance co. & policy # _____________________________________ PLEASE LIST ANY CONDITIONS, MEDICATIONS OR ALLERGIES BELOW:

ISS-Athletic-001-rev5/12



P U S D HEA SION CONCUS

A FACT SHEET FOR ATHLETES

IN HIGH SCHOOL SPORTS

What is a concussion?

What should I do if I think I have a concussion?

All concussions are serious. A concussion can affect your ability to do schoolwork and other activities (such as playing video games, working on a computer, studying, driving, or exercising). Most people with a concussion get better, but it is important to give your brain time to heal.

• Tell your coaches and your parents. Never ignore a bump or blow to the head even if you feel fine. Also, tell your coach right away if you think you have a concussion or if one of your teammates might have a concussion. • Get a medical check-up. A doctor or other health care professional can tell if you have a concussion and when it is OK to return to play. • Give yourself time to get better. If you have a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have another concussion. Repeat concussions can increase the time it takes for you to recover and may cause more damage to your brain. It is important to rest and not return to play until you get the OK from your health care professional that you are symptom-free.

What are the symptoms of a concussion?

How can I prevent a concussion?

You can’t see a concussion, but you might notice one or more of the symptoms listed below or that you “don’t feel right” soon after, a few days after, or even weeks after the injury. • Headache or “pressure” in head • Nausea or vomiting • Balance problems or dizziness • Double or blurry vision • Bothered by light or noise • Feeling sluggish, hazy, foggy, or groggy • Difficulty paying attention • Memory problems • Confusion

Every sport is different, but there are steps you can take to protect yourself. • Use the proper sports equipment, including personal protective equipment. In order for equipment to protect you, it must be: - The right equipment for the game, position, or activity - Worn correctly and the correct size and fit - Used every time you play or practice • Follow your coach’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times.

A concussion is a brain injury that: • Is caused by a bump, blow, or jolt to the head or body. • Can change the way your brain normally works. • Can occur during practices or games in any sport or recreational activity. • Can happen even if you haven’t been knocked out. • Can be serious even if you’ve just been “dinged” or “had your bell rung.”

If you think you have a concussion: Don’t hide it. Report it. Take time to recover.

It’s better to miss one game than the whole season. For more information and to order additional materials free-of-charge, visit: www.cdc.gov/Concussion.

U.S. D EPARTMENT June 2010

OF H EALTH AND H UMAN S ERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION 

P U S D HEA SION IN HIGH SCHOOL SPORTS

CONCUS What is a concussion?

A concussion is a brain injury. Concussions are caused by a bump, blow, or jolt to the head or body. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms?

You can’t see a concussion. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days after the injury. If your teen reports one or more symptoms of concussion listed below, or if you notice the symptoms yourself, keep your teen out of play and seek medical attention right away. Signs Observed by Parents or Guardians

• Appears dazed or stunned • Is confused about assignment or position • Forgets an instruction • Is unsure of game, score, or opponent • Moves clumsily • Answers questions slowly • Loses consciousness (even briefly) • Shows mood, behavior, or personality changes • Can’t recall events prior to hit or fall • Can’t recall events after hit or fall

Symptoms Reported by Athlete

• Headache or “pressure” in head • Nausea or vomiting • Balance problems or dizziness • Double or blurry vision • Sensitivity to light or noise • Feeling sluggish, hazy, foggy, or groggy • Concentration or memory problems • Confusion • Just not “feeling right” or is “feeling down”

How can you help your teen prevent a concussion?

Every sport is different, but there are steps your teens can take to protect themselves from concussion and other injuries. • Make sure they wear the right protective equipment for their activity. It should fit properly, be well maintained, and be worn consistently and correctly.

A FACT SHEET FOR PARENTS

• Ensure that they follow their coaches' rules for safety and the rules of the sport. • Encourage them to practice good sportsmanship at all times.

What should you do if you think your teen has a concussion?

1. Keep your teen out of play. If your teen has a concussion, her/his brain needs time to heal. Don’t let your teen return to play the day of the injury and until a health care professional, experienced in evaluating for concussion, says your teen is symptom-free and it’s OK to return to play. A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death. 2. Seek medical attention right away. A health care professional experienced in evaluating for concussion will be able to decide how serious the concussion is and when it is safe for your teen to return to sports. 3. Teach your teen that it’s not smart to play with a concussion. Rest is key after a concussion. Sometimes athletes wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don’t let your teen convince you that s/he’s “just fine.” 4. Tell all of your teen’s coaches and the student’s school nurse about ANY concussion. Coaches, school nurses, and other school staff should know if your teen has ever had a concussion. Your teen may need to limit activities while s/he is recovering from a concussion. Things such as studying, driving, working on a computer, playing video games, or exercising may cause concussion symptoms to reappear or get worse. Talk to your health care professional, as well as your teen’s coaches, school nurse, and teachers. If needed, they can help adjust your teen’s school activities during her/his recovery.

If you think your teen has a concussion: Don’t assess it yourself. Take him/her out of play. Seek the advice of a health care professional.

It’s better to miss one game than the whole season. For more information and to order additional materials free-of-charge, visit: www.cdc.gov/Concussion.

U.S. D EPARTMENT June 2010

OF H EALTH AND H UMAN S ERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION