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Microsoft word - aa12-13 physical paperwork risk acknowledgement

WEST ASHLEY HIGH SCHOOL SPORTS MEDICINE
Pre-participation Physical Evaluation Form
2013-2014 School Year
Personal Information (PLEASE PRINT) USE INK ONLY (Invalid if written in pencil) ALL INFORMATION MUST BE COMPLETED
NAME_______________________________________________ SEX: M F AGE___________ Date of Birth_________/_________/__________
Current Grade Level__________ School you attend NOW__________________________________SPORT(S):_________________________________________
Home Address__________________________________________________ City ______________________________________ Zip Code _____________________
___________________________________________________ ____________________________

_______________________________
Name of PARENT(s) or/Legal Guardian
Primary Phone #
Alternate Phone #

IN CASE OF EMERGENCY, PLEASE CONTACT: (In event Parent/Guardian cannot be reached)
Name________________________________ Relationship________________ Phone (H)_______________________ (WORK/CELL)__________________________

PERMISSION TO PARTICIPATE and RISK ACKNOWLEDGEMENT
As parent or guardian of the above named student-athlete, I hereby give my permission/consent for his/her participation in interscholastic athletics for the 2013-14 school year, and for
the physical exam evaluation required for participation. I understand that by participating in interscholastic athletics, my son/daughter is exposing him/herself to the risk of
serious injury and/or death.
There have been accidents resulting in serious permanent physical impairments as a result of athletic competition. NO AMOUNT OF INSTRUCTION,
PRECAUTION, AND SUPERVISION WILL TOTALLY ELIMINATE ALL THE RISK OF SERIOUS, CATASTROPHIC, OR EVEN FATAL INJURY.
Students will be instructed in the
proper techniques and are expected to adhere to proper technique and the use of proper equipment to ensure their own safety and the safety of others, both in practices and games.
By granting permission for your son/daughter to participate in athletic competition, you the parent or guardian acknowledges that such risks exist.
I further give the South
Carolina High School League permission to exam the school records of the above student in order to verify eligibility.
Secondly, I hereby give permission to the West Ashley High Sports Medicine Department, its staff and associated providers to dispense appropriate medical treatment for
my son/daughter in event of an injury / emergency.
I further consent to the release of pertinent medical information to the appropriate authorities upon proper and legal request. I
consent to allow the Head Athletic Trainer (ATC) to act on my behalf in the case of an emergency requiring transport to and treatment of my son/daughter at a hospital. I understand
that every attempt will be made to contact me in the event of such injury. I further acknowledge that I am responsible for any medical costs arising from their participation in
athletics at West Ashley High School.

Lastly, I hereby give the West Ashley High Sports Medicine Department permission to dispense OTC medication to my son/daughter in event that this becomes necessary in the
course of treatment. Said OTC medications may be prescribed under standing orders of the team physicians, while participating in interscholastic athletics. This includes such OTC
medications/drugs as Tylenol, Ibuprofen, Aleve, Pepto-Bismol, decongestants, anti-histamines and other like medications. (A complete list of over-the counter (OTC) drugs available to
WAHS athletes is available upon request). I further certify that the medical history on the following page is accurate to the best of my knowledge.
INFORMATION CONCERNING PARTICIPATION IN SPORTS
By its very nature, competitive athletics puts students in situations in which serious, catastrophic, and sometimes fatal accidents and illnesses may occur. Many forms of athletic
competition and practice result in violent physical contact. The use of athletic equipment may result in accidents, injury, or death. Strenuous physical exertion and numerous other
exposures to the risk of injury occur while participating in interscholastic athletics.
A student and his/her parents must assess the risks involved in participation in competitive athletics and make a decision concerning whether or not the student participates in spite of
the risks. No amount of instruction, precaution, or supervision will totally eliminate the risk of death, injury, or illness associated with participation in athletic activities. Just as driving an
automobile involves risks, athletic participation by middle or senior high school students also may be inherently dangerous. The responsibility that parents and students have in making a
choice to participate cannot be overstated. There have been accidents resulting in death, paraplegia, quadriplegia, and other very serious permanent physical impairments as a result of
athletic competition and/or practice.
By granting permission for your child to participate in athletic competition and practice, you are acknowledging that you fully understand that such risks exist.
Students will be instructed in the proper techniques to be used in athletic competition and practice and in the proper utilization of equipment worn or used in practices and competitions.
Students must always adhere to that instruction and utilization and must refrain from improper use or techniques.
As previously stated, no amount of instruction, precaution, and supervision will eliminate the risk of serious, catastrophic, and fatal injury or illness.
ADDITIONAL INFORMATION CONCERNING PARTICIPATION IN FOOTBALL
Football is a collision sport and injuries can, and do, occur. Safety is the major concern of the Rules Committees of the National Federation of State High School Associations, and recent
rule changes have reduced the number of serious injuries.
This document does not cover all potential injury possibilities in playing football, but it is an attempt to make players and their parents aware that fundamentals and proper-fitting
equipment are important to student safety and enjoyment in playing football.
By rule, the helmet is not to be used as a "ram." Initial contact is not to be made with the helmet. However, it is not possible to play the game safely or correctly without making contact
with the helmet when properly blocking and tackling an opponent. Therefore, technique is most important to prevention of injuries.
Tackling and blocking techniques are basically the same. The play should always be in a position of balance: knees bent, back straight, body slightly bent forward, head up, target area
as near to the body as possible with the main contact being made with the shoulder.
Blocking and tackling by not putting the helmet as close to the body as possible could result in shoulder injury such as a separation or pinched nerve in the neck area. The dangers of not
following the safety rules in making contact with the upper body and helmet is that improper body alignment can put the spinal column in a vulnerable position for injury.
If the head is bent downward, the cervical (neck) vertebrae are in a straight line and contact on the top of the helmet could result in a dislocation, nerve damage, paralysis, or even death.
If the back is not straight, the thoracic (midback) and lumbar (low back) vertebrae are also vulnerable to injury with similar results.
If the knees are not bent, the chance of knee injury is greatly increased. Fundamentally, a player should be in the proper hitting position at all times during live ball play. The injury could
be anything such as, but not limited to, strained muscles, ankle injuries, or serious knee injuries requiring surgical care. Blocking below the waist is permitted only in a defined area
known as the "free-blocking zone" and only under the conditions specified by the football rules. Cleats have been restricted in length to further help in preventing knee injuries. A runner
with the ball, however, may be tackled around the legs.
In tackling, the rules prohibit initial contact with the helmet or grabbing the face mask or edge of the helmet. Serious injuries may result from non-compliance. Initial helmet contact could
result in a bruise, dislocation, fracture, head injury, or internal injury to organs such as, but not limited to, kidneys, spleen, bladder, etc. Grabbing the face mask or helmet edge could
cause a serious neck injury resulting in, but not limited to, muscle strain, dislocation, fracture, nerve injury, spinal damage, paralysis, or death.
If any of the foregoing is not completely understood, please contact the school's Athletic Director or Athletic Trainer for further information and clarification.
ACKNOWLEDGEMENT
I have read and understand the above information, I give my son/daughter permission to participate in athletics and I understand the risks involved with participating in
interscholastic athletic activities, including practices.


PARENT/GUARDIAN SIGNATURE___________________________________________DATE_________________________

STUDENT ATHLETE SIGNATURE___________________________________________DATE_________________________
Kyle Prothro, ATC/SCAT
Head Athletic Trainer
Richard Luden
Athletic Director
4060 W. Wildcat Blvd, Charleston, S.C. 29414 TELEPHONE: (843) 573-1201 EXT 1504 FAX: (843) 573-1224 West Ashley High School Sports Medicine PPE 2013-2014
Medical History (Answer ALL questions by checking the YES or NO boxes. Explain ALL "Yes" answers in the space below!!)
Last Name: 
First Name: 
Date of Birth 
1. HAVE YOU HAD ANY MEDICAL PROBLEM OR PHYSICAL INJURY SINCE  26. Do you feel stressed out, overly tired, or depressed?  YOUR LAST PHYSICAL EXAM? 2. Do you have asthma?  27. Are there any other issues you would like to discuss with the doctor?  CARDIAC HISTORY: 
1. Have you ever passed out during or after exercise?  4. Do you have high blood pressure  2. Have you ever been dizzy during or after exercise?  3. Have you ever had chest pain or chest pressure during or after  6. Do you have sickle cell trait?  4. Do you tire easily or more quickly than your friends during exercise?  7. Have you had any other major medical problem?  5. Have you ever had racing of your heart or skipped heartbeats?  8. Have you ever been hospitalized or had surgery?  6. Have you ever been told you had a heart murmur?  9. Do you cough, wheeze, or have trouble breathing when exercising?  7. Have you ever been told you had an enlarged heart?  8. Has any member of your family:  ‐ died of heart problems or sudden death before age 50?  11. Do you have a single organ (testicle or kidney)?  ‐ been told they had a serious heart problem before age 50?  12. Are you currently taking any medicines or do you take any medicines on  ‐ been told they had Marfan's Syndrome?  a regular basis(prescription or over‐the‐counter)? 13. Have you ever taken any supplements or vitamins to help with weight  ‐Has a physician ever denied or restricted your participation in sports?  loss, weight gain, or to improve performance?  ORTHOPAEDIC HISTORY: 
14. Do you have any allergies (seasonal, insects, food, or medicines)?  1. Have you ever broken or fractured any bones?  15. Have you ever had a rash or hives develop during or after exercise?  2. Have you ever dislocated or partially dislocated any joint?  16. Do you have any skin problems other than acne?  3. Have you had any problems related to your:  17. Have you ever had a head injury, been knocked out, lost your memory,  had your "bell rung", or a concussion? 18. Have you ever had numbness or tingling in your arms, hands, legs, or  feet? 19. Have you ever had a "stinger", "burner", or pinched nerve?  20. Have you ever become ill from exercising in the heat?  21. Have you had mono or any significant illness in the last 60 days?  22. Do you have trouble with your eyes/vision/wear glasses or contacts?  23. Do you have trouble with your hearing/wear hearing aids?  FEMALES ONLY 
24. Do you want to weigh more or less than you do now?  1. Are your periods regular (every month)? 2. Are your periods heavy?  25. Do you lose weight regularly to meet weight requirements for your sport  3. When was your first period? Month Year   ______/______  4. When was your last period? Month Year   ______/______                   
         Physical Exam (To be completed by your physician) 

Height: _________ Weight:_________ BP:______ /______ Pulse:_________ Respiration: __
Vision: R 20/_____ L 20/_____ Corrected (CIRCLE): Yes No If yes, with? (CIRCLE) Glasses Contacts 
Normal 
Abnormal Findings
Initials
Cleared after completing evaluation/treatment for:
e
eck
h

NOT CLEARED for activity/sport (list):
On
C
NOT CLEARED for ANY sport due to:
        Physician Signature: ____________________________________ Physician Name (Print):________________________________          Date of Exam: _________________________________                   Clinic Name or Stamp:  

Source: https://spclarkccsd.sharpschool.net/UserFiles/Servers/Server_2879766/File/Donnie%20Newton/Physical%20Form.pdf

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