hillsdale public schools › cms › lib03... · diving cheerleadirn field hockey fencing football...

HILLSDALE PUBLIC SCHOOLS

DR. NOREEN J. HAJINLIAN PRINCIPAL

E-MAIL: nhajinlian@ hillsdaleschools.com

June 2012

w GEORGE G. WHITE SCHOOL 120 MAGNOLIA AVENUE

HILLSDALE, NJ 07642 201-664-0286

FAX: 201-664-2715

To: Parents/Guardians of Fifth, Sixth and Seventh Grade Candidates for InterScholastic Fall Sport Teams 2012-2013

Good physical condition, freedom from injury and full recovery from illness shall be prerequisites to participation in athletics, whether in practice or in competition. Each candidate for a place on a school athletic squad shall be given a physical examination by their own licensed physician within 365 days prior to the first practice session.

NOTE: Only one medical examination yearly will be required as a prerequisite to subsequent participation by pupils in other sports unless an injury or illness has been sustained by the pupil during the course of the year.

Soccer and Volleyball tryouts for teams are scheduled to begin on Wednesday, September 5, 2012. Therefore, all Physicals (yellow), Health history questionnaire (pink) and Athletic Permit Form (green) must be submitted to the school nurse for final approval by the school doctor no later than Monday, August 13, 2012. You may mail or drop off these forms to the school office over the summer break.

Very truly yours,

Christina Fanelli, R.N. School Nurse

To ParentJGuardian,

PLEASE BE ADVISED --THESE ARE FORMS MANDATED BY 1HE STATE OF NEW JERSEY FOR 6TII 7TII AND 8m GRADERS

PLEASE READ THE FOLLOWll\fG CAREFULLY TO ENSURE YOUR CI-DLD'S PARTICIPATION IN INTERSCHOLASTIC/INTRAMURAL

SPORTS TEAMS ATHLETICS

e Forms MUST be completed in their entirety_ If ail blanks are not filled in, the form will be returned to you to be completed, thereby~ possibly delaying participation in the desired sport_

e Should your physician question this, he may refer to State Code 6A: 16-2_2, speci:fi:cally hl-6_

o The examination date on the top left hand corner on the fronLofthe Athletick>r:e Earticipation Physical Evaluation Form (yellow) must be within 365 days prior to ihe first practice session_ If you already handed in a physical, there is no need to hand in annther form_

e Computer printouts are preferred for required immunization records_

g The Parental Health History Questionnaire (pink form) must be completed front and back, signed and dated within 60 days of the first day of practice.

o The Athletic Permit Form (green form) must be completed front and back, naining the specific sport your child will be trying out for_

e To avoid any delay in your child's clearance and participation in athletics, we are asking that you return the completed forms by the desired date to the school nurse for the school physician's final approval_

Sincerely, Christina Fanelli, RN, CSN

HILLSDALE BOARD OF EDUCATION Hillsdale, NJ 07642

FILE CODE: 6145.1/6145.2 Exhibit

ANNUALATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM Part B: Physical Evaluation Form

(Completed by the examining licensed provider MD, DO, APN or PA} GRADE: EXA~DATE=-----------------=~~~~~~~----------=---~~----

-sruoENT INFORMATION-

Student's Name: --:------------- Sport(s): --------------------Sex: M F {circle one) Age: Grade: --~-- Date of Birth:---------------Address: ---

City/State/Zip:__________________ Home Phone: -----------'-------School: District: -----------------Pa~UG~u~~i~an~·s-F=u~II~N~a-m_e: ________ ~------

-EXAMINING PHYSICIANJPROVIDER CONTACT INFORMATION-

If conducted by school physician check here 0

Nam~ ------------ Phone: ___ ~------ Fa~ -------

Address: ____ _______ _ City/State/Zip:. _________________ _

· - RNDINGS OF PHYSICAL EVALUATION-

Height ___ _ Weight ___ _ Blood Pressure: '--- Puts~ __ bpm.

Vrslon: R 201 __ L 20/ Corrected: Y I N Contacts: Y I N Glasses: Y I N

INDICATORS NORMAL? ABNORMAL FINDINGS/COMMENTS

General Appearance YES Head/Neck YES Eyes/Sclera/Pupils YES Ears YES

Gross Hearing YES Nose/Mouthlfhroat YES Ly_mph Glands YES Cardiovascular YES

Heart Rate YES Rhythm YES Murmur ABSENT If murmur present . ::··:· "' ; : .: . .; _:~ Standing makes it Louder Softer No Change

... : . :. -: ~ -: ~ ·_: : .. . ~. . ' • : Squattingmakes it Louder Softer No Change

. '. ; -~ -~ .. :. . ~ .. :-·: .. Valsalva makes It Louder Softer NoChan_ge . . ... .. .

Femoral Pulses YES Lungs: Auscultation/Percussion YES Chest Contour YES Skin YES Abdomen (liver, spleen masses) YES Assessment of physical maturation or YES Tanner Scale Testicular Exam (Males Only) YES Neck/BackiSpine: YES

Range of Motion YES Scoliosis ABSENT

Upper Extremities: (ROM, Strength, YES Stability) · Lower Extremities: (ROM, Strength, StabifJty)

YES

NeuroiOQical: Balance & Coordination YES Hernia ABSENT Evidence of Marfan Syndrome ABSENT

PLEASE ATTACH IMMUNIZATION SHE1J1B.rt B Page 1 of 4

NJDOFJAPPEF Revised 3110 Use of this form is required by N.JAC. 6A;l6-Programs to Support StJuknt Dwe~Lgmrent

HILLSDALE BOARD OF EDUCATiON Hillsdale, NJ 07642

Most recent Immunizations and dates administered:

Medications currently presaibed with dose and frequency: Medication Name Dosage

Additional observations:


Frequency

Gen~rna~~s: ________________________________________________________ __

General Recommendations:

THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.

Part B Page 2 of 4

NJDOE/APPEF Revised 3110 Use oftbis furm is required byNJ.A.C. 6k16-Programs to SupporlStlulent Development

IDLLSDALE BOARD OF EDUCATION Hillsdale, NJ 07642


I CLEARANCES: This section is completed by the examining healthcare proVider.

After examining the student and reviewing the medical history the student is:

0

0

0

A.

B.

c.

Cleared for participation in all sports without res1rictions.

Not deared for participation in any sport until evaluation/treatment of:

Cleared for limited participation in the following types of sports only. Please see below for sport classifications. CHEcKALL lW\T APPLY

_ CONTACT/COWSION UMITED CONTACT

NON-CONTACT/STRENUOUS NON-CONTACT/NON-81RENUOUS

Limitations due to: -----------------~------------

NOTES TO THE EXAMINING PROVIDER .

Conditions requiring clearance before sports participation include, but are not limited to the followjng:

Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension; Congenital heart disease; Dysrhythmia; Mii:Ial valve prolapse; Heart murmur;. Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Mangnancy; Seizure Disorder; Marfan's Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye.

SAMPlES OF CLASSIFICATION OF SPORTS BY CONTACT Contact/ColDs ion Umited Contact

Basketball Baseball Diving Cheerleadirn

Field Hockey Fencing Football HiQhJump

Ice Hockey Pole vault Lacrosse Gymnastics Soccer Skiing

Wrestling Softball Volleyball

Effects of physiologic maneuvers on heart sounds

Standing Increases munnur of HCM Decreases murmur of AS, MR MVP click occurs eartier in systole

Squatting Increases munnur of AS, MR, AI Decreases murmur of MCH MVP click delayed

Valsalva Increases munnur of HCM Decreases murmur of AS, MR MVP click occurs earner in systole

HCM: . AS:

AJ: MR: MVP:

Hypertrophic Cardia Myopathy Aortic Stenosis Aortic Insufficiency Mitral Regugitation Mitral Valve Prolapse

Non-Contact us Non-strenuous

Discus Bowling Javelin Golf

Shot put Rowing

Running/Cross Country Strength Training

Part B Page 3 of 4

Swimming Tennis Track

Physical Stigmata of Marfan's Syndrome

Kyphosis High arched palate Pectus excavatum Arachnodactyly Arm span> height 1.05:1 or greater Mitral Valve Prolapse Aortic Insufficiency Myopia Lenticular dislocation

NJDOFJAPPEF Revised 3/10 Use of this form is required by NJ.AC. 6A: 16-Progroms to Support Studem /Jevelopment

•.: :


HISTORY REVIEWED AND STUDENT EXAMINED BY:

o Primary Care Provider o School Physician Provider o License Type:

DMD/00 OAPN DPA


Physician's/Providers Stamp:

PHYSICIAN'S/PROVIDER's SIGNATURE:---------------------

Today's Date: _____ _ Date of Exam: _____ _

RESERVED FOR SCHOOL DISTRICT USE

NOTE: N.J.A.C. 6A:16-2.2requires the .sch6ol physician to provide written notification to the.parentllegal guardian stating approval or disapproval of the student's participation in athletics based on this physical evaluation. This evaluation and the notification letter become part of the student's school health record.

History and Physical Reviewed By: Date: _____ _

Trtle of Reviewer (please check one): o School Nurse 0 School Physician

Medical Eligibility Notification Sent to Parent/Guardian by School Physician

0 Letter of notification is attached.

OR

Parent notification indicates that

0 Participation Approved without limitations.

0 Participation Approved with limitations pending evaluation.

o Participation NOT AJ)proved

Reason(s) for Disapproval:

Part B Page 4 of 4

Date

NJDOFJ APPEF Revised 3/l 0 Use of this furm is required by N.J.AC. 6A.:16-Programs to Suppurl Student Devdopment


FILE CODE: 6145.1/6145.2 Exhibit -

New Jersey Department of Education ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM

Part A:. HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA

Part A: HEALTH HISTORY QUESTIONNAIRE

TodaysD~e: ________________ _ Date of Last Sports Physical: ----------

Student's Name: ---------------------- Sex: M F (circle one) Age: __ Grade: __ _

Date of Birth: __ /_/ __ _ School: ----------------------o~mct: __________ _

Sport(s): -------------------------------------------- Home Phone: (____) ________ _

Provider Name (Medical Home): ------------------- Phone: --------------- Fax: ____ _

EMERGENCY CONTACT INFORMATION

Name of parent/guardian:----------~--------- Relationship to student ------------------------

Phone (work): ---------------- Phone (home): ______________ _ Phone (eel~:----------

Additional emergency contact: ------------------- Relationship to student ------------------

Phone (work): ---------------- Phone(hom~=----------------- Phone (cell):------------

Directions: Please answer the following questions about the student's medical history by CIRCUNG the correct response. Explain all "yes· responses on the lines below the questions. Please respond to all questions.

1. Have you ever had, or do you currently have: a. Restriction from sports for a health related problem? b. An injury or illness since your last exam? c. A chronic or ongoing illness (such as diabetes or asthma)?

(1.) An inhaler or other prescription medicine to control asthma? d. Any prescribed or over the counter medications that you take on a regular basis? e. Surge!)', hospitalization or any emergency room visit(s)? f. Any allergies to medications? g. Any allergies to bee stings, pollen, latex or foods?

(1.) If yes, check type of reaction:

0 Rash 0 Hives 0 Breathing or other anaphylactic reaction (2.) Take any medication/Eplpen taken for allergy symptoms? (List below.)

h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? L A blood relative who died before age 50?

Explain all uyes· answers here {indude relevant dates):

Ust all medications here: I M""catlon N""e I Freq,ener

Part A Page 1 of 3

Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know

Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know

NJDOE/APPEF Revised 3/10 Use oflhis form is required byN.J.A.C. 6A:l6~Programs to Support Student Development



2. Have you ever had, or do you currently have, any of the following hearJ.related oonditlons: a. Concussion or head injury (including "bell rung" or a "ding")? b. Memory loss? c. Knocked out? c. A seizure? d. Frequent or severe headaches (With or without exercise)? e. Fuzzy or bluny vision f. Sensitivity to light/noise

Explain all"yes• answers here (include relevant dates):

3. Have you ever had, or do you currently have, any of the following heatt-related conditions: a. Restriction from sports for heart problems? b. Chest pain or discomfort? c. Heart murmur? d. High blood pressure? e. Elevated cholesterol level? f. Heart infection? g. Dizziness or passing out during or after exercise without known cause? h. Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? L Racing or skipped heartbeats? j. ·Unexplained difficulty breathing or fatigue during exerdse? k. Any family member (blood relative):

(1.) Under age 50 with a heart condition? (2.) With Marfan Syndrome? {3.) Died of a heart problem before age 50? If yes, at what age? --------(4.} Died with no known reason? (5.) Died while exercising? If yes, was it during or after? (Circle one.)

Explain all "yes• answers here (include relevant dates):

YIN I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know

Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know

Y I N I Don't Know YIN I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know

4. Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conolfions: a. Vision problems? Y I N I Don't Know

(1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) YIN I Don't Know b. Hearing loss or problems? Y I N I Don't Know

(1.) Wear hearing aides or implants? YIN I Don't Know c. Nasal fractures or frequent nose bleeds? Y I N I Don't Know d. Wear braces, retainer or protective mouth gear? Y I N I Don't Know e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? YIN I Don't Know

Explain all "yes" answers here (include relevant dates):

5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conolflons. a. Numbness, a "burner", "stinger" or pinched nerve? b. Asprain? c. Astrain? d. Swelling or pain in muscles, tendons, bones or joints? e. Dislocated joint(s)? f. Upper or lower back pain? g_ Fracture(s), stress fracture(s), or broken bone(s)? h. Do you wear any protective braces or equipment?

Explain all (yes) answers here (include relevant dates):

Part A Page 2 of 3


NJDOE/APPEF Revised 3/10 Use of this furm is required by N.J.A.C. 6.k16-Programs to Support Student Developmmt



6. Have you ever had or do you currently have any of the following general or exercise related conditions: a. Difficulty breathing?

(1.) During exercise? (2.) After running one mile? (3.) Coughing, wheezing or shortness of breath in weather changes? {4.) Exercise-induced asthma?

i. Controlled with medication? {specify~.......,...-=---------' il. Experience dizziness, passing out or fainting?

b. Viral infections {e.g. mono, hepatitis, coxsackie virus)? c. Become tired more quickly than others? d. Any of the following skin conditions:

(1.) Cold sores/herpes, impetigo, MRSA, ringworm, warts? (2.) Sun sensitivity?

e. Weight gain/loss (of 10 pounds or more)? {1.) Do you want to weigh more or less than you do now?

f. Ever had feelings of depression? g. Heat-related problems (dehydration, dizziness, fatigue, headache)?

(1.) Heat exhaustion (cool, clammy, damp skin)? (2.) Heat stroke (hot, red, dry skin)? (3.) Muscle cramps?

h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)?

Explain all "yes" answers here (include relevant dates):

7. Females only:


Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know Y I N I Don't Know

Age of onset of menstruation: __ How many menstrual periods in the last twelve (12) months?

How many periods missed in the last twelve (12) months?

8. Males only: Have you had any swelling or pain in your testicles or groin? Y I N I Don't Know

PARENT/GUARDIAN SIGNATURE

I certify that the infonnation provided herein is accurate to the best of my knowledge as of the date of my signature.

Signature, Parent/Guardian or Student Age 18 Date of Signature:

THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.

Part A Page3 of3 NJDOE/APPEF Revised 3/10 Use of this form is required byN.J.AC. 6A:16-Programs to Support Studm Development

Name ____________________________ ~--------~--~~--------------Date of Birtl1 Place of Birth Last Fir.st Grade

Arldress ______ ~--------------------------------~~--------------Telephone Number Street Town

George G. white School Athletic Permit Form

I hereby gr3J..~t perroission for my son/ daug_hter to participate in.

------------------~----- durt.~.~.g the cu.rrent school year. I also agree (l'{aJJle nf soort or activity) .

tb.ai ne1 sne 'may accompany any team_ on regularly scheduled trips if he/she

becomes a me~ber of the team. I attest that this permission is effective unless

and until revoked in ·w:n-fu'"lg by the ~ignatory.

REALIZING TIIAT ATHLETIC ACTIVITY. INVOLVES TilE POTENTIAL FOR . .

INJURY WHICH IS INHERENT IN ALL SPORTS, I ACENOWLEDGE THAT

EVEN WITH THE BEST COACHING, USE OF THE MOST PROTECTIVE . .

EQUIPMENT AND_ STRICT OBSERVANCE OF RULES AND REGUlATIONS.

INJURIES ARE STilL A DISTINcr POSSIBJLITY. ON RARE OCCAsiONS

TIIESE INJURIES CAN BE SO SEVERE AS TO RESULT IN TOTAL DISABILITY,

Pf\.RALYSIS OR EVEN DEATH. I ACKNOWLEDGE THAT I HAVE READ AND

UNDERSTAND TillS WARNING.

Although the school ma:y assist parents, the responsibility for adjusbnent of

any insurance claims lies with the parents.

I have read the above statements, understand them and hereby grant my

permission for my son/ daughter to participate.

'¥; Date Signed;{s __ ---:------:---------(Parent/Guardian)

I i PL~;·~=-;;~MPLf;;;~R SIDE OF ~RM 1

•&eh-=:;;==,..esyeeeiE"""""'¥4 •'?""§.........,.,..ag; ;;s ;; c- .,.<·+? ea ?"'?: & · ;

,_

' \

.. · ' . . . ' ·.: . . #

'·

I _request pe.nnission to be enrolled as a candidate and to practice ~d play in-.

~---~~--------.,..,---- during the current school year~----(Name of §port or Activityj ~

. ' ~ ·· .. . -.

Jf I• • .It • _____ ... ~~~·__,· ~-,.,__.· ' ::; ·. ~ ·.· ;· ~--~

Realizing that athletic activity involves the potential for mjury. which is ·

inherent in all sports, I acknowledge that even with the best coaching~ lise of

the most advaneed _prbtective equipment and strict observance of the rUles and regulations. injuries are still a r~al possibilit-y. On rare occasions these

injuries can be so severe as to result in ~otal disability. paralysis or even dea:tli~~- · :·,

I r-ealize that I may be injured.

I will practice good sportsmanship - representing my school sclf and

·. .·: ::.~: :' ~

:! ·:.·~:.-. -:.: ·-~ -~.

; . . . . ) ·· .

.. . : ...

·. '

·'.I ::.

·'· i

. ' .

( ;; .·. ,.· :·.·· .. . • . :. •• . . ... # :-

parents in a positive manner. __ :.- . :--/:~:~,:.: · -.·:·).~~j;~{\; I will be responsible for and will return an equipment loaned ~ me ·by : : · .; ._;-)-~ :· :_.!,;,:· ' r};;}j~

- . - . : :..: . .-:_:<- • --~ :··:. :-_;:.~~:··-::3:~::~ the Athletic Department. .- : · · · · -... -·, · · : ,~,·-

I have read the above statement and agree. __ :_~'~:_:<~~-·>/;'.~f~~: ·: ·- :.-.. ·· .. : .. r.~~ . -. ':. ' • .

Signed : ~ . _ . _, _' :. ·:". >:;s (Player) .

. .:: ··::_

hillsdale public schools › cms › lib03... · diving cheerleadirn field hockey fencing football...

Documents