PIAA COMPREHENSIVE INITIALPRE.PARTICIPATION PHYSICAL EVALUATION

lNlTlAL EVALUATION: Pr¡or to any student participat¡ng in Pract¡ces, lnterSchool Practices, Scrimmages, and/or Contests,at any PIAA member school in any school year, the student is required to (l) complete a Comprehensive lnitial Pre-Participation Physicat Evaluatlon (CIPPE); and (2) have the appropriate person(s) complete the first six Sections of theCIPPE Form. Upon completion of Sections 1 and 2 by the parenUguardian; Sectlons 3, 4, and 5 by the student andparenUguardian; and Section 6 by an Authorized Medical Examiner (AME), those Sections must be turned in to thePrincipal, or the Principal's deslgnee, of the student's school for retention by the school. The CIPPE may not be authorizedearliei thân June l"t and shall bJeffective, regardless of when performed Ouiing a school year, until the ñext May 31"t.

SUBSEQUENT SPORT(S) lN THE SAME SCHOOL YEAR: Following completion of a CIPPE, the same student seeking topartlcipate in Practices, Inter-School Practices, Scrimmages, and/or Contests in subsequent sport(s) in the same schoolyear, must complete Section 7 of thls form and must turn in that Section to the Principal, or Princlpal's designee, of his orher school. The Principal, or the Principal's designee, will then determine whether Section 8 need be completed.

PERSONAL INFORMATIONStudent's Name Male/Female (circle one)

Date of Student's Birth: / Age of Student on Last Birlhday: _ Grade for Current School Year:

-Current Physical Address

Current Home Phone # ( ParenVGuardian Current Cellular Phone # ( )

Fall Sport(s): Wnter Sport(s): Spring Sport(s):

EMERGENCY INFORMATIONParent's/Guardian's Name Relationship

Address Emergency Contact Telephone # (

Secondary Emergency Contact Person's Name Relationship

Address Emergency Contact Telephone # (

Medical lnsurance Carrier Policy Number

Address Te lephone # ( )

Address Telephone # (

)

Family Physician's Name , MD or DO (circle one)

Secron l: PensoruAl AND EnneRee¡rcy INFoRMATToN

Student's

Student's Health Condition(s) of Which an Emergency Phys ician Should be Aware

Student's Prescription Medications

Revised: March 19, 2015

2: CenrtncATroN or Ptnenr/GueThe student's parenUguardian must complete all parts of this form.

A. I hereby give my consent for born onwho turned on his/her last birthday, a student ofand a resident of the

Schoolpublic school district,

to participate in Practices, lnter-School Practices, Scrimmages, and/orin the sport(s) as indicated by my signature(s) following the name of the

Contests during the 20- - 20-school yearsaid sport(s) approved below.

Slgnature of Parentor Guardlan

FallSports

CrossCountrvFieldHockevFootballGolfSoccerGirls'TennisGirls'VollevballWaterPoloOther

WinterSports

S¡gnature of Parentor Guardlan

BasketballBowlingCompetitiveSDirit SouadGirls'Gvmnast¡csRifleSwimmingand DivinqTrack & Fieldllndoor)WrestlingOther

SprlngSports

Signature of Parentor Guardian

BaseballBoys'LacrosseGirls'LecrôsseSoftballBoys'TennisTrack & Field(Outdoor)Boys'VollevballOther

B. Understanding of eligibility rules: I hereby acknowledge that I am familiar with the requirements of PIAAconcerning the eligiñility of s[udenis at PIAA member schools to participate in lnter-school Practices, Scrimmages, and/orContests involving PIAÂ member schools. Such requirements, which are posted on the PIAA Web site at www.piaa.orq,include, but are ñot necessarily limited to age, amateur status, school attendance, health, transfer from one school toanother, season and out-of-seãson rules and regulations, semesters of attendance, seasons of sports participation, andacademic performance.

Parent's/Guardian's Signature

C. Disclosure of records needed to determine eligibility: To enable PIAA to determine whether the herein namedstudent is eligible cholastic ¿ I

to PIAA of any a ool recordspecifically includ e generalitof parent(s) or gu ddress of t rand attendance data.

Parent's/Guardian's Signature

I

tlD. Permission to use namer likeness, and athletic information: I consent to PIAA's use of the herein namedstudent's name, likeness, and athletically related information in video broadcasts and re-broadcasts, webcasts and reportsof lnter-School practices, Scrimmages, ând/or Contests, promotional literature of the Association, and other materials andreleases related to interscholastic athlet¡cs.

Parent's/Guardian's Signature Dale-J-l-E. Permission to administer emergency med¡cal care: I consent for an emergency medical care provider toadminister any emergency medical care deemed advisable to the welfare of the herein named student while the student ispracticing tor

-or partiãipatìng in lnter-School Practices, Scrimmages, and/or Contests. Further, this authorization permits,

if reasonãble efforts to'contáct me have been unsuccessful, physicians to hospitalize, secure appropriate consultation, toorder injections, anesthesia (local, general, or both) or surgery for the herein named student. I hereby agree to pay forphysiciáns' and/or surgeons' fees, hospital charges, and related expenses for such emergency medical care.

Parent's/Guardian's Signature Dale-.1--l-

EcnoN 3: UruoensrANDrNG o¡ Rrsx or GorcussroN AND TRluutnc Bmln lt¡u

What is a concussion?A concussion is a brain injury that:. ls caused by a bump, blow, or jolt to the head or body.

. Can change the way a student's brain normally works.

. Can occur during Practices and/or Contests in any sport.

. Can happen even if a student has not lost consciousness.

. Can be serious even if a student has just been "dinged" or "had their bell rung."

All concussions are serious. A concussion can affect a student's ability to do schoolwork and other activities (such asplaying video games, working on a computer, studying, driving, or exercising), Most students with a concussion getbetter, but it is important to give the concussed student's brain time to heal.

What are the symptoms of a concussion?Concussions cannot be seen; however, in a potentially concussed student, one or more of the symptoms listed belowmay become apparent and/or that the student "doesn't feel right" soon after, a few days after, or even weeks after theinjury.. Headache or "pressure" in head . Feeling sluggish, hazy, foggy, or groggy

. Nausea or vomiting . Difficulty paying attention

. Balance problems or dizziness . Memory problems

. Double or blurry vision . Confusion

. Bothered by light or noise

What should students do if they believe that they or someone else may have a concussion?. Students feeling any of the symptoms set foÉh above should immediately tell their Coach and their

parents. Also, if they notice any teammate evidencing such symptoms, they should immediately tell their Coach.. The student should be evaluated. A licensed physician of medicine or osteopathic medicine (MD or DO),

sufficiently familiar with current concussion management, should examine the student, determine whether thestudent has a concussion, and determine when the student is cleared to return to participate in interscholasticathletics.. Concussed students should give themselves time to get better. lf a student has sustained a concussion, thestudent's brain needs time to heal. While a concussed student's brain is still healing, that student is much morelikely to have another concussion. Repeat concussions can increase the time it takes for an already concussedstudent to recover and may cause more damage to that student's brain. Such damage can have long termconsequences. lt is important that a concussed student rest and not return to play until the student receivespermission from an MD or DO, sufficiently familiar with current concussion management, that the student issymptom-free.

How can students prevent a concussion? Every sport is different, but there are steps students can take to protectthemselves.. Use the proper sports equipment, including personal protective equipment. For equipment to properly protect a

student, it must be:The right equipment for the sport, position, or activity;Worn correctly and the correct size and flt; andUsed every time the student Practices and/or competes.

. Follow the Coach's rules for safety and the rules of the sport.

. Practice good sportsmanship at alltimes.

lf a student believes they may have a concussion: Don't hide it. Report it. Take time to recover.

I hereby acknowledge that I am familiar with the nature and risk of concussion and traumatic brain injury whileparticipãting in intersèholastic athletics, including the risks associated with continuing to compete after a concussion ortraumatic brain injury.

Student's Signature Date / /

I hereby acknowledge that I am familiar with the nature and risk of concussion and traumatic brain injury whileparticipáting in interscholastic athletics, including the risks associated with continuing to compete after a concussion ortraumatic brain injury.

Parent's/Guardian's Signature Dale I I

Seclol,l 4: UHoeRsTANDtNG or Suooer Crnonc ARResr Syuproms Rno Wlnune Slons

What is sudden cardiac arrest?

Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens bloodstops flowing to the brain and other vital organs, SCA is NOT a heart attack. A heart attack may cause SCA, but they arenot the same. A heart attack is caused by a blockage that stops the flow of blood to the heart. SCA is a malfunction inthe heart's electrical system, causing the heart to suddenly stop beating.

How common is sudden cardiac arrest in the United States?

There are about 300,000 cardiac arrests outside hospitals each year. About 2,000 patients under 25 die of SCA eachyear.

Are there warning signs?

Although SCA happens unexpectedly, some people may have signs or symptoms, such as¡ dizziness. lightheadedness. shortness of breath. diffìculty breathing. racing or fluttering heartbeat (palpitations). syncope (fainting)

These symptoms can be unclear and confusing in athletes. Often, people confuse these warning signs with physicalexhaustion. SCA can be prevented if the underlying causes can be diagnosed and treated.

What are the risks of practicing or playing after experiencing these symptoms?

There are risks associated with continuing to practice or play after experiencing these symptoms. When the heart stops,so does the blood that flows to the brain and other vital organs. Death or permanent brain damage can occur in just a fewminutes. Most people who have SCA die from it.

Act 59 - the Sudden Gardiac Arrest Prevention Act (the Act)

The Act is intended to keep student-athletes safe while practicing or playing. The requirements of the Act are:

lnformation about SCA symptoms and warning signs.. Every student-athlete and their parent or guardian must read and sign this form, lt must be returned to the school

before participation in any athletic activity. A new form must be signed and returned each school year.. Schools may a/so hold informational meetings. The meetings can occur before each athletic season, Meetings

may include student-athletes, parents, coaches and school officials. Schools may also want to include doctors,nurses, and athletic trainers.

Removalfrom play/return to play

Any student-athlete who has signs or symptoms of SCA must be removed from play. The symptoms can happenbefore, during, or after activity. Play includes all athletic activity.Before returning to play, the athlete must be evaluated. Clearance to return to play must be in writing. Theevaluation must be performed by a licensed physician, certified registered nurse practitioner, or cardiologist (heartdoctor). The licensed physician or certified registered nurse practitioner may consult any other licensed orcertified medical professionals.

I have reviewed and understand the symptoms and warning signs of SCA.

Date I ISignature of Student-Athlete Print Student-Athlete's Name

. fatigue (extreme tiredness). weakness

. nausea. vomiting

. chest pains

a

Date tlSignature of ParenVGuardian Print ParenUGuardian's Name

PA Depaftment of Health: Sudden Card¡ac Arrest Symptoms and Warning Signs lnformation Sñeef and Acknowledgement ofReceipt and Review Form. 7/2012

Student's Name

Explain "Yes" answers at the bottom of this form.Circle questions you don't know the answers to.

YesHas a doctor ever denied or restricted your

participation in sport(s) for any reason?Do you have an ongoing medical condition

(like asthma or diabetes)?Are you currently taking any prescription or

nonprescription (over-the-counter) medicinesor pills?

Do you have allergies to medicines,pollens, foods, or stinging insects?

Have you ever passed out or nearlypassed out DURING exercise?

Have you ever passed out or nearlypassed out AFTER exercise?

Have you ever had d¡scomfort, pain, orpressure in your chest during exercise?

Does your heart race or skip beats duringexercise?

Has a doctor ever told you that you have(check all that apply):

High blood pressure E Heart murmurHigh cholesterol E Heart infection

Has a doctor ever ordered a test for yourheart? (for example ECG, echocardiogram)

Has anyone in your family died for noapparent reason?

Does anyone in your family have a heartproblem?

Has any family member or relative beendisabled from heart disease or died of heartproblems or sudden death before age 50?

Does anyone in your family have Marfansyndrome?

Have you ever spent the night in ahospital?

Secroru 5: Healrn HrsroRv

No

trtr 23.

24.

25.

26.

27.

trtr

34.35.

Has a doctor ever told you that you haveasthma or allergies?

Do you cough, wheeze, or have diffìcultybreathing DURING or AFTER exercise?

ls there anyone in your family who hasasthma?

Have you ever used an inhaler or takenasthma medicine?

Were you born without or are your mlssinga kidney, an eye, a testicle, or any otherorgan?

Have you had infectious mononucleosis(mono) within the last month?

Do you have any rashes, pressure sores,or other skin problems?

Have you ever had a herpes skin

Age Grade-

Yes No

trtr

trtr

1.

2.

4.

5.

6.

7.

8.

trfl10.

11.

12.

2B

29

30

trtrtr!tr

trtrtrtrtr

trtrtr

trtrtr

trtrtr

Etrtr

trtrtr

trtrtr

trtrtr

trtrtr

14.

15.

16

you ever aHave you ever had numbness, tingling, or

weakness in your arms or legs after being hitor falling?

36. Have you ever been unable to move yourarms or legs after being hit or falling?

37. When exercising in the heat, do you havesevere muscle cramps or become ill?

38. Has a doctor told you that you or someonein your family has sickle cell trait or sickle celldisease?

39. Have you had any problems with youreyes or vision?

40. Do you wear glasses or contact lenses?41. Do you wear protective eyewear, such as

goggles or a face shield?42. Are you unhappy with your weight?43. Are you trying to gain or lose weight?44. Has anyone recommended you change

your weight or eating habits?45. Do you limit or carefully control what you

eat?46. Do you have any concerns that you would

like to discuss with a doctor?FEMALES ONLY47. Have you ever had a menstrual period?48. How old were you when you had your first

menstrual period?49. How many periods have you had in the

last 12 months?

trtr

trtrtrtrtrtrtrtrtrtrtr

trtr

trtrDtrtrtrtrtrtrtrtr

Have

Head Neck Shoulder

Lowerback

Hip

20.21.

22.

Upperarmlhìgh

Elbow

KneeFrngersAnkleUpper

backCalíshin

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

you had an x-ray for atlantoaxial (neck)instability?

Do you regularly use a brace or assistivedevice?

FooVToestr

tru

tr

trtr

Are

I hereby certify that to the best of my knowledge all of the information he true and complete.n

Student's Signature

I hereby cer.tify that to the best of my knowledge all of the informat¡on here¡n is true and complete.

tl

Date I I

31. Have you ever had a concussion (i.e. bellrung, ding, head rush) or traumatic braininjury?

32. Have you been hit in the head and beenconfused or lost your memory?

33 Do you experience dizziness and/orheadaches with exercise?

trtrtrtr

c N INJURY

muscle, or ligament tear, or tendonitis, whichcaused you to miss a Practice or Contest?lf yes, circle affected area below:

Have you had any bÍoken or fracturedbones or dislocated joints? lf yes, circlebelow:

Have you had a bone orjoint injury thatrequired x+ays, MRl, CT, surgery, injections,

17

18.

19

trtrHave you ever had an injury, like a n,

rehabilitation,tfor

therapy, a brace, acircle below:

#'s Explain "Yes" answers here:

Parent'siGuardian's Signature

Secnox 6: PIAA CorupnexeNstvE lnlrll Pne-PnnrcrpATtoN Pnvstctl- Evnlualon¡¡¡o GeRrFrcATroN or Aurnonlzeo Meolctl Exnmtten

Must beinitial

the Authorized Medical Examiner (AME)uation (CIPPE) and turned in to the Principal, or the Principal's

the herein named student's comprehensivedesignee, ofthe student's school.

Aoe GradeStudent's Name

Enrolled in School Sport(s)

Height Weight % Body Fat (optional) BrachialArtery BP / (--l- RP-lf either the brachial artery blood pressure (BP) or resting pulse (RP) is above the following levels, further evaluation by the student'sprimary care physician is recommended.Age 10-12: BP:>126t82, RP: >104; Age 13-15: BP: >136/86, RP >100; Age l6-25: BP:>142192, RP >96.

Vision: R 201 L20l Corrected: YES NO (circle one) Pupils: Equal-Unequal-

reviewed the HenlrH HtsroRv, pe a comprehensive initial pre-participation p evaluation of thespecifìed below,herein named student, and, on the basis of such evaluation and the student's Henlrn Hrstony, certify that, except as

the student is physically fit to participate in Practices, lnter-School Practices, Scrimmages, and/or Contests in the sport(s) consented toby the student;s þarenúguardian in Section 2 of the PIAA Comprehensive lnitial Pre-Participation Physical Evaluation form:

tr CLEARED tr CLEARED, with recommendation(s) for further evaluation or treatment

tr NOT CLEARED for the following types of sports (please check those that apply):El Cou-rsro¡ E Corurncr E Norl-corrRcr E Srn¡ruuous E MooEnRteLY SrReuuous E Noru-srnEuuous

Due to

Recommend ation(s)/Refena l(s)

AME's Name (prinUtype) License #Phone (

MEDICAL NORMAL ABNORMAL FINDINGS

Appearance

Eyes/Ears/Nose/Throat

Hearing

Lymph Nodes

E Heart murmur fl Femoral pulses to exclude aortic coarctationE Phvsical stiqmata of Marfan svndrome

Cardiovascular

Cardiopulmonary

Lungs

Abdomen

Genitourinary (males only)

Neurological

Skin

MUSGULOSKELETAL NORMAL ABNORMAL FINDINGS

Neck

Back

Shoulder/Arm

Elbow/Forearm

WrisVHand/Fingers

HipiThigh

Knee

Leg/Ankle

FooUToes

AME's Signature MD, DO, PAC, CRNP, or SNP lclrcle one) Authorized Date of CIPPE -J-l-

East Stroudsburg Area School DistrictStudent-Athlete Goncussion Statement

n I understand that it is my responsibility to report all injuries and illnesses to myathletic trainer and/or team physician.

n I have read and understand the CDC Concussion Fact Sheet for Athletes,E I have read and understand Section 3 of the PIAA athletic physical

After reading the CDC Concussion fact sheet for athletes, I am aware of the followinginformation:

A concussion is a brain injury, which I am responsible for reporting to myrniriar team physician or athletic trainer._ A concussion can affect my ability to perform everyday activities, and affectrntiaì reaction time, balance, sleep, and classroom performance.

You cannot see a concussion, but you might notice some of the symptomstnitiar right away. Other symptoms can show up hours or days after the injury.

If I suspect a teammate has a concussion, I am responsible for reporting thernitiar injury to my team physician or athletic trainer.

I will not return to play in a game or practice if I have received a blow tornirÍar the head or body that results in concussion-related symptoms.

Following concussion the brain needs time to heal. You are much more likelyrnirial to have a repeat concussion if you return to play before your symptoms

resolve.In rare cases, repeat concussions can cause permanent brain damage, and

rnitiaì eVen death.I understand that if I am experiencing concussion-related symptoms after a blow to

rniriar the head or body I will not be able to drive myself home.

Signature of Student-Athlete Date

Printed name of Student-At¡lete

Signature of Paren! Date

Printed name ofParent

East Stroudsburg Area School DistrictParent Concussion Statement

n I have read and understand the CDC Concussion Fact Sheet for Parentsn I have read and understand Section 3 of the PIAA athletic physical

After reading the CDC Concussion Fact Sheet for Parents I am aware of the following information:_ A concussion is a brain injury which student-athletes should report to the medicalInirial Staff,

A concussion can affect the student athlete's ability to perform everyday activities, andtnitiat affect reaction time, balance, sleep, and classroom performance. You cannot see a

concussion, but you might notice some of the symptoms right away. Othersymptoms can show up hours or days after the injury.I will not knowingly allow my student athlete to return to play in a game or practice if

rniriar he/she has received a blow to the head or body that results in concussion relatedsymptoms,

_student athletes shall not return to play in a game or practice on the same day thattniriar they are suspected of having a concussion.

If I suspect one of my student athlete has a concussion, it is my responsibility torniriat have that athlete see the medical staff._l will encourage my student athlete to report any suspected injuries and illnesses tornitiar the medical stafl including signs and symptoms of concussions.

Following concussion the brain needs time to heal. Concussed student athletes arerniriat much more likely to have a repeat concussion if they return to play before

their symptoms resolve. In rare cases, repeat concussions can cause permanentbrain damage, and even death.I am aware that every student-athlete grades 9-12 participating on ESASD teams must be

tn¡ial baseline tested prior to participation in sport. These tests allow for comparison of ,

symptoms, neurocognition, and balance if the athlete were to become injured.I am aware that athletes diagnosed with a concussion and/or displaying concussion signs

rniriãt and symptoms will be assessed by a physician. Athletes will begin a graduated return toplay protocol following a physician's clearance as well as full recovery of neurocognitionand balance,I am aware that if my student athlete has received a blow to the head or body that results is

rn¡ial concussion related symptoms, he/she may not drive themselves and must find alternate. transportation home.

SiBnatùre of Parent Date

Printed name ofParent

East Stroudsburg Area School District ATHLETIC/ACTIVITIES CONSENT/EMERGENCY CARD

SPORT/ACTIVITY:_____________________________________________SCHOOL YEAR:_________ (MUST be completed and submitted prior to participation in any sport/activities/season). Athlete’s name:_______________________________________________D.O.B.__________Grade:_____ Address________________________________________________________________________________ Home phone:____________ Parent e-mail address:________________________________________ I/We hereby give my/our consent for ________________________________to participate in the above sport/activity as player/manager. I/We waive any and all claims against the East Stroudsburg Area School District for any personal injury which might occur. In case of accident, illness, injury or emergency, I/We authorize the officials of the District to contact directly the persons named on this form. In the event that I/We cannot be contacted, I/We, the undersigned, authorize school officials to take whatever action is deemed necessary for the health and safety of my/our student and to consent to any ambulance or other emergency vehicle transportation, x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care to be rendered to the above-referenced student under the general and special supervision, and on the advice of a physician and/or surgeon listed under the provisions of the Medical practice Act of 1985, 63 P.S. SS422.1 or, if in another state or country, the law governing the practice of medicine. ____________________________________________________________ Date______________________ Signature of Parent (s)/Guardian (s) PARENT OR GUARDIAN CONTACT: Name of Parent/Guardian #1:______________________________________Relationship_____________ Telephone: (H)________________________ (W)____________________(C)_____________________ Name of Parent/Guardian #2:______________________________________Relationship_____________ Telephone (H)________________________(W)_____________________(C)_____________________ EMERGENCY CONTACT PERSON (S), in case parent(s)/guardian(s) cannot be reached: Contact person:__________________________________________________Relationship_____________ Telephone:______________________________________________________________________________ FAMILY PHYSICIAN:___________________________________________Telephone_______________ Pre-existing circulatory/pulmonary conditions:_______________________________________________ Diabetes:___________________________________ Inhalers:____________________________________ Allergies or allergic reactions:_____________________________________________________________ Medications being used:__________________________________________________________________ Date of last Tetanus immunization:_________________________________________________________ Other pertinent information:______________________________________________________________ PERMISSION to TREAT Athlete:________________________________ DATE:__________________ Signature of parent/guardian:________________________________________________________________________6/17/10