2014 BCHS Softball Packet

1. Please see the attached schedules for team conditioning. The GHSA (Georgia High School Association) met April 14th and decided to allow high school teams to have spring tr outs !eginning April of "#1$. This ear we will have tr %outs August 4th%$th. ". &e will 'eep a total of ""%"( pla ers this ear. (. Start running and throwing )*&+ ,f ou plan to ma'e the team- ou must !e in shape now. &e will condition ever da . ,t will !e hard to ma'e this ear.s team if ou are not in good ph sical condition. 4. /ach girl must purchase !lac' cleats (white trim is o')- and !lac' hair ri!!ons. There will !e a team store availa!le in 0une to purchase the other re1uired attire for practices and games. ,f ou purchased this last ear ou will not need it. $. /ighth grade pla ers will not !e allowed to tr out for the 02 team this ear. 3. *ur !udget each season runs at appro4imatel 51(-###. 6earl items754-$##- Tournament 8ees9:ooms 5;-###- and *fficials 7 51-$##. <ast ear.s fundraisers covered this amount. Sign Sponsors 5$###- Summer Tournament 5$###- T%Shirt Sale 5$##- Gate 51$##- and =hristmas Trees 51###. &e will discuss this more in depth at the parent meeting. The team is as'ing for new uniforms. , have priced these through >oom>ah. :ed 0erse 9>lac' Pants9>elt9Soc's 51"$ per pla er (ever one should have !lac' pants) >lac' 0erse 9:ed Pants9>elt9Soc's 51"$ per pla er "" pla ers ? 5"$# each 7 5$-$## (, am o' with whatever we decide. &e can order one set- two- or pla with what we currentl have. &e could also go with a slightl cheaper @erse which would save !etween 5$##%51###. ,f we decide on new uniforms- mone will !e needed ASAP+)

7. BCHS will be having mass physicals afte school !ay 2n". #he cost is $%.
,f ou must !e a!sent or have an other concerns please contact me ASAP ? (A1") 33(%1;B;. Than'sAl >utler

&''
PAP/:&*:C ,S DE/ FA6 $ +++++
6*E C&( ()# PA:T,=,PAT/ &,TH*ET ,T+++
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BRYAN COUNTY BOARD OF EDUCATION Paul Brooksher, Superintendent

B*+&( C),(#+ H-.H SCH))'

Pa ental Consent an" -ns/ ance -nfo mation 0o m
Warning: Although participation in supervised interscholastic athletics and school activities ma !e one of the least haGardous in which students will engage in or out of school- B+ -#S (&#,*12 P&*#-C-P&#-)( -( -(#1*SCH)'&S#-C &#H'1#-CS an" SCH))' &C#-3-#-1S -(C',41S & *-S5 )0 -(6,*+ 7H-CH !&+ *&(.1 -( S131*-#+ 0*)! !-()* #) ')(.8 #1*! C&#&S#*)PH-C2 -(C',4-(. P1*!&(1(# P&*&'+S-S 0*)! #H1 (1C5 4)7( )* 41&#H. Although serious in@uries are not common in supervised school athletic programs or the school setting- it is onl possi!le to minimiGe- not eliminate the ris'. Students can and do have the responsi!ilit to reduce the chance of in@ur . S#,41(#S &(4 P'&+1*S !,S# )B1+ &'' S&01#+ *,'1S2 *1P)*# &'' PH+S-C&' P*)B'1!S #) #1&CH1*S9C)&CH1S2 0)'')7 & P*)P1* C)(4-#-)(-(. P*).*&!2 &(4 -(SP1C# #H1-* 1:,-P!1(# 4&-'+. > signing this permission form- ou ac'nowledge that ou have read and understand this warning . P&*1(#S )* S#,41(#S 7H) 4) ()# 7-SH #) &CC1P# #H1 *-S5S 41SC*-B14 -( #H-S 7&*(-(. SH),'4 ()# S-.( #H-S P1*!-SS-)( 0)*!. , (we) here! give permission for m (our) child- HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH- toI 1. =ompete in all athletics at >r an =ount High School under the Georgia High School Association e4cept HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH. ". Accompan an school team9activit on an form if its. local or out%of%town trips. (. , here! verif that the information on this form is correct and understand that an false information ma result in m son9daughter !eing declared ineligi!le for participation. 4. , consent to ,nternet storage and deliver of this information to medical providers as appropriate. This ac'nowledgement of ris' and consent to allow participation shall remain in effect until revo'ed in writing. -ns/ ance -nfo mation ;please check one< HHHHF son9daughter is ade1uatel and currentl covered ! accident insurance that will cover in@uries sustained while participating in an school%authoriGed activit . HHHHHHHHHHHHHHHHHHHHHHHHHHHHH =ompan providing insurance HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH )ame of insured HHHHHHHHHHHHHHHHHH polic 9group num!er

HHHHF son9daughter is not currentl covered ! accident insurance. HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH Student signature HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH Signature of Person authoriGed to =onsent for Student (parent or legal guardian) HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH :elationship to student HHHHHHHHHHHHHHHHHH date HHHHHHHHHHHHHHHHHH date HHHHHHHHHHHHHHHHHH witness

BRYAN COUNTY BOARD OF EDUCATION Paul Brooksher, Superintendent

Bryan County High School Athletics

&/tho i=ation to *elease !e"ical -nfo mation an" Consent fo !e"ical # eatment
,- HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH- (parent or guardian *: 1B% ear%old patient) here! authoriGe and consent >r an =ount School S stem.s =ertified Athletic Trainer(s) and9or its =onsulting Ph sicians to provide an re1uested medical information on a need% to%'now !asis to other ph sicians- certified athletic trainers- other healthcare providers- school coaching staff and school administration information that directl pertains to m 9 m child.s athletic participation at >r an =ount High School. Said authoriGation to release medical information shall include- !ut is not necessaril limited to- information concerning illnesses- in@uries- treatments- hospitaliGationse4aminations- J%ra s- or other forms of evaluation and diagnostic testing while participating in competitive athletics at the a!ove%named school. , further authoriGe the =ertified Athletic Trainer- school official- coach- or chaperone involved in the activit to see' medical aid or render care if such attention is necessar in the sole discretion of the person involved. ,n the event of emergenc - and when , cannot !e immediatel reached ! telephone or in person- , give permission to /mergenc Fedical Services and the ph sician selected ! the =ertified Athletic Trainer or school official to provide proper care including- !ut not necessaril limited to- hospitaliGation- in@ectionsanesthesia- diagnostics- or emergenc surger for m child.

, understand that , ma revo'e this authoriGation ! providing written notice to the Athletic Director of >r an =ount High School. , also understand that , am waiving m right to privac with regard to the medical records and patient identifia!le information ! authoriGing the release of m information. This authoriGation shall !e valid for one (1) ear commencing on the effected date e4ecuted !elow. , understand that the release of information is !eing carried out with m consent and so assume full responsi!ilit . If patient is less than 18 years of age and not self-supporting or not otherwise able to gi e consent: !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Parent or uardian

!!!!!!!!!!!!!!!!!!!!!!!!!!!
Date

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Relationship to Patient

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! "itness

If patient is 18 years of age or self-supporting: HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH

Si#nature o$ Patient

HHHHHHHHHHHHHHHHHHHHHHHHHHH
Date

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! "itness

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Date

'&4+S5-( S)0#B&''
&thletic Pa ent Cont act
*ne of the goals of the athletic department at >r an =ount High School is to ma'e the athletic e4perience a positive one for the athletes- the parents- and those who choose to watch our teams perform. To achieve that goal we must all wor' together and support each other. ,n effort to facilitate that- we as' that each parent9guardian read the following guidelines regarding their role as a parent9guardian of an interscholastic athletics participant. > signing this contract ou are demonstrating our support for the sportsmanship initiatives !eing underta'en ! this program. 1. As a parent- , recogniGe that it is vital that , support the efforts and decisions of the coaching staff. ,n the event that , have a 1uestion regarding m childKs role on the team , will communicate those concerns to the coach in a respectful fashion (not during or immediatel after a game when emotions are high). 2. As a parent- , also recogniGe the importance of !eing a positive role model. Therefore- , agree to conduct m self in a manner consistent with good sportsmanship at all contests- !oth at >=HS as well as opposing school sites. , agree to cheer in a positive fashion for outstanding pla and will refrain from criticiGing the efforts of the officials- the pla ers (!oth teams)- and the decisions made ! the coaches. >. As a parent- , also recogniGe that , have great influence over the actions of m athlete. , will refrain from ma'ing negative comments concerning the >=HS Soft!all program and the coaching staff to m athlete at all times- especiall at home. 4. , will also refrain from conversing with the pla ers during practices or games without consent from the coaching staff. /mergenc situations are the onl e4ception. %. Attendance at practice is a priorit for all team mem!ers. As a parent of a team mem!er- , will ma'e ever attempt to assure that m child will !e a!le to attend all practices and contests. ,n the event of a foreseen a!sence- the coaching staff will !e notified as earl as possi!le. , will also support an disciplinar actions set forth ! the coaching staff due to the a!sence. ?. , will support and endorse all the rules- policies and procedures discussed in the >=HS Student9Parent Athletic Hand!oo'.

Playe @s (ame AAAAAAAAAAAAAAAAAAA Pa ents9./a "ians (ames AAAAAAAAAAAAAAAAAAAAAAAAA

Pa ents9./a "ians Signat/ e AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

'&4+S5-( S)0#B&'' &#H'1#-C C)(#*&C#

1. Fem!ers of the soft!all team are responsi!le for these rules and regulations- !eginning with the first meeting until the last game. > @oining this team- pla ers have agreed to a!ide ! all of the following conditions. 2. Pla ers are e4pected to follow coachKs instructions- directions- and decisions. ,nstructions from outside sources such as other coaches- friends- or adults need to !e discussed with the coaching staff. >. =oaches recogniGe the following order of prioritiesI 1) 8amil ") Academics () Soft!all. Additional commitments !e ond this scope should !e considered !efore @oining this team. 4. As a mem!er of this team- ou have made a commitment to !e in attendance. Pla ers are e4pected to !e at all practices- games and team activities. 6ou have !een provided with a schedule of games. An pla er missing a practice or game- might not start the following game. =ollege visitation trips are e4cused a!sences with prior permission from our coach. 6ou must inform a coach prior to the a!sence. %. Pla ers are not to 1uestion umpires calls. Pla ers are not to use negative comments towards teammates or to the visiting team and coaching staff. :emem!er negative comments ma'e negative pla ers. ?. Pla ers are not to converse with or ac'nowledge parents9fans during games and practices. Sta focused+ 7. >ench pla ers are team mem!ers. The ma !e inserted in to the lineup at an time and should !e mentall read . Sta positive and !e alert+ B. Throwing of !ats- helmets- gloves or other actions of displa ed anger on the field ma result in a pla er.s removal from the game or practice. Pla ers e@ected from a game for poor sportsmanship will !e suspended from that game and the " following games. C. 6our appearance and conduct while in or out of uniform is important. Avoid confrontations which ma result in a suspension or termination from the team. 11. An pla er ma !e moved to the 0unior 2arsit or 2arsit level at an time. =oaches will discuss this with pla ers as the situation arises. 12. All pla ers must ride school transportation (!us) to

an" f om all games.

1>. Pla ers are to !e dressed and read for practice 1$ minutes after the last !ell rings. Pla ers must have the following items dail I (proper uniform decided ! team). Pla ers will get dressed in the loc'er room or restrooms. 6our e1uipment (glove- cleats- etc) should alwa s !e with ou (tennis shoes for rain da s). 14. =ell phones are not allowed during practices or games. 1%. ,f pla ers are in@ured or not at full a!ilit to pla - ou must notif our coach. ,f ou are una!le to participate with the team ou ma not practice or pla until released ! the >=HS trainer.

&thlete Signat/ e AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

D*).T 8*:G/T T* ATTA=H A =*P6 *8 6*E: -(S,*&(C1 C&*4DDDDD

LLL Pre%participation Ph sical /valuation

H,ST*:6 8*:F
(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.) Date of Exam ___________________________________________________________________________________________________________________ Name __________________________________________________________________________________ Date of birth __________________________ Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________ Medicines and Allergies: Please list all of the prescription and o er!the!co"nter medicines and s"pplements (herbal and n"tritional) that #o" are c"rrentl# ta$ing

Do #o" ha e an# allergies% M Medicines

M &es M No 'f #es( please identif# specific allerg# belo)* M Pollens M +ood

M Stinging 'nsects

Explain ,&es, ans)ers belo)* -ircle ."estions #o" don/t $no) the ans)ers to*
GENE0A1 23ES4'5NS 6* 7as a doctor e er denied or restricted #o"r participation in sports for an# reason% 8* Do #o" ha e an# ongoing medical conditions% 'f so( please identif# belo): M Asthma M Anemia M Diabetes M 'nfections 5ther: _______________________________________________ 9* 7a e #o" e er spent the night in the hospital% :* 7a e #o" e er had s"rger#% 7EA04 7EA14723ES4'5NS A;534&53 <* 7a e #o" e er passed o"t or nearl# passed o"t D30'NG or A+4E0 exercise% =* 7a e #o" e er had discomfort( pain( tightness( or press"re in #o"r chest d"ring exercise% >* Does #o"r heart e er race or s$ip beats (irreg"lar beats) d"ring exercise% ?* 7as a doctor e er told #o" that #o" ha e an# heart problems% 'f so( chec$ all that appl#: M 7igh blood press"re M A heart m"rm"r M 7igh cholesterol M A heart infection M Ea)asa$i disease 5ther: _____________________ A* 7as a doctor e er ordered a test for #o"r heart% (+or example( E-GFEEG( echocardiogram) 6C* Do #o" get lightheaded or feel more short of breath than expected d"ring exercise% 66* 7a e #o" e er had an "nexplained sei@"re% 68* Do #o" get more tired or short of breath more ."ic$l# than #o"r friends d"ring exercise% 7EA04 7EA147 23ES4'5NS A;534 &530 +AM'1& 69* 7as an# famil# member or relati e died of heart problems or had an "nexpected or "nexplained s"dden death before age <C (incl"ding dro)ning( "nexplained car accident( or s"dden infant death s#ndrome)% 6:* Does an#one in #o"r famil# ha e h#pertrophic cardiom#opath#( Marfan s#ndrome( arrh#thmogenic right entric"lar cardiom#opath#( long 24 s#ndrome( short 24 s#ndrome( ;r"gada s#ndrome( or catecholaminergic pol#morphic entric"lar tach#cardia% 6<* Does an#one in #o"r famil# ha e a heart problem( pacema$er( or implanted defibrillator% 6=* 7as an#one in #o"r famil# had "nexplained fainting( "nexplained sei@"res( or near dro)ning% ;5NE AND G5'N4 23ES4'5NS 6>* 7a e #o" e er had an inD"r# to a bone( m"scle( ligament( or tendon that ca"sed #o" to miss a practice or a game% 6?* 7a e #o" e er had an# bro$en or fract"red bones or dislocated Doints% 6A* 7a e #o" e er had an inD"r# that re."ired x!ra#s( M0'( -4 scan( inDections( therap#( a brace( a cast( or cr"tches% 8C* 7a e #o" e er had a stress fract"re% 86* 7a e #o" e er been told that #o" ha e or ha e #o" had an x!ra# for nec$ instabilit# or atlantoaxial instabilit#% (Do)n s#ndrome or d)arfism) 88* Do #o" reg"larl# "se a brace( orthotics( or other assisti e de ice% 89* Do #o" ha e a bone( m"scle( or Doint inD"r# that bothers #o"% 8:* Do an# of #o"r Doints become painf"l( s)ollen( feel )arm( or loo$ red% 8<* Do #o" ha e an# histor# of D" enile arthritis or connecti e tiss"e disease%
&es No &es No

MED'-A1 23ES4'5NS 8=* Do #o" co"gh( )hee@e( or ha e diffic"lt# breathing d"ring or after exercise% 8>* 7a e #o" e er "sed an inhaler or ta$en asthma medicine% 8?* 's there an#one in #o"r famil# )ho has asthma% 8A* Bere #o" born )itho"t or are #o" missing a $idne#( an e#e( a testicle (males)( #o"r spleen( or an# other organ% 9C* Do #o" ha e groin pain or a painf"l b"lge or hernia in the groin area% 96* 7a e #o" had infectio"s monon"cleosis (mono) )ithin the last month% 98* Do #o" ha e an# rashes( press"re sores( or other s$in problems% 99* 7a e #o" had a herpes or M0SA s$in infection% 9:* 7a e #o" e er had a head inD"r# or conc"ssion% 9<* 7a e #o" e er had a hit or blo) to the head that ca"sed conf"sion( prolonged headache( or memor# problems% 9=* Do #o" ha e a histor# of sei@"re disorder% 9>* Do #o" ha e headaches )ith exercise% 9?* 7a e #o" e er had n"mbness( tingling( or )ea$ness in #o"r arms or legs after being hit or falling% 9A* 7a e #o" e er been "nable to mo e #o"r arms or legs after being hit or falling% :C* 7a e #o" e er become ill )hile exercising in the heat% :6* Do #o" get fre."ent m"scle cramps )hen exercising% :8* Do #o" or someone in #o"r famil# ha e sic$le cell trait or disease% :9* 7a e #o" had an# problems )ith #o"r e#es or ision% ::* 7a e #o" had an# e#e inD"ries%

&es

No

&es

No

:<* Do #o" )ear glasses or contact lenses% :=* Do #o" )ear protecti e e#e)ear( s"ch as goggles or a face shield% :>* Do #o" )orr# abo"t #o"r )eight% :?* Are #o" tr#ing to or has an#one recommended that #o" gain or lose )eight% :A* Are #o" on a special diet or do #o" a oid certain t#pes of foods% <C* 7a e #o" e er had an eating disorder% <6* Do #o" ha e an# concerns that #o" )o"ld li$e to disc"ss )ith a doctor% +EMA1ES 5N1& <8* 7a e #o" e er had a menstr"al period%

&es

No

<9* 7o) old )ere #o" )hen #o" had #o"r first menstr"al period% <:* 7o) man# periods ha e #o" had in the last 68 months% Explain ,#es, ans)ers here

' hereb# state that( to the best of m# $no)ledge( m# ans)ers to the abo e ."estions are complete and correct*
Signat"re of athlete __________________________________________ Signat"re of parentFg"ardian ____________________________________________________________ Date _____________________

N2010 American Academy of amily !hysicians" American Academy of !ediatrics" American #ollege of $ports %edicine" American %edical $ociety for $ports %edicine" American &rthopedic $ociety for $ports %edicine" and American &steopathic Academy of $ports %edicine. !ermission is granted to reprint for noncommercial" educational purposes 'ith ackno'ledgment.

7EC<C9

A!8=?6FC:6C

LLL Pre%participation Ph sical /valuation

PH6S,=A< /JAF,)AT,*) 8*:F

Name __________________________________________________________________________________ Date of birth __________________________

P7&S'-'AN 0EM'NDE0S
6* -onsider additional ."estionson moresensiti eiss"es O Do#o"feelstressedo"tor"nderalotofpress"re% O Do#o"e erfeelsad(hopeless(depressed(oranxio"s% O Do#o"feelsafeat#o"rhomeorresidence% O 7a e#o"e ertriedcigarettes(che)ingtobacco(sn"ff(ordip% O D"ringthepast9Cda#s(did#o""seche)ingtobacco(sn"ff(ordip% O Do#o"drin$alcoholor"sean#otherdr"gs% O 7a e#o"e erta$enanabolicsteroidsor"sedan#otherperformances"pplement% O 7a e#o"e erta$enan#s"pplementstohelp#o"gainorlose)eightorimpro e#o"rperformance% O Do#o")earaseatbelt("seahelmet(and"secondoms% 8* -onsider re ie)ing ."estions on cardio asc"lar s#mptoms (."estions <!6:)* EHAM'NA4'5N 7eight ;P F ( F Beight ) P"lse M Male M +emale Iision08CF 18CF -orrected M & M N N50MA 1 A;N50MA1 +'ND'NGS

MED'-A1 Appearance O Marfan stigmata ($#phoscoliosis( high!arched palate( pect"s exca at"m( arachnodact#l#( arm span J height( h#perlaxit#( m#opia( MIP( aortic ins"fficienc#) E#esFearsFnoseFthroat O P"pils e."al O 7earing 1#mphnodes 7eart a O M"rm"rs (a"sc"ltation standing( s"pine( KF! Ialsal a) O 1ocationofpointofmaximalimp"lse(PM') P"lses O Sim"ltaneo"sfemoral andradial p"lses 1"ngs Abdomen Genito"rinar# (males onl#)b S$in O 7SI(lesionss"ggesti eofM0SA(tineacorporis Ne"rologic c M3S-315SEE1E4A1 Nec$ ;ac$ Sho"lderFarm Elbo)Fforearm BristFhandFfingers 7ipFthigh Enee 1egFan$le +ootFtoes +"nctional

O D"c$!)al$( singleleg hop

-onsider E-G(echocardiogram( andreferraltocardiolog# forabnormalcardiac histor#orexam* b-onsi der G3examifinpri atesetting*7a ingthirdpart#presentisrecommended* c-onsi der cogniti e e al"ation or baseline ne"rops#chiatric testingifahistor# of significant conc"ssion*
a

-leared forall sports )itho"t restriction -leared for all sports )itho"t restriction )ith recommendations for f"rther e al"ation or treatment for ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ N54 cleared Pending f"rther e al"ation 8or an#sports 8or certain sports ________________________________________________________________________________________________________________________ 0eason ____________________________________________________________________________________________________________________________ 0ecommendations ___________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________ ' ha e examined the abo e!named st"dent and completed the preparticipation ph#sical e al"ation* 4he athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as o"tlined abo e* A cop# of the ph#sical exam is on record in m# office and can be made a ailable to the school at the re."est of the parents* 'f condi! tions arise after the athlete has been cleared for participation( the ph#sician ma# rescind the clearance "ntil the problem is resol ed and the potential conse."ences are completel# explained to the athlete (and parentsFg"ardians)* Name of ph#sician (printFt#pe) _____________________________________________________________________________________________________ Date ________________ Address ___________________________________________________________________________________________________________ Phone _________________________ Signat"re of ph#sician _______________________________________________________________________________________________________________________( MD or D5

N2010 American Academy of amily !hysicians" American Academy of !ediatrics" American #ollege of $ports %edicine" American %edical $ociety for $ports %edicine" American &rthopedic $ociety for $ports %edicine" and American &steopathic Academy of $ports %edicine. !ermission is granted to reprint for noncommercial" educational purposes 'ith ackno'ledgment.
7EC<C9 A!8=?6FC:6C

LLL Pre%participation Ph sical /valuation

=</A:A)=/ 8*:F
Name _______________________________________________________ Sex M Age _________________ Date of ;irth _________________ -leared for all sports )itho"t restriction -leared for all sports )itho"t restriction )ith recommendations for f"rther e al"ation or treatment for ______________________________________________ _________________________________________________________________________________________________________________________ Not cleared Pending f"rther e al"ation 8or an# sports 8or certain sports ___________________________________________________________________________________________________ 0eason _________________________________________________________________________________________________________ +

0ecommendations _____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________

' ha e examined the abo e!named st"dent and completed the pre!participation ph#sical e al"ation* 4he athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as o"tlined abo e* A cop# of the ph#sical exam is on record in m# office and can be made a ailable to the school at the re."est of the parents* 'f conditions arise after the athlete has been cleared for participation( the ph#sician ma# rescind the clearance "ntil the problem is resol ed and the potential conse."ences are completel# explained to the athlete (and parentsFg"ardians)*
Name of ph#sician (printFt#pe) _________________________________________________________________________________ Date ________________ Address _______________________________________________________________________________________ Phone _________________________ Signat"re of ph#sician __________________________________________________________________________________________________( MD or D5 EME0GEN-& 'N+50MA4'5N Allergies _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ 5ther information _______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________

HHHHHHHHHHHHH
N%&'& A(eri)an A)ade(* o$ Fa(il* Ph*si)ians, A(eri)an A)ade(* o$ Pediatri)s, A(eri)an Colle#e o$ Sports +edi)ine, A(eri)an +edi)al So)iet* $or Sports +edi)ine, A(eri)an Orthopedi) So)iet* $or Sports +edi)ine, and A(eri)an Osteopathi) A)ade(* o$ Sports +edi)ine, Per(ission is #ranted to reprint $or non)o((er)ial, edu)ational purposes -ith a)kno-led#(ent,
H/#$#( A%"3B19#41#