Pre-Participation Physical Packet
TIMBER CREEK HIGH SCHOOL PRE-PARTICIPATION PHYSICAL PACKET
Physical Packet Instructions Attention Parents and Student Athletes: Thank you for taking the time to read the following instructions for completing your preparticipation physical packet. In order to participate in interscholastic sports at Timber Creek High School, you must have the following forms completed. Please make sure every form is complete prior to turning it in to an Athletic Trainer. Incomplete forms/physical packets will be returned to you or your child and will delay his/her eligibility to participate in sports. Please note that all athletic physicals are valid for only one calendar year! If your child's physical expires during the season, they will be ineligible to participate until an updated physical is received. Download the physical packet by going to timbercreekathletics.com
Forms Checklist 2017-2018 Sports Activity Participation Forms (2 pages - Student Name, Parent Signature & Dated) EL2 Forms (3 pages - Student & Medical Info, Parent & Student Signature, Physician Signature & Dated) EL3 Forms Consent & Release from Liability Certificate - Sudden Cardiac Arrest, Concussion & Heat-Related Illness (4 pages - Signed & Dated on each form) Impact Concussion Consent Form (2 pages - Parent & Student Signature & Dated) Electrocardiogram Screen Consent Form & Release of Liability (Completed, Signed & Dated) Emergency Treatment Authorization Cards (1 page - Both cards need to be completed, Parent Signature & Dated) Questions? Email: Heather Klein - [email protected] or Sam Mizener - [email protected]
EL2 Florida High School Athletic Association
Revised 03/16
Preparticipation Physical Evaluation (Page 3 of 3) This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2. This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted. Student’s Name: _____________________________________________________________________________________________ ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable) I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s): ____ Cleared without limitation ____ Disability: _____________________________________________________ Diagnosis: ___________________________________________________________ _______________________________________________________________________________________________________________________________________ ____ Precautions: ________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ ____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________ ____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________ Recommendations: _______________________________________________________________________________________________________________________ Name of Physician (print): ___________________________________________________________________________________________ Date: ____/____/_______ Address: _______________________________________________________________________________________________________________________________
Signature of Physician: ___________________________________________________________________________________________________________________ Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.
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ELECTROCARDIOGRAM SCREEN (ECG) CONSENT FORM AND RELEASE OF LIABILITY An ECG screen (also referred to as an EKG) can help identify young athletes who are at risk for sudden cardiac death, a condition where death results from an abrupt loss of heart function. An ECG screening may assist in diagnosing several different heart conditions that may contribute to sudden cardiac death. By signing below, I am electing an ECG screen provided by Timber Creek High School for my child. By electing to receive an ECG screen, I acknowledge the limitations of an ECG screen and that sudden cardiac death or other cardiac events may still occur, despite this screening. I further acknowledge that students with an abnormal ECG screen will be required to undergo further testing (e.g. an echo or ultrasound) and/or a medical consultation prior to being released to resume participation in Timber Creek High athletics. By my signature below, I hereby release and forever discharge, and waive, any and all claims against Timber Creek High School, its employees, sponsors, trustees, consultants, volunteers and contractors that relate to my election regarding and/or my child’s participation in this ECG screening project. I authorize medical personnel to review the ECG results, and interpret and use the same for diagnostic and aggregated statistical purposes in accordance with the Family Education Rights and Privacy Act and Health Insurance Portability and Accountability Act of 1996. I DO HEREBY CONSENT to participation in the ECG screening on behalf of my minor child. I understand that it is FREE or that I can donate $15 per student screened to “pay it forward” so that others can benefit from this endeavor in the future. Note: Through our December to ReMem6er fundraiser, we’re able to assist families with the cost of this program if it will in any way be a financial hardship. Please choose one of the options below: _____ We choose to pay the $15 in full. (Make checks out to Who We Play For) _____ We can afford a partial donation of _______. Our donation is enclosed. _____ We would appreciate full financial assistance. I DECLINE participation in the ECG screen on behalf of my child.
__________________________________ __________________________________ Child's Name Printed Date __________________________________ __________________________________ Parent/Guardian Name Printed Parent/Guardian Signature __________________________________ __________________________________ Parent/ Guardian email address Parent/ Guardian phone # Participant Information Ethnicity: Afro American/ Black _____ Asian _____ Caucasian/ White _____ Hispanic _____ Other _____ (Mark all that apply) Age: ____ Gender: Male ____ Female ____ Birthdate ____/____/______ Height: ______ Weight: ______ Previous Cardiac Issues (if any): ______________________________________________________________ Family Cardiac History (if any): ________________________________________________________________ Do you currently take any of the following medications? (circle any that apply): ADD/ADHD Beta Blockers Asthma medication/inhaler Cardiac Medications
Physical Packet Instructions Attention Parents and Student Athletes: Thank you for taking the time to read the following instructions for completing your preparticipation physical packet. In order to participate in interscholastic sports at Timber Creek High School, you must have the following forms completed. Please make sure every form is complete prior to turning it in to an Athletic Trainer. Incomplete forms/physical packets will be returned to you or your child and will delay his/her eligibility to participate in sports. Please note that all athletic physicals are valid for only one calendar year! If your child's physical expires during the season, they will be ineligible to participate until an updated physical is received. Download the physical packet by going to timbercreekathletics.com
Forms Checklist 2017-2018 Sports Activity Participation Forms (2 pages - Student Name, Parent Signature & Dated) EL2 Forms (3 pages - Student & Medical Info, Parent & Student Signature, Physician Signature & Dated) EL3 Forms Consent & Release from Liability Certificate - Sudden Cardiac Arrest, Concussion & Heat-Related Illness (4 pages - Signed & Dated on each form) Impact Concussion Consent Form (2 pages - Parent & Student Signature & Dated) Electrocardiogram Screen Consent Form & Release of Liability (Completed, Signed & Dated) Emergency Treatment Authorization Cards (1 page - Both cards need to be completed, Parent Signature & Dated) Questions? Email: Heather Klein - [email protected] or Sam Mizener - [email protected]
EL2 Florida High School Athletic Association
Revised 03/16
Preparticipation Physical Evaluation (Page 3 of 3) This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2. This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted. Student’s Name: _____________________________________________________________________________________________ ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable) I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s): ____ Cleared without limitation ____ Disability: _____________________________________________________ Diagnosis: ___________________________________________________________ _______________________________________________________________________________________________________________________________________ ____ Precautions: ________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ ____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________ ____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________ Recommendations: _______________________________________________________________________________________________________________________ Name of Physician (print): ___________________________________________________________________________________________ Date: ____/____/_______ Address: _______________________________________________________________________________________________________________________________
Signature of Physician: ___________________________________________________________________________________________________________________ Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.
–3–
ELECTROCARDIOGRAM SCREEN (ECG) CONSENT FORM AND RELEASE OF LIABILITY An ECG screen (also referred to as an EKG) can help identify young athletes who are at risk for sudden cardiac death, a condition where death results from an abrupt loss of heart function. An ECG screening may assist in diagnosing several different heart conditions that may contribute to sudden cardiac death. By signing below, I am electing an ECG screen provided by Timber Creek High School for my child. By electing to receive an ECG screen, I acknowledge the limitations of an ECG screen and that sudden cardiac death or other cardiac events may still occur, despite this screening. I further acknowledge that students with an abnormal ECG screen will be required to undergo further testing (e.g. an echo or ultrasound) and/or a medical consultation prior to being released to resume participation in Timber Creek High athletics. By my signature below, I hereby release and forever discharge, and waive, any and all claims against Timber Creek High School, its employees, sponsors, trustees, consultants, volunteers and contractors that relate to my election regarding and/or my child’s participation in this ECG screening project. I authorize medical personnel to review the ECG results, and interpret and use the same for diagnostic and aggregated statistical purposes in accordance with the Family Education Rights and Privacy Act and Health Insurance Portability and Accountability Act of 1996. I DO HEREBY CONSENT to participation in the ECG screening on behalf of my minor child. I understand that it is FREE or that I can donate $15 per student screened to “pay it forward” so that others can benefit from this endeavor in the future. Note: Through our December to ReMem6er fundraiser, we’re able to assist families with the cost of this program if it will in any way be a financial hardship. Please choose one of the options below: _____ We choose to pay the $15 in full. (Make checks out to Who We Play For) _____ We can afford a partial donation of _______. Our donation is enclosed. _____ We would appreciate full financial assistance. I DECLINE participation in the ECG screen on behalf of my child.
__________________________________ __________________________________ Child's Name Printed Date __________________________________ __________________________________ Parent/Guardian Name Printed Parent/Guardian Signature __________________________________ __________________________________ Parent/ Guardian email address Parent/ Guardian phone # Participant Information Ethnicity: Afro American/ Black _____ Asian _____ Caucasian/ White _____ Hispanic _____ Other _____ (Mark all that apply) Age: ____ Gender: Male ____ Female ____ Birthdate ____/____/______ Height: ______ Weight: ______ Previous Cardiac Issues (if any): ______________________________________________________________ Family Cardiac History (if any): ________________________________________________________________ Do you currently take any of the following medications? (circle any that apply): ADD/ADHD Beta Blockers Asthma medication/inhaler Cardiac Medications
