Perquimans County High Schools Athletic Participation Form Athlete's Name: lass of last First Middle School ID: Date of Birth: Gender: MF Ethnicity: Street Address: city: Nc:___TipCode:, Hoine Phone: Father's Name: Daytime Phone: cell Mother's Name: Daytime Phone’ cell Legal Guardian: Daytime Phone: cell, ‘Alternative Emergency Contact: Phone #: Family Physicia Phone tt: Insurance Company Name: Policy Number: Medical Alerts: Please list all allergies to medications as well Explain any other Medical condition that may post problems for your participatio Request for Permission: We, the above mentioned student and the student's parent/legal custodian, apply for permission to participate in interscholastic athletics in the following sports, Note: Weight lifting may be a required component for conditioning. (Baseball ( }Football (_)Softball ( J0ther (Basketball ( }Soccer ( YTrack ( )cheerleading (_)softbatt { Wolleyball Insurance: The Perquimans County High Schools System furnishes an Interscholastic Athletic Insurance Polley that provides limited benefits forall students in the system participating in middle/high school sponsored and supervised interscholastic athletic activities, This policy provides EXCESS coverage for students with other insurance coverage, but pays only when other benefits have been ‘exhausted. In cases in which a student has no other coverage, either with 2 commercial insurance agency, Medicare, ar Medicaid, the PCS athletic insurance poliey is the primary policy. I your son or daughter should be injured while participating ina school sponsored or supervised interscholastc athletic event, the following procedures must be followed to process a claim under the insurance provided by PCS. (1) Pick up a claim form from the Athletic Director in the front office. (2) See a physician within 30 days of the injury. (3) Complete and submit the Accident Claim form. The claim form must be filed with the insurance company within 90 days of the injury and should include the Explanation of Benefits Form from your Primary Insurance carrier. A student-athlete AND his/her parents mus sign this form before the student is eligible to participate In any game or practice. | certify that this information is up-to-date. | wll inform the school my child attends if this information changes. Parent/Legal Guardian DatePerquimans County Schools Athletic Participation Form 4 do hereby declare that | willbe a participant in the Perquimans County School Board approved drug screening of athletes. Ido authorize the school to administer drug testing and release the results ONLY to my Parent/Legal Guardian, Athletic Director, Athletic Trainer, or Principal. ‘As the Parent/Legal Guardian, |, ‘consent to and authorize Perquimans County Schools to conduct atest on the urine sample provided by my son/daughter to test for drug use. Consent is also given for the release of Information concerning the results of such test ONLY to the Parent/Legal Guardian, Athletic Director, Athletic Trainer, and Principal. ‘Student Signature Date Parent/Guardian Signature Date Custody and Control Form Collection |. Perquimans County Schools: Athietic Orug Testing. Collection Date: Donor Name: 1D or SSN Reason for Screen: __Pre-employment __Post Accident __-Random “Reasonable Suspicion ___Post-Employment Offer Other (specify), “Type of Screen: __SPanel _2 Panel Til, _] Specimen Temperature ‘Within Normal Range (90.5 - 98.8) Outside Normal Temperature Remarks: IV, | DONOR CERTIFICATION: | certify that I provided my urine to the collector, that the split specimen (if required} container was sealed with tamper-proof seals in my presence; and that the information provided on this form and on the specimen container seals's correct. Donor’s Signature Date Daytime Phone # CollecorsSigrature ——=~=~S~*~*~*~*«CS v. Custody and Control Purpose of Change Released By Received By Date: Proved for Test, DONOR Screening Results Date of Screen: Time of Screen:, AM/PM. Time of Result AM/PM Positive Results Confirmed By: Results of Screen: 1. Cocaine Pos __neg Specimen Destroyed 2. Cannabinoids POS ___NEG specimen forwarded to lab of confirmation 3. Methamphetamin POS ___NEG 4. Pheneyelidines Pos NEG 5. Heroin/Opiates Pos ___NEG Test Operator's Sgnature Date RAPID TESTING, INC; P.0.BOX 4722; NORFOLK, VA 23523NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient’s Name: Age: This is a screening examination for participation in sports. This does not substitute for a comprehensive examination with your child’s regular physician where important preventive health information can be covered. Athlete's Directior knowledge. Parent’s Directions: Please assure that all questions are answered to the best of your knowledge. Not disclosing accurate information may put your child at risk during sports activity. Physician’s Directions: We recommend carefully reviewing these questions and clarifying any positive answers. Please review all questions with your parent or legal custodian and answer them to the best of your 3 Explain “Yes” answers below Yes 1, las the athlete ever been hospitalized or had surgery? 2._Is the athlete presently taking any medications or pills? 3._Does the athlete have any allergies (medicine, bees or other stinging insects, latex)? 4. Has the athlete ever passed out or nearly passed out DURING exereise, emotion or startle? 5._Has the athlete ever fainted or pessed out AFTER exercise? ‘6._Has the athlete had extreme fatigue associated with exercise different from other children)? 7.__Has the athlete ever had trouble breathing during exercise, or a cough with exercise? 8._ Has the athlete ever been diagnosed with exercise-induced asthma? 9._ Has doctor ever told the athlete that they have high blood pressure? 10, Has a doctor ever told the athlete that they have a heart infection? 11. Has a doctor ever ordered an EKG or other test forthe athlete's heart, or has tho atte ever been told they have a murmur? 12, Has the athlete ever had discomfort, pain, or pressure in his chest during or after exercise oF complained of their heart “acing” or “skipping beats"? 13. Has the athlete ever had a head injury, been knocked out, or bad a concussion? 14, Has the athlete ever had a seizure or been diggnosed with an unexplained seizure problem? 15. Has the athlete ever had a stinger, bumer or pinched nerve? 16, Has the athlete ever had a heat injury (heat stroke) or severe muscle cramps with activities? 17, Has the athlete ever had any problems with their eyes or vision? 18. Has the athlete ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury oF any bones or joints? Head — QShoulder Thigh Neck Glow Knee Chest Giilip Forearm O Shivealf _QBeck_QWrist__QAnkle__ Hand __ Foot, 19, Has the athlete ever had an eating disorder, or do you have any concems about your eating habits or weight? 20. Does the athlete have any chronic medical illnesses (diabetes, asthma, kidney problems, etc.)? 21, Has the athlete had a medieal problem or injury since their lst evaluation” ‘22, Does the athlete have the sickle cell trait? FAMILY HISTORY 23. Has any family member had a sudden, unexpected death before age 50 Gnchuding from sudden infant death mdrome [SIDS], car accident, drowning)? 2a, Flas any family member had unexplained heart attack, fainting or seizures? 25. Does the athlete have @ father, mother or brother with sickle cell disease? glo|o|o|c|o| o| Sle|o/e/a}uIClo|O On y Gojoloole) of o/ofo}o|g|olo|o)ofo|c! glooloelo) of o)ofo|olojo}u|o|o|o|c! oo) ole)elojo}a) fo] qfolojo/ojo o\o} ofolojojolo Elaborate on any positive (yes) answers: Thave reviewed and answered each question above, and assure that all are accurate responses. Furthermore, I give permission for ray child to participate in sports, Signature of parent/legal custodian: Date: Signature of Athlete: Date: Phone #:Physical Examination (Must be Completed by a Licensed Physician, Nurse Practitioner or Physician's Assistant) Athlete's Name, Age Date of Birth Height Weight, Be, {tite / “ He) Vision R20) 1.201, Corrected: ¥_N ‘These are required elements for all examinations ‘ABNORMAL "ABNORMAL FINDINGS LUNGS) SKIN NECK/BACK ‘Other Orthopedic Problems ‘Optional Examination Blements ~ Should be done i hsiory indicates HEENT ABDOMINAL, (GENITALIA (MALES) HERNIA (MALES) Clearance™ DA. Clesrea QB. Cleared after completing evaluation/rehabi a C, Not cleared for: Q Conision OD Contact O Non-contact Strenuous Moderately strenuous Non-strenuons, Due to: sal Recommendations/Rehab Instructions: [Name of Physician/Extender: Signature of Physician/Pxtender, MD DO PA NP (Signature and cirele of designated degree required) Date of exam: Physician Office Stampr Address: Phone ‘FT Tollowing are considered dfsquallfying unl appropriate medical and parental releases are obtained post-operative clearance, acuielafoctTon, Obvious growth retardation, diabetes, jaundice, severe visual or auditory impairment, pulmonary insufficiency, organic heart disease or hypertension, enlarged liver ot spleen, a chronic musculoskeletal condition that Limits ability for safe exercise/sport (Le. Klippel-Feil anomaly, Sprengel’s deformity, histary of convulsions ‘or concussions, sbsence of or one kidney, eye, testicle or ovary, ete) This form approved bythe North Carolina High School Athletic Association Sports Medicine Advisory Committe December 9, andthe NCHSAA Board of Directors reviewed annually.