NORTH COUNTRY UNION JUNIOR HIGH

NORTH COUNTRY UNION JUNIOR HIGH SCHOOL

SPORTS PARTICIPATION HEALTH RECORD

To be filled out every year prior to participating in sports

This evaluation is only to determine readiness for sports participation. It should not be used as a substitute for regular health maintenance examinations.

Name: _______________________Age _______ DOB__________Grade______ Date___________

Address: _________________________________ Phone: _________________________________

Sports: __________________________________________________________________________

Note: A sports physical must be done by a MD/DO/Nurse Practitioner/ Physicians Assistant/ every two years.

This sports physical will be in effect for two years from the date of the physical examination. All requirements must be turned in to the health office in order to be eligible to participate in the sport of your choice. If any items listed below are inadequate, you will not be placed on the coaches’ sports roster until you have completed all the requirements. All students who play sports must sign new training rules for each sport that you choose to play.

If your health history poses any question regarding your physical ability to participate in sports you will be requested to obtain a release from your physician.

First year:

Prior to participating in sports at NCUJHS, a physical exam, done by your medical care provider, stating; cleared for sports or, stating; full participation in all sports. The following forms must be completed:

1. Health History

2. Physical Examination Form (signed by your Medical Care provider).

3. Insurance Information

4. Training Rules

Second year of sports participation:

All the above forms, except the Physical exam form, must be completed and on file in the Health Office.

North Country Union Junior High School

SPORTS PARTICIPATION HEALTH RECORD

Name: _____________________________________ Date: ___________________________________

Sport: _____________________________________ Grade:___________________________________

These sections are to be completed by the athlete and the parent/guardian. Please check yes or no in the spaces provided. Please explain any YES answers.

YES	NO	Have you ever had a childhood/adolescent illness, or one in the past year that:
		Required you to stay in the hospital?
		Lasted longer than a week?
		Caused you to miss 3 to 5 consecutive days of practice or competition in the past year?
		Is related to allergies? (i.e. Hay fever, hives, asthma, insect stings?
		Required an operation?
		Is considered Chronic? (asthma, diabetes, etc.)
		Was diagnosed in the past year?

If yes, Please explain: ____________________________________________________________

______________________________________________________________________________

YES	NO	Have you ever had a childhood/adolescent injury, or one in the past year that:
		Required you go to an emergency room or see a doctor?
		Required you to stay in the hospital?
		Required x-rays?
		Caused you to miss 3 consecutive days of participation in routine activities?
		Required an operation?

If yes, Please explain: ____________________________________________________________

______________________________________________________________________________

YES	NO	Have you had a seizure, concussion or been unconscious for any reason in the past year?
		Do your take any prescription or over the counter medications?
		Do you have any allergies to medications?

If Yes, Please explain, and list medications:

______________________________________________________________________________

YES	NO	Are you able to run 1/2 mile (2 times around the track) without stopping?
		Do you wear glasses or contacts?
		Do you wear dental bridges, plates or braces?

If yes, Please explain: ____________________________________________________________

______________________________________________________________________________

YES	NO	Have any members of your family under the age of 50 had a heart attack, heart problem or died unexpectedly?
		Have you ever had a heart murmur, high blood pressure or a heart abnormality?
		Are you missing a kidney?

If yes, Please explain:

______________________________________________________________________________

YES	NO	Have you had any changes in your physical/emotional health in the past year that would compromise your participation in sports?
		Are you worried about a medical problem or condition at this time?

If yes, Please explain:

______________________________________________________________________________

I hereby state that, to the best of my knowledge, my answers to the above questions are correct.

Date: _________________ Signature of Athlete: _____________________________________

Signature of Parent: ______________________________________

Height_____Weight _____ Pulse _____ Blood Pressure ____/____ Vision: Corrected Y or N

1. Eyes----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2. Ears, nose, throat-------------------------------------------------------------------------------------------------------------------------------------------------------

3. Mouth and teeth ----------------------------------------------------------------------------------------------------------------------------------------------------------

4. Cardiovascular ------------------------------------------------------------------------------------------------------------------------------------------------------------

5. Chest and Lungs ---------------------------------------------------------------------------------------------------------------------------------------------------------

6. Abdomen --------------------------------------------------------------------------------------------------------------------------------------------------------------------

7. Skin ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

8. Genitalia-Hernia ----------------------------------------------------------------------------------------------------------------------------------------------------------

10. Neuromuscular------------------------------------------------------------------------------------------------------------------------------------------------------------

11. Physical Maturity (Tanner Stage) ---------------------------------------------------------------------------------------------------------------------------------

Hemoglobin/ Hematocrit (optional) -----------------------------------------------------------------------------------------------------------------------------------

Urinalysis (Optional) ---------------------------------------------------------------------------------------------------------------------------------------------------------

Comments regarding abnormal findings ---------------------------------------------------------------------------------------------------------------------------

? Cleared ? Cleared after completing evaluation/rehabilitation for: --------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

? Not cleared for ---------------------------------------- Reason: -----------------------------------------------------------------------------------------------------

Recommendations: -----------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

MD/DO/NP/PA SIGNATURE: ---------------------------------------------------------------------------------------------------------------------------------------------

DATE: ------------------------ --------PHONE: --------------------------------------------------------------------------------------------------------------------------------

I/We give our permission for North Country Union Junior High School to release “Directory Information” concerning our child, including individual statistics to the general public through the media via radio, newspapers, TV, Internet, and game programs.

Player’s Signature____________________________________________

Parent’s/Guardian’s Signature__________________________________ Date___________________________

I/We give our permission for _______________________to participate in organized high school athletics, realizing that such activity involves the potential for injury, which is inherent in all sports. I/We acknowledge that even with best coaching, use of the most advanced protective equipment and strict observance of the rules, injuries are still a possibility. On rare occasions these injuries can be so severe as to result in total disability, paralysis, and/or death.

In the event of an injury or an illness and we, the parents, cannot be contacted I give permission to the school to allow the coach or staff member to make the decision as to the care and transportation of my child to the necessary emergency facility. I certify that he/she is covered by health insurance as listed below.

I/We acknowledge that I/We have read and understand the above information and warning.

Player’s Signature____________________________________________

Parent’s/Guardian’s Signature _________________________________ Date ___________________________

All students participating in sports must be insured. The following options are available:

Commercial Travelers Mutual Insurance is available for those who do not have insurance coverage or would like additional coverage due to a high deductible with their existing insurance company.

If you wish to purchase the Commercial Travelers Mutual Insurance (Richard J. Horan Agency) the Enrollment forms with a complete explanation of the Student Insurance Plans, can be obtained in the NCUJHS Health Office.

Payment for the purchase of this coverage must be included with this form.

Football levels of participation fluctuate throughout the season, therefore it is strongly recommended you purchase the “Football only” package to afford your student athlete full coverage while playing football.

NOTE: The football plan does not include other sports, school time or 24-hour coverage.

	ELITE PLAN	SUPERIOR PLAN	ECONOMY PLAN
24 hour accident	$140.00	$98.00	$62.00
24 hour accident/sickness	$479.00	$336.00	$198.00
School time only accident	$39.00	$27.00	$16.00
Extended Dental	$6.00	$6.00	$6.00
Football only	$198.00	$143.00	$84.00

Player’s Signature____________________________________________

Parent’s/Guardian’s Signature________ Date_

Player’s Signature____________________________________________

Parent’s/Guardian’s Signature _______ Date _

ELITE PLAN

SUPERIOR PLAN

ECONOMY PLAN

Payment for the purchase of this coverage must be included with this form.