CSCS MS Athletic Packet 2018-19

Colorado Springs Christian Middle School

Athletic Department

Athletic Forms Packet

Nam

e (Last, First):

Grade:

Sport:

All forms must be turned in as a packet. Please check to be sure all forms are included and signatures are in place. Participation will not be allowed unless all forms are turned in. Please do not staple forms together.

Check List: Physical (signed by doctor and dated within last year) Emergency/Contact Information Permit for Participation Insurance Athletic Fee Form with Payment(s)

PHYSICAL EXAMINATION AND PARENT PERMIT

FOR ATHLETIC PARTICIPATION - PART I

I hereby certify that I have examined and that the

student was found physically fit to engage in middle school/high school sports (except as listed on back).

Student’s birth date Exp. Date (good for 365 days)

PARENT OR GUARDIAN PERMIT

WARNING: Although participation in supervised interscholastic athletics and activities may be one of the least hazardous in which any student will engage in or out of school, BY ITS NATURE, PARTICIPATION IN INTERSCHOLASTIC ATHLETICS INCLUDES A RISK OF INJURY WHICH MAY RANGE IN SEVERITY FROM MINOR TO LONG-TERM CATASTROPHIC INJURY. Although serious injuries are not common in supervised school athletic programs, it is impossible to eliminate this risk.

PLAYERS MUST OBEY ALL SAFETY RULES, REPORT ALL PHYSICAL PROBLEMS TO THEIR COACHES,

FOLLOW A PROPER CONDITIONING PROGRAM, AND INSPECT THEIR OWN EQUIPMENT DAILY.

By signing this Permission Form, we acknowledge that we have read and understood this warning. PARENTS OR

STUDENTS WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS PERMISSION FORM. By signing this form it allows my students medical information to be

shared with appropriate medical staff when necessary in compliance with HIPPA (Health Insurance

Portability and Accountability Act) Regulations.

I hereby give my consent for to compete in athletics for Middle/High School in Colorado High School Activities Association approved sports, except as listed on back, and

I have read and understand the general guidelines for eligibility as outlined in the Competitor’s Brochure.

Parent or Guardian Signature Date

I have read, understand and agree to the General Eligibility Guidelines as outlined in the Competitor’s Brochure.

Student Signature Date

No student shall represent their school in interschool athletics until there is on file with the superintendent or

principal a statement signed by his parent or legal guardian and a signed physical certifying that he/she has passed an adequate physical examination within the past year, that in the opinion of the examining physician, physician’s assistant, nurse practitioner or a certified/registered chiropractor, he/she is physically fit to participate in high school athletics; and that he/she has the consent of his/her parents or legal guardian to participate.

NOTE: It is strongly recommended by the Colorado Department of Health that individuals participating in athletic

events have current tetanus boosters. Tetanus boosters are recommended every 10 years throughout

life. Boosters are recommended at the time of injury if more than five years have elapsed since the last booster.

If significant intervening illnesses and/or injuries have occurred, a more complete physical examination should be

conducted. The physical examination form must be signed by a practicing physician, physician assistant, or nurse practitioner.

If a student athlete has been injured in practice and/or competition, the nature of which required medical

attention, the student athlete should not be permitted to return to practice and/or competition until he/she has

received a release from a practicing physician.

NOTE: The CHSAA urges an adequate physical examination be given when a student athlete changes levels of competition, i.e. Little League to Middle School, Middle School to High School.

PHYSICIAN SIGNATURE REQUIRED ON BACK

MED

ICAL H

ISTO

RY O

F S

TU

DEN

T &

FAM

ILY

YES

NO

M

ED

ICAL H

ISTO

RY O

F S

TU

DEN

T &

FAM

ILY

YES

NO

1.

Has a

docto

r ever d

enie

d o

r restricte

d y

our

particip

atio

n in

sports fo

r any re

ason?

32.

Do y

ou h

ave a

ny ra

shes, p

ressu

re so

res, or o

ther

skin

pro

ble

ms?

2.

Do y

ou h

ave a

n o

ngoin

g m

edica

l conditio

n

(like d

iabete

s or a

sthm

a)?

33.

Have y

ou e

ver h

ad h

erp

es sk

in in

fectio

n?

3.

Are

you cu

rrently

takin

g a

ny p

rescriptio

n o

r non-p

rescrip

tion (o

ver th

e co

unte

r) medicin

es or p

ills?

34.

H

ave y

ou e

ver h

ad a

head in

jury

or co

ncu

ssion?

4.

Do y

ou h

ave a

llerg

ies to

medicin

es, p

olle

ns,

foods o

r stingin

g in

sects?

35.

Date

of la

st head in

jury

or co

ncu

ssion:

5.

Do y

ou h

ave p

rescrip

tions fo

r use

of

epin

ephrin

e, a

dre

nalin

, inhale

r, or o

ther

alle

rgy m

edica

tions?

36.

Have y

ou e

ver b

een h

it in th

e h

ead a

nd b

een

confu

sed o

r lost y

our m

em

ory?

6.

Have y

ou e

ver p

asse

d o

ut o

r nearly

passe

d

out d

urin

g o

r afte

r exercise

?

37.

Have y

ou e

ver b

een kn

ock

ed u

nco

nscio

us?

7.

Have y

ou e

ver p

asse

d o

ut o

r nearly

passe

d

out a

t any o

ther tim

e?

38.

Have y

ou e

ver h

ad a

seizu

re?

8.

Have y

ou e

ver h

ad d

iscom

fort, p

ain

, or

pre

ssure

in y

our ch

est d

urin

g e

xercise

?

39.

Do y

ou h

ave h

eadach

es w

ith e

xercise

?

9.

Have y

ou e

ver h

ad to

stop ru

nnin

g a

fter ¼

to

½ m

ile fo

r chest p

ain

or sh

ortn

ess o

f bre

ath

?

40.

Have y

ou e

ver h

ad n

um

bness, tin

glin

g, o

r weakness

in y

our a

rms o

r legs a

fter b

ein

g h

it or fa

lling?

10.

Does y

our h

eart ra

ce o

r skip

beats d

urin

g

exercise

?

41.

Have y

ou e

ver b

een u

nable

to m

ove yo

ur a

rms o

r le

gs a

fter b

ein

g h

it or fa

lling?

11.

Has a

docto

r ever to

ld yo

u th

at y

ou h

ave

(check

all th

at a

pply):

H

igh B

lood P

ressure

A h

eart m

urm

ur

H

igh ch

ole

stero

l

A h

eart in

fectio

n

42.

When e

xercisin

g in

heat, d

o yo

u h

ave se

vere

muscle

cra

mps o

r beco

me ill?

43.

Has a

docto

r told

you th

at yo

u o

r som

eone in

your

12.

Has a

docto

r ever o

rdere

d a

test fo

r your

heart?

44.

Have y

ou h

ad a

ny o

ther b

lood d

isord

ers o

r am

enia

?

13.

Has a

nyone in

your fa

mily

die

d su

ddenly

for

no a

ppare

nt re

aso

n?

45.

Have y

ou h

ad a

ny p

roble

ms w

ith yo

ur e

yes o

r vision?

14.

Does a

nyone in

your fa

mily

have a

heart

pro

ble

m?

46.

Do y

ou w

ear g

lasse

s or co

nta

ct lense

s?

15.

Has a

ny fa

mily

mem

ber o

r rela

tive d

ied o

f heart p

roble

ms o

r sudden d

eath

befo

re a

ge

50? (T

his d

oes n

ot in

clude a

ccidenta

l death

.)

47.

Do y

ou w

ear p

rote

ctive e

yew

ear, su

ch a

s goggle

s or

a fa

ce sh

ield

?

16.

Does a

nyone in

your fa

mily

have M

arfa

n

syndro

me?

48.

Are

you h

appy w

ith y

our w

eig

ht?

17.

Have y

ou e

ver sp

ent th

e n

ight in

a h

osp

ital?

49.

Are

you try

ing to

gain

or lo

se w

eig

ht?

18.

Have y

ou e

ver h

ad su

rgery?

50.

Do y

ou lim

it or ca

refu

lly co

ntro

l what y

ou e

at?

19.

Have y

ou e

ver h

ad a

n in

jury, lik

e a

spra

in,

muscle

or lig

am

ent te

ar, o

r tendonitis th

at

cause

d y

ou to

miss a

pra

ctice o

r gam

e?

51.

Has a

nyone re

com

mended y

ou ch

ange y

our w

eig

ht

or e

atin

g h

abits?

20.

Have y

ou h

ad a

ny b

roken o

r fractu

red b

ones

or d

isloca

ted jo

ints?

52.

Do y

ou h

ave a

ny co

nce

rns th

at y

ou w

ould

like to

discu

ss with

a d

octo

r?

21.

Have y

ou h

ad a

bone o

r join

t inju

ry that

require

d x

-rays, M

RI, C

T, su

rgery, in

jectio

ns,

rehabilita

tion, p

hysica

l thera

py, a

bra

ce, a

ca

st, or cru

tches?

53.

W

hat is th

e d

ate

of y

our last T

eta

nus im

muniza

tion?

Date

:

22.

Have y

ou e

ver h

ad a

stress fractu

re?

FEM

ALE

S O

NLY

23.

Have y

ou e

ver h

ad a

n x

-ray o

f your n

eck

for

atla

nto

-axia

l insta

bility

? O

R H

ave yo

u e

ver

been to

ld th

at y

ou h

ave

that d

isord

er o

r any

neck

/spin

e p

roble

m?

54.

Have y

ou e

ver h

ad a

menstru

al perio

d?

55.

Age w

hen y

ou h

ad y

our first m

enstru

al perio

d?

24.

Do y

ou re

gula

rly u

se a

bra

ce o

r assistiv

e

device

?

56.

How

many p

erio

ds h

ave y

ou h

ad in

the la

st 12

month

s?

25.

Have y

ou e

ver b

een d

iagnose

d w

ith a

sthm

a

or o

ther a

llerg

ic diso

rders?

57.

Do y

ou ta

ke a

calciu

m su

pple

ment?

26.

Do y

ou co

ugh, w

heeze

, or h

ave d

ifficulty

bre

ath

ing d

urin

g o

r afte

r exercise

?

E

xp

lain

“Y

es” a

nsw

ers

here

:

27.

Is there

anyone in

your fa

mily

who h

as

asth

ma?

28.

Have y

ou e

ver u

sed a

n in

hale

r or ta

ken

asth

ma m

edicin

e?

29.

Were

you b

orn

with

out o

r are

you m

issing a

kid

ney, a

n e

ye, a

testicle, o

r any o

ther o

rgan?

30.

Have y

ou h

ad in

fectio

us m

ononucle

osis

(mono) w

ithin

the la

st thre

e m

onth

s?

31.

Have y

ou e

ver h

ad m

ono o

r any illn

ess la

sting

more

than tw

o w

eeks?

N

Abnorm

al

N

Abnorm

al

Eyes

Cerv

ical S

pin

e/n

eck

Ears

Back

N

ose

Should

ers

Thro

at

Arm

/elb

ow

/wrist/h

and

Teeth

Knees/h

ips

Skin

Ankle

/feet

Lym

phatic

Marfa

n S

creen

Lungs

*U

rine

Heart

*H

em

oglo

bin

or H

CT

and o

r Iron sto

res

Perip

hera

l pulse

s

^

Ech

oca

rdio

gra

m

Abdom

en

^N

euro

psy

c Testin

g

Genita

lia/h

ern

ia

(male

only

)

^

Pelv

ic Exam

inatio

n

PA

RT

II -- ME

DIC

AL H

IST

OR

Y

This fo

rm m

ust b

e co

mple

ted a

nd sig

ned, p

rior to

the p

hysica

l exam

inatio

n, fo

r revie

w b

y e

xam

inin

g p

hysicia

n.

Expla

in “Y

es” a

nsw

ers b

elo

w w

ith n

um

ber

of th

e q

uestio

n. C

ircle q

uestio

ns yo

u d

on’t k

now

the a

nsw

ers to

.

P

AR

T III -- P

HY

SIC

AL E

XA

MIN

AT

ION

N

AM

E:

SCH

OO

L:

H

EIG

HT:

W

EIG

HT:

SEX:

AG

E:

D

OB

:

*Tanner S

tage o

r Matu

ratio

n In

dex? (m

ale

s only

):

*Perce

nt B

ody F

at:

Pulse

: *(re

st)

BP:

*Audio

gra

m

*(E

xercise

)

*(R

eco

very

)

*FEV o

r Peak

Flo

w (re

st)

* V

ision: C

orre

cted: (L

)

Unco

rrecte

d (L

)

(R)

(R

)

(Both

)_

(B

oth

)_

*(E

xercise

)

*(R

eco

very

)

fa

mily

has sickle

cell tra

it or sickle

cell d

isease

?

*

WH

EN

ME

DIC

ALLY

IND

ICA

TE

D

(Physicia

n ju

dgm

ent b

ase

d o

n h

istory

, exam

, and k

now

ledge o

f oth

er re

cent p

hysica

l and la

bora

tory

evalu

atio

ns)

^

WIT

H S

PE

CIA

L IN

DIC

AT

ION

S

(These

studie

s may b

e re

com

mended to

the a

thle

te b

eca

use

of h

istory

or p

hysica

l findin

gs a

nd m

ay o

r may n

ot b

e re

quire

d

befo

re m

akin

g p

articip

atio

n d

ecisio

n.)

I h

ave

revie

we

d th

e d

ata

ab

ove, re

vie

we

d h

is/h

er m

ed

ica

l his

tory

form

an

d m

ak

e th

e fo

llow

ing

re

co

mm

en

da

tion

s fo

r his

/h

er p

artic

ipa

tion

in a

thle

ti cs.

CLE

AR

ED

WIT

HO

UT

RE

ST

RIC

TIO

NS

Cle

are

d A

FT

ER

furth

er e

valu

atio

n o

r treatm

ent fo

r:

Cle

are

d fo

r Lim

ited

pa

rticip

atio

n (ch

eck

and e

xpla

in “re

aso

n” fo

r all th

at a

pply):

N

ot cle

are

d fo

r (specific sp

orts):

Cle

are

d o

nly fo

r (specific sp

orts):

Reaso

n(s):

NO

T C

LE

AR

ED

FO

R P

AR

TIC

IPA

TIO

N:

Reaso

n(s):

Oth

er R

eco

mm

endatio

ns:

Reco

mm

end m

onito

ring d

urin

g e

arly

conditio

nin

g b

eca

use

of w

eig

ht/fitn

ess/o

ther

Reco

mm

end re

strictions o

r monito

ring o

f weig

ht lo

ss or g

ain

Oth

er: R

easo

ns:

M

D/D

O, P

A, N

P, D

E-S

PC

#, S

ign

atu

re:

D

ate

of E

xam

inatio

n:

D

ate

Sig

ned:

NA

ME

OF P

HY

SIC

IAN

/P

A/N

UR

SE

PR

AC

TIT

ION

ER

/C

ER

TIF

IED

-RE

GIS

TE

RE

D C

HIR

OP

RA

CT

OR

an

d d

eg

ree

: (prin

t):

Pare

nt/G

uard

ian S

ignatu

re:

Addre

ss:

City

S

tate

Z

ip

Ath

lete

’s Sig

natu

re:

CSCS MS Athletic Packet 2018-19

Colorado Springs Christian Middle SchoolAthletic Emergency/Contact Form

Player's Name: Grade: Sport:

Birthdate:

Parent/Guardian’s Name:

Home Phone:

Work Phone:

Cell Phone:

Email:

Additional Emergency Contact Name(s):

Emergency Contact Phone Number: Cell Work Home

Physican Name:

Insurance Company: Policy#

Hospital Preference:

Chronic Ailments:

Consent For Emergency Treatment for Interscholastic Activity Injuries

I, , parent or guardian of

in consideration of my son’s/daughter’s opportunity to participate in interscholastic activities,

hearby consent to emergency medical treatment, hospitalization or other medical treatments

as may be necessary for the welfare of the above named child, by physican, qualified nurse,

and/or hospital, in the event of injur or illness during periods of time in which the student is

away from his/her legal residence as a member of an interscholastic activity team or group,

and herby waive on behalf of myself and the above named child any liability of the School, and

any of its agents or employees, arising out of such medical treatment.

Parent/Guardian Signature: Date:

(Parent Name) (Student Name)

CSCS MS Athletic Packet 2018-19

Colorado Springs Christian Middle SchoolPermission for Participation

Warning: Although participation in supervised interscholastic athletics and activities may be one of the least hazardous in which any student will engage in or out of school, BY ITS NATURE, PARTICIPATION IN INTERSCHOLASTIC ATHLETICS INCLUDE A RISK OF INJURY WHICH MAY RANGE IN SEVERITY FROM MINOR TO LONG-TERM CATASTROPHIC INJURY AND PERHAPS, FATAL ACCIDENTS MAY OCCUR. Although serious injuries are not common in supervised athletic programs, it is impossible to eliminate the risk.

Students and parents must assess the risk involved in such participation and make their choice to participate in spite of those risks. No amount of instruction, precaution, or supervision will totally eliminate all risk of injury. Just as driving an automobile involves choice of risk, athletic participation also may be inherently dangerous. The obligation of parents and students in making this choice to participate cannot be overstated. There have been accidents resulting in death, paraplegia, quadriplegia and other very serious physical impairment as a result of athletic competition.

PLAYERS MUST OBEY ALL SAFETY RULES, REPORT ALL PHYSICAL PROBLEMS TO THEIR COACHES, FOLLOW A PROPER CONDITIONING PROGRAM, AND INSPECT THEIR OWN EQUIPMENT DAILY.

By signing this PERMISSION FORM, I acknowledge that I have read and understood this warning. PARENTS OR STUDENTS WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS PERMISSION FORM.

I hereby give consent for to compete in athletics for Colorado Springs Christian Schools.

Parent/Guardian Signature Date:

(Student Name)

No student shall represent their school in interscholastic athletics until there is on file with the superintendent or principal a statement signed by their parent or legal guardian, a signed physical certifying that he/she has passed an adequate physical examination within the past year, that in the opinion of the examining physician, physician’s assistant, nurse practitioner or a certified registered chiropractor, he/she is physically able to participate in athletics; and that he/she has the consent of his/her parents or legal guardian to participate.

Note: It is strongly recommended by the Colorado Department of Health that individuals participating in athletic events have current tetanus boosters. Tetanus boosters are recommended every 10 years throughout life. Boosters are recommended at the time of injury if more than five years have elapsed since the last booster.

If a student athlete has been injured in practice and/or competition, the nature of which required medical attention, the student athlete should not participate or return to practice and/or competition until he/she has received a release from a practicing physician.

CSCS MS Athletic Packet 2018-19

Colorado Springs Christian Middle SchoolInsurance Information

CSCS does not offer insurance for athletes. In order for your child to participate in athletics he/she must be covered by a separate insurance policy or sign a waiver. Please fill out the information below so that it may be kept on file in the school office.

has insurance coverate with the following insurance company.

Insurance Company: Policy #:

Parent/Guardian Signature Date:

waiver

does not have insurance coverate. By sigining below,

I authorize CSCS supervisory personnel, in the case of medical emergency of said athlete, to

determine emergency medical treatment until a parent can be notified or can assume respon-

sibility for the continued medical care of said athlete. The parent also agrees to fully pay for all

emergency costs of said athlete (including, if applicable, ambulance, hospital emergency room,

and other associated medical costs.)

Parent/Guardian Signature: Date:

(Student Athlete)

(Student Athlete)

CSCS MS Athletic Packet 2018-19

Student Athlete Name: Grade: Sport:

Parent/Guardian’s Signature: Date:

Colorado Springs Christian Middle SchoolAthletic Fees

Fees By Sport: l 6th grade Basketball and Volleyball $40 to CSAL and $35 to CSCS l 6th grade Cross Country, Soccer and Wrestling $35 to CSCS l 7th & 8th Volleyball: $60 to CSCS (If CSAL team is formed, add $40) l 7th & 8th Football: $60 to CSCS l 7th & 8th Cross Country: $60 to CSCS l 7th & 8th Soccer: $60 to CSCS l 7th & 8th Basketball: $60 to CSCS l 7th & 8th Wrestling: $60 to CSCS l 7th & 8th Track: $60 to CSCS

l Non-traditional athletes have different fee structure. See the athletic director for these fees.

Please enclose payment(s) with the sports packet