Dear Parents, Your child has indicated a desire to become a member of the dance team (the Dazzlers) at Crestview High School. The attached packet of materials has been put together to give you an understanding of the personal and financial responsibilities of becoming a dance team member. Please read all of the information regarding costs and policies with your child. Your signature is required to signify that you have read and understood the policies. In this packet, you will find:. CLINIC AND TRYOUT INFORMATION. TENTATIVE SUMMER PRACTICE AND CAMP SCHEDULES. DANCER INFORMATION SHEET. GENERAL EXPENSES INCURRED DURING DANCE SEASON. PHYSICAL FORM AND EMERGENCY MEDICAL AUTHORIZATION. DANCE RULES AND REGULATIONS /DEMERITS SHEET (view on-line on the CHS website) A clinic to prepare your student for tryouts will be held in the CHS gym on April 30th, May 1st and 2nd from 3:15 p.m. to 5:15 p.m. Tryouts will be held Friday, May 3rd at 4:00 p.m. in the CHS auditorium. Cost for the clinic is $30.00. This fee will include judges fee and music sent to them via email. Clinic and tryouts will be closed to spectators. Please be aware that your child must have an unweighted cumulative 2.0 grade point average from the first semester of the 2012-2013 and a current unweighted non- cumulative 2.0 grade point average to be eligible to try out. The tryout fee is nonrefundable for those whom coaches deem ineligible due to GPA. Members of the team will be selected based on the following criteria: fifty percent judges scores on a learned routine and fifty percent judges scores on technique. The decision of the judges will be considered final. All forms, along with a $30.00 non-refundable check made payable to Crestview High School, are due by Wednesday April 24th at 12:00 p.m. in the front office at CHS. No late paperwork will be accepted. I look forward to meeting you and wish you the best of luck at tryouts! Sincerely, Cheri Hinson Sponsor CHS Dazzlers Chsdazzlers1213@yahoo.com
Important Information Mandatory Meeting: April 29 th at 6:00 in the CHS dance room for all students and parents interested in try-outs Clinic Dates: Clinic Time: Clinic Clothing: April 30th May 2nd 3:15 p.m.-5:15 p.m. in the CHS Gymnasium Tights, black hot shorts or black jazz pants, black tank top/shirt, dance shoes, ponytail, and no jewelry (ear, body, or facial) Tryout Date/time: Friday, May 3 rd in the CHS Auditorium beginning at 4:00 p.m. Tryout Uniform: Tights, black hot shorts or black jazz pants, black tank top/shirt, dance shoes, ponytail, and no jewelry (ear, body, or facial) Technique: Members of the dance team will be required to attend a team technique class in Northwood Elementary School s dance room one day a week. This is an extra charge of $40 a month. ALL PRACTICES ARE MANDATORY! There will be at least one day each week when there is no after school practice. That designated off day might change from month to month. Medical and Dental appointments and should be scheduled for those days. Calendar given at 1st parent meeting. July Camp at UNO (New Orleans)-time still to be determined Final scores come from the following: Technique (splits, leaps, pirouettes, etc.) 50% Routine Performance (learned at clinic) 50% (see sample score sheets that are attached) Tryout Paperwork Checklist In order to participate in clinic and tryouts for the 2013-2014 dance season, the following paperwork must be completed and turned in no later than Wednesday, April 24 th at 12:00 p.m. in the front office at Crestview High School. Tryout fee of $30.00 (make checks payable to Crestview High School) Physical Form (must be signed by physician and notarized) Emergency Medical Authorization Form (must be signed, dated, and notarized) Dancer information sheet Consent and Release from Liability Certificate A copy of your report card showing your 1 st semester GPA of 2012-2013 as well as a copy of your current grades.
Dance Team Expenses: The following is a list of general expenses for the dance season. These numbers are only estimates from the preceding year s expenses. Summer Camp $360.00 Clothing, shoes, & accessories $525.00 (sports bras, Capri, home routine costume, and replacement items not included) Dance bags $ 50.00 Uniform rental $ 40.00 Technique instruction (paid to CHS) $ 40.00 *Note-Competition costs are not included in this estimated list. A competition team will be established at the same time as try-outs. You can be chosen for either team or just the school team. Each person chosen for the competition team has the option of opting out of the competition team position without losing position on the noncompetition team. If opting out, please do so immediately so as not to interfere with the dance formations, schedule, extra costs, or time. They are usually scheduled in February. The average competition year will cost between $500 and $800 per dancer. However, some competition expenses MAY be defrayed through fundraising and sponsorships. The team as a whole may attend a competition if given the opportunity and financing is available. Total estimated cost for the regular dance season (excluding studio technique class & Competition) is $975.00. Payment should be made in the following manner: Payment in full: on or before May 7 th...$975.00 (minus the $200 payment made at parent meeting in May) Installment Plan: Payment is due on the 1 st of each month May payment (due at parent meeting) $200.00 June payment (for camp expenses) $200.00 July payment (for camp expenses) $200.00 August payment (for camp clothing) $125.00 September and October Payments $125.00 each Make checks payable to Crestview High School and include your student s name and phone number on the check.
Dancer Information Please turn this in with your check, try-out forms check list sheet, and all completed forms. Students Name: Grade: I HAVE RECEIVED, READ, UNDERSTAND AND AGREE TO ABIDE BY THE POLICIES AND RULES FOR CRESTVIEW HIGH SCHOOL DANCE TEAM MEMBERS. I ALSO UNDERSTAND THE COSTS INVOLVED AND MY RESPONSIBILITY IN PAYING THESE COSTS. Bob Jones, Principal Cheri Hinson, Sponsor Parent Signature Student Signature
Pg1 Participant # 2013-2014 Dance Team Try-outs Dance Score Sheet Judge# Confidence /15 Knowledge of Routine /20 Crowd Appeal/Facials /10 Strength of movement /15 Timing/Rhythm /20 Overall Quality of Performance /15 Uniformity in a group dance /15 Proper Technique /15 Energy Level TOTAL /135 /10 Pg2 Participant# 2013-2014 Dance Team Try-outs Dance Score Sheet Judge# 1. Left Split /10 2. Right Split /10 3. Middle Split /10 4. Single Pirouette /10 5. Double Pirouette /10 6. Triple Pirouette /05 7. Right Battement /10 8. Left Battement /10 9. Right leap /10 10. Left Leap /10 11. Arabian /05 12. Right Calypso /10 13. Right Axel /05 14. Left Surprise Leap /10 15. Right Surprise Leap /10 BONUS: Turns in 2 nd /5 Stall /5 TOTAL: /135
EL3 Florida High School Athletic Association Revised 05/11 (Page 1 of 2) Consent and Release from Liability Certificate This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature. Part 1. Student Acknowledgement and Release (to be signed by student at the bottom) I have read the (condensed) FHSAA Eligibility Rules printed on the reverse side of this "Consent and Release Certificate" and know of no reason why I am not eligible to represent my school in interscholastic athletic competition. If accepted as a representative, I agree to follow the rules of my school and FHSAA and to abide by their decisions. I know that athletic participation is a privilege. I know of the risks involved in athletic participation, understand that serious injury, including the potential for a concussion, and even death, is possible in such participation, and choose to accept such risks. I voluntarily accept any and all responsibility for my own safety and welfare while participating in athletics, with full understanding of the risks involved. Should I be 18 years of age or older, or should I be emancipated from my parent(s)/ guardian(s), I hereby release and hold harmless my school, the schools against which it competes, the school district, the contest officials and FHSAA of any and all responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no legal action against FHSAA because of any accident or mishap involving my athletic participation. I hereby authorize the use or disclosure of my individually identifiable health information should treatment for illness or injury become necessary. I hereby grant to FHSAA the right to review all records relevant to my athletic eligibility including, but not limited to, my records relating to enrollment and attendance, academic standing, age, discipline, finances, residence and physical fitness. I hereby grant the released parties the right to photograph and/or videotape me and further to use my name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein. I understand that the authorizations and rights granted herein are voluntary and that I may revoke any or any all of time them by at submitting said revocation in writing to my school. By doing so, however, I understand that I will no longer be eligible for participation in interscholastic athletics. Part 2. Parental/Guardian Consent, Acknowledgement and Release (to be completed and signed by a parent(s)/guardian(s) at the bottom; where divorced or separated, parent/guardian with legal custody must sign). A. I hereby give consent for my child/ward to participate in any FHSAA recognized or sanctioned sport except for the following sport(s): List sport(s) exceptions here: B. I understand that participation may necessitate an early dismissal from classes. C. I know of, and acknowledge that my child/ward knows of, the risks involved in interscholastic athletic participation, understand that serious injury, and even death, is possible in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. With full understanding of the risks involved, I release and hold harmless my childs/wards school, the schools against which it competes, the school district, the contest officials and FHSAA of any and all responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no legal action against the FHSAA because of any accident or mishap involving the athletic participation of my child/ward. I authorize emergency medical treatment for my child/ward should the need arise for such treatment while my child/ward is under the supervision of the school. I further hereby authorize the use or disclosure of my childs/wards individually identifiable health information should treatment for illness or injury become necessary. I consent to the disclosure, by my childs/wards school, to the FHSAA, upon its request, of all records relevant to his/her athletic eligibility including, but not limited to, his/her records relating to enrollment and attendance, academic standing, age, discipline, finances, residence and physical fitness. I grant the released parties the right to photograph and/or videotape my child/ward and further to use said childs/wards name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein. D. I am aware of the potential danger of concussions and/or head and neck injuries in interscholastic athletics. I also have knowledge about the risk of continuing to participate once such an injury is sustained without proper medical clearance. READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF MY CHILD'S/WARD'S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO RECOVER FROM MY CHILD'S/WARD'S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND MY CHILD'S/WARD'S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM. E. I agree that in the event we/i pursue litigation seeking injunctive relief or other legal action impacting my child (individually) or my childs team participation in FHSAA state series contests, such action shall be filed in the Alachua County, Florida, Circuit Court. F. I understand that the authorizations and rights granted herein are voluntary and that I may revoke any or all of them at any time by submitting said revocation in writing to my school. By doing so, however, I understand that my child/ward will no longer be eligible for participation in interscholastic athletics. G. Please check the appropriate box(es): My child/ward is covered under our family health insurance plan, which has limits of not less than $25,000. Company: Policy Number: My child/ward is covered by his/her schools activities medical base insurance plan. I have purchased supplemental football insurance through my childs/wards school. I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (Only one parent/guardian signature is required) Name of Parent/Guardian (printed) Signature of Parent/Guardian Date Name of Parent/Guardian (printed) Signature of Parent/Guardian Date I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (student must sign) Name of Student (printed) Signature of Student Date - 1 -
EL3 Florida High School Athletic Association Revised 05/11 Consent and Release from Liability Certificate This completed form must be kept on file by the school (Page 2 of 2) Attention Student and Parent(s)/Guardian(s) Your school is a member of the Florida High School Athletic Association (FHSAA) and follows established rules. To be eligible to represent your school in interscholastic athletics, in an FHSAA recognized sport (i.e. bowling, competitive cheerleading, girls flag football, lacrosse, boys volleyball, water polo and girls weightlifting or sanctioned sport (i.e. baseball, basketball, cross country, tackle football, golf, soccer, fast-pitch softball, swimming and diving, tennis, track and field, girls volleyball, boys weightlifting and wrestling), the student: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Must be regularly enrolled and in attendance at your school. If the student is a home education student or attends a charter school, the student must declare in writing his/her intention to participate in athletics to the school at which the student is permitted to participate. Home education students must be approved by the FHSAA office prior to any participation. (FHSAA Bylaw 9.2) Must attend school within 10 days of the beginning of each semester to be eligible during that semester. (FHSAA Bylaw 9.2) Must maintain at least a cumulative 2.0 grade point average on a 4.0 unweighted scale prior to the semester in which the student wishes to participate. This GPA must include all courses taken since the student entered high school. A sixth, seventh or eighth grade student must have earned at least a 2.0 grade point average on 4.0 unweighted scale the previous semester. (FHSAA Bylaw 9.4) Must not have graduated from any high school or its equivalent. (FHSAA Bylaw 9.4) Must participate at the school in which the student first enrolls (attends), or at which the student first takes part in an athletic practice, at the beginning of the school year. (FHSAA Bylaw 9.2) Must not transfer schools after the first day of fall practice or the first day of school, or otherwise the student cannot participate at the new school for the remainder of the school year. (FHSAA Bylaw 9.3) Must not participate on a non-school team (i.e., AAU, American Legion, club setting, etc.) which is affiliated with a school or coached by a representative of a school other than the one the student attends, or has attended, and then attend that school, otherwise the student will be ineligible there for one year. (FHSAA Bylaw 9.3) Must not transfer to a school that the students coach has relocated to within a year, otherwise the student will be ineligible there for one year. (FHSAA Bylaw 9.3) Must not have enrolled in the ninth grade for the first time more than four school years ago. If the student is a sixth, seventh or eighth grade student, the student must not participate if repeating that grade. (FHSAA Bylaw 9.5) Must have signed permission to participate from the students parent(s)/guardian(s) on a form (EL3) provided the school. (Bylaw 9.8) Must be less than 19 years 9 months old to participate in high school; 16 years 9 months old to participate in junior high school; and 15 years 9 months old to participate in middle school, otherwise the student becomes ineligible to participate at that level. (FHSAA Bylaw 9.6) Must undergo a pre-participation physical evaluation and be certified as being physically fit for participation in interscholastic athletics (form EL2). The physical evaluation is valid for 365 calendar days from the date that it was administered after which time the student must successfully undergo another physical evaluation to continue his/her participation. (FHSAA Bylaw 9.7) Must be an amateur. This means the student must not accept money, gift or donation for participating in a sport, or use a name other than his/her own when participating. (FHSAA Bylaw 9.9) Must not participate in an all-star contest in a sport prior to completing his/her high school eligibility in that sport. (FHSAA Policy 26) Must display good sportsmanship and follow the rules of competition before, during and after every contest in which the student participates. If not, the student may be suspended from participation for a period of time. (FHSAA Bylaw 7.1) Must not provide false information to his/her school or to the FHSAA to gain eligibility. (FHSAA Bylaw 9.1) Foreign exchange and international students must be approved by the FHSAA office prior to any participation. (FHSAA Policy 17) If the student is declared or ruled ineligible due to one or more of the FHSAA rules and regulations, the student has the right to request that the school file an appeal on behalf of the student. See the principal or athletic director for information regarding this process. - 2 -
School: MIS 4178 REV 07/11 SCHOOL DISTRICT OF OKALOOSA COUNTY INTERSCHOLASTIC ATHLETICS PARENTAL PERMISSION, RELEASE EMERGENCY MEDICAL AUTHORIZATION AND AUTHORIZATION TO RELEASE INFORMATION NOTICE TO THE MINOR CHILD S NATURAL GUARDIAN READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF OKALOOSA COUNTY SCHOOL DISTRICT, ITS SCHOOL BOARD, ITS EMPLOYEES, AGENTS OR ASSIGNS USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD S RIGHT AND YOUR RIGHT TO RECOVER FROM OKALOOSA COUNTY SCHOOL DISTRICT, ITS SCHOOL BOARD, ITS EMPLOYEES, AGENTS OR ASSIGNS IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND OKALOOSA COUNTY SCHOOL DISTRICT, ITS EMPLOYEES, AGENTS OR ASSIGNS HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM. No student will be allowed to practice or participate in any organized interscholastic athletic activity until this document is signed, notarized and returned to the school Athletic Department. Student Name Grade Address Home Phone Emergency Phone PURPOSE: To provide the consent of parents and/or guardians for students to participate in interscholastic activities of the School District and provide a hold harmless and release of liability, to authorize the provision of emergency medical treatment for that student who may become ill or injured during such activities and authorizing the release of protected health information. PLEASE COMPLETE PARTS I, II, AND III. PART I PARENTAL/GUARDIAN PERMISSION, ACKNOWLEDGEMENT AND RELEASE A. I, hereby grant permission for (the Student Athlete ) to participate in interscholastic athletics at School during the school year, and I know of, and acknowledge that my child/ward knows of, the risks involved in interscholastic athletic participation, understand that serious injury, and even death, is possible in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. With full understanding of the risks involved, I release and hold harmless my child s/ward s school, and the Okaloosa County School District, its School Board, its officers, employees, agents or assigns, of any and all responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no legal action against the Okaloosa County School District, its School Board, its officers, employees, agents or assigns, because of any accident or mishap involving the athletic participation of my child/ward. I understand the Florida High School Activities Association requires all students participating in interscholastic athletics be covered by a medical insurance policy providing a minimum of $25,000 limit for medical expenses. I hereby certify is covered by medical insurance providing at least $25,000 for medical expenses. The name of our medical insurance company is which will cover this child in the event of an injury. I assume full responsibility and liability for any and all expenses connected with an injury and/or illness that is not paid by our insurance company or through Military benefits if this child is entitled to military privileges. I further certify I will notify the principal of the school this child is attending if there is any change in this insurance coverage, and I will purchase the Student and/or Football insurance offered at the school. I also hereby consent to allow to be transported by private automobile in connection with. For the inclusive dates of:. STUDENT AND/OR TEAM SPORTS INSURANCE MAY BE PURCHASED AT YOUR SCHOOL B. I grant the released parties the right to photograph and/or videotape my child/ward and further to use said child s/ward s name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein.
PART II EMERGENCY MEDICAL AUTHORIZATION In the event reasonable attempts to contact me at (Phone number) have been unsuccessful, I give my consent for (1) the administration of any treatment deemed necessary by (Preferred physician) or (Preferred dentist), or in the event the designated preferred practitioner is not available, by another physician or dentist and (2) the transfer and admission of the child to (Preferred hospital) or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist concurring in the necessity for such surgery are obtained prior to the performance of such surgery. I hereby authorize any treating physicians, including athletic trainers and team volunteer doctors, to provide information to school officials regarding my child s medical condition or injuries. Facts concerning the child s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: MEDICAL PROVIDERS MAY ACCEPT A PHOTOCOPY OF THIS SIGNED AUTHORIZATION AS IF IT WERE AN ORIGINAL FOR ALL PURPOSES. PART III AUTHORIZATION/CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby authorize the athletic trainers, sports medicine staff and other health care personnel representing, to release information regarding the Student Athlete s protected health information and related information regarding any injury or illness during the Student Athlete s training for and participation in interscholastic sports at School. This protected health information may concern the Student Athlete s medical status, medical conditions, injuries, prognosis, diagnosis, athlete s participation status, and related personally identifiable health information. This protected health information may be released to other health care providers, hospitals and/or medical clinics and laboratories, Student Athlete s coaches, medical insurance coordinators, the school s Athletic Director and Principal, athletic and/or school administrators, chaplains and/or clergy members, and officials of the Florida High School Activities Association. I also authorize the Student Athlete s coaches and other school staff to release protected health information to the athletic trainers, sports medicine staff and other health care personnel as identified above and to other health care professionals providing services to the Student Athlete. As the parent or guardian of the Student Athlete, I hereby confirm that I have signed this authorization/consent for the disclosure of the Student Athlete s protected health information voluntarily. I understand that my child s protected health information is protected by federal regulations under the Health Information Portability and Accountability Act (HIPAA) of the Family Educational Rights and Privacy Act of 1974 ( the Buckley Amendment) and may not be disclosed without either parent/legal guardian authorization under HIPAA or consent under the Buckley Amendment. I the parent/legal guardian understand that once protected health information is disclosed per authorization or consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment. I, the parent/legal guardian, understand that I may revoke this authorization/consent any time by notifying in writing to the school s Athletic Director, but if I do, it will not have any effect on the actions the Okaloosa County School officials took in reliance on this authorization/consent prior to receiving the revocation. I understand that I may see and obtain a copy of all protected health information described on this form, for a reasonable copy fee, if I ask for it. I further understand that I may request a copy of this form after I sign it. This authorization/consent expires one year from the date it is signed. I HAVE READ THE ABOVE AND AUTHORIZE THE DISCLOSURE AND RELEASE OF THE STUDENT ATHLETE S PROTECTED HEALTH INFORMATION AS STATED. ***************************************************************************************** BY SIGNING BELOW I VERIFY THAT I HAVE READ, REVIEWED AND COMPLETED ALL THREE (3) PARTS OF THIS PERMISSION, RELEASE AND AUTHORIZATION FORM. Date Signature of Parent or Guardian STATE OF FLORIDA-COUNTY OF OKALOOSA The foregoing instrument was acknowledged before me this by Date Name of Person Acknowledged Who is personally known to me or who has produced as identification and who did/did not take an oath Type of identification Signature of Notary Taking Acknowledgment Name of Notary (Typed, Printed or Stamped) Notary Expiration:
Florida High School Athletic Association Preparticipation Physical Evaluation (Page 1 of 3) EL2 Revised 03/10 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. Part 1. Student Information (to be completed by student or parent) Student s Name: Sex: Age: Date of Birth: / / School: Grade in School: Sport(s): Home Address: Home Phone: ( ) Name of Parent/Guardian: E-mail: Person to Contact in Case of Emergency: Relationship to Student: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Personal/Family Physician: City/State: Office Phone: ( ) Part 2. Medical History (to be completed by student or parent). Explain yes answers below. Circle questions you don t know answers to. Yes No 1. Have you had a medical illness or injury since your last check up or sports physical? 2. Do you have an ongoing chronic illness? 3. Have you ever been hospitalized overnight? 4. Have you ever had surgery? 5. Are you currently taking any prescription or non- prescription (over-the-counter) medications or pills or using an inhaler? 6. Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance? 7. Do you have any allergies (for example, pollen, latex, medicine, food or stinging insects)? 8. Have you ever had a rash or hives develop during or after exercise? 9. Have you ever passed out during or after exercise? 10. Have you ever been dizzy during or after exercise? 11. Have you ever had chest pain during or after exercise? 12. Do you get tired more quickly than your friends do during exercise? 13. Have you ever had racing of your heart or skipped heartbeats? 14. Have you had high blood pressure or high cholesterol? 15. Have you ever been told you have a heart murmur? 16. Has any family member or relative died of heart problems or sudden death before age 50? 17. Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month? 18. Has a physician ever denied or restricted your participation in sports for any heart problems? 19. Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, blisters or pressure sores)? 20. Have you ever had a head injury or concussion? 21. Have you ever been knocked out, become unconscious or lost your memory? 22. Have you ever had a seizure? 23. Do you have frequent or severe headaches? 24. Have you ever had numbness or tingling in your arms, hands, legs or feet? 25. Have you ever had a stinger, burner or pinched nerve? Yes No 26. Have you ever become ill from exercising in the heat? 27. Do you cough, wheeze or have trouble breathing during or after activity? 28. Do you have asthma? 29. Do you have seasonal allergies that require medical treatment? 30. Do you use any special protective or corrective equipment or medical devices that aren t usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, shunt, retainer on your teeth or hearing aid)? 31. Have you had any problems with your eyes or vision? 32. Do you wear glasses, contacts or protective eyewear? 33. Have you ever had a sprain, strain or swelling after injury? 34. Have you broken or fractured any bones or dislocated any joints? 35. Have you had any other problems with pain or swelling in muscles, tendons, bones or joints? If yes, check appropriate blank and explain below: Head Elbow Hip Neck Forearm Thigh Back Wrist Knee Chest Hand Shin/Calf Shoulder Finger Ankle Upper Arm Foot 36. Do you want to weigh more or less than you do now? 37. Do you lose weight regularly to meet weight requirements for your sport? 38. Do you feel stressed out? 39. Have you ever been diagnosed with sickle cell anemia? 40. Have you ever been diagnosed with having the sickle cell trait? 41. Record the dates of your most recent immunizations (shots) for: Tetanus: Measles: Hepatitus B: Chickenpox: FEMALES ONLY (optional) 42. When was your first menstrual period? 43. When was your most recent menstrual period? 44. How much time do you usually have from the start of one period to the start of another? 45. How many periods have you had in the last year? 46. What was the longest time between periods in the last year? Explain Yes answers here: We hereby state, to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida Statutes, and FHSAA Bylaw 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test. Signature of Student: Date: / / Signature of Parent/Guardian: Date: / / 1
EL2 Florida High School Athletic Association Preparticipation Physical Evaluation (Page 2 of 3) Revised 03/10 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. Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed physician assistant or certified advanced registered nurse practitioner). Student s Name: Date of Birth: / / Height: Weight: % Body Fat (optional): Pulse: Blood Pressure: / ( /, / ) Temperature: Hearing: right: P F left: P F Visual Acuity: Right 20/ Left 20/ Corrected: Yes No Pupils: Equal Unequal FINDINGS NORMAL ABNORMAL FINDINGS INITIALS* MEDICAL 1. Appearance 2. Eyes/Ears/Nose/Throat 3. Lymph Nodes 4. Heart 5. Pulses 6. Lungs 7. Abdomen 8. Genitalia (males only) 9. Skin MUSCULOSKELETAL 10. Neck 11. Back 12. Shoulder/Arm 13. Elbow/Forearm 14. Wrist/Hand 15. Hip/Thigh 16. Knee 17. Leg/Ankle 18. Foot * station-based examination only ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER I hereby certify that each examination listed above was 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: Referred to For: Recommendations: Name of Physician/Physician Assistant/Nurse Practitioner (print): Date: / / Address: Signature of Physician/Physician Assistant/Nurse Practitioner: 2
EL2 Florida High School Athletic Association Preparticipation Physical Evaluation (Page 3 of 3) Revised 03/10 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. 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