2017 2018 VSU Cheerleading Tryout Application April 15, 2017 10AM 5PM at: Valdosta State University/ PE Complex 401 Baytree Road Valdosta, GA 31601 NAME (Last) (First) (Middle) GENDER (Check one) Male Female BIRTH DATE (MM/DD/YYYY) ADDRESS (Street Address) (City, State, Zip) HOME PHONE # CELL PHONE # PROBABLE/CURRENT MAJOR GPA VSU 870 # EMAIL ADDRESS (Current students or student who have already been accepted) (Confirmation email will be sent once your tryout packet has been received) HIGH SCHOOL/COLLEGE ATTENDED SIZING INFORMATION Please fill in all that apply. Height feet inches Weight lbs. Sports Bra Cheer Shoe Size Hot Pant T Shirt Dry Fit Top Sweatshirt Shorts
If you are a high school senior or transfer student, have you been formally accepted to VSU or South Georgia? If yes, you MUST include a copy of your official acceptance letter with this application. If not, the highest position you can try out for is alternate status. Please check the statement below that applies to you: YES! I have been accepted to VSU or South Georgia. Enclosed you will find my official letter of acceptance. NO! I have not yet been accepted to VSU or South Georgia, and I will be trying out for alternate status. When you tryout for alternate status, it means just that. If you are accepted to VSU after tryouts this DOES NOT mean that you will automatically be added to the team. If there are spots still available, it will be left to the discretion of the coaches on whether you will be placed on the team. Please initial next to which team or position you are trying out for. If you are interested in trying out for BOTH the Coed Advanced and All girl/coed Intermediate programs, please initial which program you would MOST prefer. Also, in order to compete, you MUST be on a student at VSU. South Georgia student will be allowed to participate in the VSU cheerleading program, however they will not be allowed to compete. VIDEO TRYOUTS ARE WELCOMED, HOWEVER ALL VIDEO TRYOUTS MUST HAVE A VALID EXCUSE FOR MISSING LIVE TRYOUTS PRIOR TO SUBMISSION (PLEASE CONTACT HEAD COACH FOR MORE INFORMATION). Please initial the option below that applies to you: I am trying out for Coed Advanced Cheer ONLY (initial) I am trying out for All girl/coed Intermediate Cheer ONLY (initial) Please rank the below positions in which you are MOST confident: (1 being the most confident and 4 being the least confident) Main Base Secondary Base Flyer Back Spot (toe & heel) (under middle of foot) I am trying out for BOTH Coed Advanced Cheer and All girl/coed Intermediate Cheer (Please initial one below) (initial) My preference is Coed Advanced Cheer (initial) My preference is All girl/coed Intermediate Cheer (initial)
VALDOSTA STATE UNIVERSITY CHEER LEADING MEDICAL AND ORTHOPEDIC EXAMINATION NAME: ADDRESS: PHONE: STUDENT ID CITY: STATE: ZIP: MEDICAL EXAMINATION N=Normal AB=Abnormal N AB COMMENTS Appearance: Marfan stigmata (kyphoscoliosis, high arched palate, pectus excavatum, arachnodactyly, Eyes/Ears/Nose/Throat: Pupils equal Hearing Lymph nodes Head: Hair, Scalp, Masses Throat: Tonsils, Lesions, Injection Mouth: Lesion, Teeth, Tongue Neck: Adenopathy, Thyroid, Vessels, Masses, Voice Abnormalities Abdomen: Organ Enlargement, Masses, Tenderness, Hernias, Scars Skin: HSV, lesions suggestive of MRSA, tinea corporis Thorax: Shape, Expansion, Deformities Lungs: Bronchi, Wheezes, Rales Heart: PMI, Thrills, Sounds, Murmurs, Gallops Cardiovascular Screen: Supine Standing Assess Femoral Artery Marfan Syndrome Other: SCT testing: [ ] declined [ ] positive [ ] negative (LAB RESULTS MUST BE ATTACHED CONFIRMING RESULTS) Height Weight BP / Neck Pulse ORTHOPEDIC EVALUATION N=Normal AB=Abnormal N AB COMMENTS Spine Shoulder Elbow Wrist/Hand Hip Thigh Ankle Knee/Patella ACL, MCL, LCL, PCL Meniscus Patellofemoral Functional: Duck walk Single leg hop Ortho Exam performed by: Results [ ] Pass [ ] Failed [ ] Pass with conditions: PHYSICIAN Signature: DATE: Printed Name or stamp: Phone: { } I hereby certify clearance for participation in cheerleading including competitive cheer.
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION TO VALDOSTA STATE UNIVERSITY ATHLETIC DEPARTMENT This form implements the requirements for patient authorization to use and disclose health information protected by the federal health privacy law, 45 C.F.R. parts 160,164. Except as otherwise permitted or required by the privacy law, a health care provider subject to the privacy law may not use or disclose protected health information without an authorization that complies with the requirements of C.F. R. 164.508(c). Printed Name of Student Athlete: Sport: Address City State Zip To all athletic trainers, physical therapists, physicians, and all other medically related agencies associated with the Athletic Department at Valdosta State University. You are hereby authorized to release to the Athletic Department staff at Valdosta State University a complete copy of all your records pertaining to my medical condition, including any treatment, rehabilitation, surgery, history, or imaging notes and all other information related to my past or present medical condition, diagnosis, history, or prognosis from your personal knowledge and/or records. The purpose of the use or disclosure is determination of physical eligibility for participation status on an athletic team. I understand that I may revoke this Authorization at any time except to the extent that action has been taken in reliance on it (or unless this Authorization is given as a condition of obtaining insurance coverage and the insurer has certain legal rights to contest the policy or a claim under the policy). If I revoke this authorization, I must do so in writing. The procedure for how I may revoke the authorization, as well as the exceptions to my right to revoke, are explained in Valdosta State University s Notice of Privacy Practices. I understand that I may refuse to sign this Authorization. I also understand that Valdosta State University cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits if I refuse to sign this Authorization. I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by the federal medical privacy law and could be re disclosed by the person or agency that receives. This Authorization expires automatically upon termination of participation either voluntarily or upon completion of eligibility. Student Athlete Signature: Date:
VALDOSTA STATE UNIVERSITY INITIAL MEDICAL HISTORY FORM NAME: LAST FIRST MIDDLE VSU Student ID#: Local Phone: VSU Email: @valdosta.edu SPORT(S): Date of Birth: / / Cell Phone: Other Email: Emergency Contact: phone /email Relation: Emergency Contact: /email Relation: MEDICAL HISTORY INFORMATION YES COMMENT/EXPLANATION 1. Have you ever been disqualified or restricted from athletic participation for any reason? (game/practice/season) 2. Are you missing a kidney, eye, testicle or any other organ? 3. Have you had a medical illness/injury since your last checkup by a physician? 4. Do you have an ongoing medical condition? 5. Have you had infectious mononucleosis in the past few months? 6. Have you had a severe viral infection within last month 7. Have you ever been hospitalized overnight or had surgery? 8. Have you ever had a sprain, strain, stress fracture? Identify bone/joint? 9. Have you ever broken a bone or dislocated a joint? Including the use of braces, crutches, or been casted? 10. Have you ever had an x ray, MRI, CT Scan, or injections? 11. Have you ever gone to physical therapy or seen an athletic trainer for an injury? 12. Do you use special protective or corrective equipment not typically used for your sport or position? 13. Have you ever had a stinger? 14. Have you ever had numbness or tingling in your arms or legs after being hit or falling? 15. Have you ever had an x ray on your neck? 16. Have you ever been diagnosed with a heart murmur, heart infection, or Kawasaki disease? 17. Has a doctor ever ordered tests for your heart? Bracing, hearing aid, retainer, etc.: 18. Has a physician ever diagnosed you with high blood pressure or high cholesterol? 19. Has a family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)? 20. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? 21. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 22. Do you cough, wheeze, or have trouble breathing during exercise? 23. Have you ever passed out or nearly passed out during or after exercise? 24. Do you get tired more quickly, or short of breath compared to others during exercise? 25. Have you ever had chest pain or pressure during or after exercise? 26. Does your heart ever race or skip beats during exercise?
27. Does anyone in your family have hypertrophic cardiomyopathy, Marfan s syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? 28. Have you ever had a head injury/concussion? 29. Have you ever had a head injury with loss of consciousness? 30. Have you ever had a head injury with confusion, memory loss, or prolonged headaches? 31. Have you ever had problems with heat illness? 32. Do you ever get muscle cramps when exercising in the heat? 33. Do you have headaches with exercise? 34. Do you have groin pain or a painful bulge or hernia in the groin area? 35. Have your or someone in your family been diagnosed with sickle cell trait or sickle cell anemia? 36. Have you ever been had a seizure or been diagnosed with epilepsy? 37. Do you have allergies? If yes, please identify specific allergy and if you carry an emergency injection kit (epipen). Medicines Pollens Food Stinging Insects Other Epipen for emergency care 38. Have you or anyone in your family been diagnosed with asthma? Do you use an inhaler? 39. Have you or anyone in your family been diagnosed with diabetes? 40. Do you have eye or sight problems? Do you wear contacts glasses protective eyewear/goggles? 41. Do you want to lose weight? 42. Do you want to gain weight? 43. Loss of weight to meet weight requirement of sport 44. Do you limit or carefully control what you eat? 45. Feelings of being stressed out 46. Have you had any recent skin infections (MRSA, herpes)? 47. Have you ever had MRSA? 48. Do you have any concerns you would like to discuss with a physician? 49. List any MEDICATIONS (prescription, over the counter, vitamins, supplements, etc.) that you are presently taking and the prescription information: Name of Medication Dosage Directions Additional Comments/Information: Valdosta State University Athletic physicals are property of VSU Athletics and can only be used to determine a student athlete s medical status for participation in Valdosta State athletics. They will not be released or copied for any other purpose. I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of Athlete Date Signature of Parent/Guardian Date
MEDICAL INSURANCE AND AUTHORIZATION FORM CHEERLEADING Please complete and mail, fax, or email to: Valdosta State University, Athletic Field House, Attn: Insurance 1500 N Patterson St, Valdosta, GA 31698; (FAX#) 229 245 2494, Email: Angela C. Colbert (awills@valdosta.edu), 229-333-5844 ATTENTION:A FRONT AND BACK COPY OF YOUR INSURANCE CARD MUST ACCOMPANY THIS FORM Please write legibly. Full Name of Cheerleader (cell #) VSU Student ID # Date of Birth Emergency Contact (Name) (Phone Number) Name of Father/Guardian Address City State Zip Email: Home Telephone Number ( ) Employer Work Telephone Number ( ) PRIMARY INSURANCE Policy Holder's Name Date of Birth Policy Number Group Number Effective Date Insurance Company Address Name of Mother/Guardian Address City State Zip Email: Home Phone Number ( ) Employer Work Phone Number ( ) Policy Holder's Name Date of Birth Policy Number Group Number Effective Date Insurance Company Address SECONDARY INSURANCE Phone Number This policy is a (please circle) HMO PPO Other Phone Number This policy is a (please circle) HMO PPO Other
Please indicate with a check one (1) of the following: I/We do not have a group medical insurance policy or my/our son/daughter is NOT covered under the policy. or I/We have a group medical insurance policy and authorize the VSU ATHLETIC DEPARTMENT to file a claim on my/our behalf for an injury sustained by the above under the group medical policy or policies shown above. Furthermore, I/we consent that any amounts payable under this policy for an athletically related injury of the above athlete be paid directly to the medical provider. I/We certify that I will keep the policy in full force and effect for the duration of my participation in VSU Cheer. All cheerleaders are required to possess primary health insurance while participating in cheer. Termination of coverage results in immediate disqualification from all cheer activities. The Athletic Department must be notified immediately of any change in insurance status. PLEASE INITIAL THE FOLLOWING STATEMENTS AFTER THEY HAVE BEEN READ AND SIGN ON THE SIGNATURE LINE ON THE BOTTOM. The Athletic department does not pay for any medical claims related to cheerleading. All medical claims are billed directly to the patient. Cheerleaders must be medically cleared from participation prior to beginning practice/ competition. I have read and agree to the medical insurance policies and procedures described on this form. Signature of Parent/Guardian/or Insured Date Signed
SQUADS/REQUIREMENTS The COED A SQUAD will consist of 25+ male and female cheerleaders. This squad competes in Small Coed Division II (16 girls & 4 guys). Most stunts will be performed "All girl" style with a main base, secondary base, and a back. In the NCA Collegiate National Championship, the COED squad claimed their first NCA Collegiate National Title in 2009, their second in 2010, and their third in 2013. In 2012 they placed second and in 2015 they placed third. Below are a list of requirements and the practice schedule for the COED A squad. The ALL GIRL SQUAD will consist of 25+ female cheerleaders. The All girl team competes in the Division II All Girl Division at the NCA Collegiate National Championship; they won their first National Championship title in 2011. Below is a list of requirements and the practice schedule for the All girl squad. The COED INTERMEDIATE B SQUAD will consist of 25+ male and female cheerleaders. This squad is NEW to our program and competes in Small Coed Intermediate Division (16 girls & 4 guys). Most stunts will be performed "All girl" style with a main base, secondary base, and a backspot. Below is a list of requirements and the practice schedule for the Coed B squad. TRYOUT MATERIAL FOR All SQUADS: Teams will learn: The fight song and/or band dance 2 chants TUMBLING: Standing tuck (on a gym floor) Toe tuck Standing back handspring tuck MINIMUM of a round off back handspring tuck Layouts and fulls strongly suggested *Coed B will only be required to do 2 standing consecutive back hand springs STUNTS: GUYS Back spotting (All girl style) or main/secondary basing Toss to hands, extension, lib STUNTS: GIRLS (performing your respective part i.e. base, back, flyer) Double down out of all body positions *Coed B will only be required to single down from of all body positions PRACTICE SCHEDULE: Monday 3 5:30 PM Wednesday 3 5:30 PM Friday 3 5:30PM Tuesday and Thursday workouts, time TBA
2017 VSU Cheerleading Tryout Checklist Please make sure when you send in your application for tryouts that you check off the following items to ensure your registration it is completed. Tryout Application (pages 1 8 of this packet) Official Acceptance Letter to VSU (if applicable) Copy of BOTH Sides of your Medical Insurance Card Proof of Recent Physical from March 2017 Current $50 Tryout Fee (can be cash, cashiers check, or money order.if paying by check, please make payable to VSU Foundation/Cheer this fee is non refundable) Once all of the above items have been received and processed, you will receive a confirmation email sent to the address listed above in the tryout application. If you have any further questions, please feel free to email Head Cheerleading Cody Hudson at cohudson@valdosta.edu. Applications are due by 5:00 PM on April 14th, 2017. Please mail your application and payment to: Valdosta State University Attn: Athletic Department/ Cody Hudson 1500 North Patterson Street Valdosta, GA 31698