All Highlighted Areas On4 Pages Must Be Completed Prior To

SOUTH GWINNETT HIGH SCHOOLATHLETIC PARTICIPATION FORM

ALL HIGHLIGHTED AREAS ON4 PAGES MUST BE COMPLETED PRIOR TO

STUDENT PARTICIPATION IN ATHLETICS

PREPARTICIPATION PHYSICAL EVALUATION HISTORY FORM

Date Of Exam______Sport(s):______

Name:______Date of Birth:______

Sex ______Age ______Grade ______School ______

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

______

Signature of Athlete Signature of Parent/Guardian Date

PHYSICAL EXAMINATION FORM /CLEARANCE FORM

Name: ______Date of Birth: ______

PHYSICIAN REMINDERS

1. Consider additional questions on more sensitive issues

• Do you feel stressed out or under a lot of pressure?

• Do you ever feel sad, hopeless, depressed, or anxious?

• Do you feel safe at your home or residence?

• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?

• During the past 30 days, did you use chewing tobacco, snuff, or dip?

• Do you drink alcohol or use any other drugs?

• Have you ever taken anabolic steroids or used any other performance supplement?

• Have you ever taken any supplements to help you gain or lose weight or improve your performance?

• Do you wear a seatbelt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

AConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
BConsider GU exam if in private setting. Having third party present is recommended.
CConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion

□Cleared for all sports without restriction

□Cleared for all sports without restriction with recommendations for further evaluation or treatment for

______

□Not Cleared ……..□ Pending further evaluation ………□ For any sports ………….□ For certain sports

Reason______

Recommendations ______
I have examined the above-named student and completed the participation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parent. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of Physician (print/type)______Phone ______

Street Address______City______State______Zip______

Signature of Physician______Date of Exam : ______

2015-16 SOUTH GWINNETT HIGH SCHOOL STUDENT/PARENTCONCUSSIONAWARENESSFORM

STUDENT NAME: STUDENT NO. ______

SPORT:______

DANGERS OF CONCUSSION

Concussionsatalllevels ofsports havereceiveda greatdeal of attentionandastatelawhas been passed toaddressthis issue. Adolescent athletes areparticularly vulnerable totheeffectsof concussion.Onceconsideredlittlemorethana minor “ding” tothe head,itis nowunderstoodthata concussionhas thepotential toresultindeath, or changes inbrainfunction(either short-termor long- term). Aconcussionis a braininjurythatresults ina temporarydisruption of normal brainfunction.A concussion occurs whenthebrainis violentlyrockedbackandforthor twistedinsidetheskullas a result ofa blowto thehead or body.Continuedparticipationinanysportfollowingaconcussioncan leadtoworseningconcussionsymptoms, aswellas increasedriskforfurther injuryto thebrain,and even death.

Player andparental educationinthis areais crucial–thatis thereasonfor this document. Refer toit regularly. Thisformmust besigned byaparent or guardianofeachstudentwhowishes toparticipate inGHSAathletics. Onecopyneedstobereturnedtotheschool,and oneretained athome.

COMMONSIGNSANDSYMPTOMSOFCONCUSSION

Headache,dizziness,poorbalance,movesclumsily,reducedenergylevel/tiredness

Nauseaorvomiting

Blurredvision,sensitivityto lightandsounds

Fogginessofmemory,difficultyconcentrating,slowedthoughtprocesses,confusedaboutsurroundingsorgame assignments

Unexplainedchangesinbehaviorandpersonality

Lossofconsciousness(NOTE:Thisdoesnotoccurin allconcussionepisodes.)

BY-LAW 2.68:GHSACONCUSSION POLICY: In accordancewith Georgia lawandnational playing rules published bytheNational Federation ofStateHigh School Associations, anyathlete who exhibits signs, symptoms, orbehaviorsconsistent with a concussion shallbeimmediatelyremoved from the practiceor contest and shallnot return to playuntil anappropriatehealth careprofessionalhasdetermined that no concussion has occurred. (NOTE: An appropriate health careprofessional mayinclude,licensedphysician (MD/DO)oranotherlicensed individual under thesupervision of alicensed physician, such as a nursepractitioner, physician assistant, or certifiedathletictrainerwho has received traininginconcussion evaluation and management.

a) Noathleteisallowedtoreturntoagameorapracticeon thesameday thataconcussion(a)hasbeen diagnosed,OR (b) cannotberuled out.

b) Any athletediagnosedwitha concussionshallbe clearedmedicallyby an appropriatehealthcare professionalpriortoresumingparticipationin any futurepracticeor contest. Theformulation of a gradualreturntoplay protocolshallbea part of themedicalclearance.

c) Itismandatorythatevery coachin eachGHSAsportparticipatein afree,onlinecourseonconcussion management prepared by theNFHS andavailableat beginningwiththe2013-2014 schoolyear.

d) Eachschoolwillberesponsibleformonitoringtheparticipationof itscoachesin theconcussion management course,andshall keeparecordof thosewhoparticipate.

I HAVE READ THISFORM ANDI UNDERSTAND THEFACTS PRESENTED INIT.

SIGNED:

(Student) (Parent or Guardian) DATE: