NJCAA ELIGIBILITY AFFIDAVIT - Rowan College at Burlington ... · Rowan College at Burlington County...

Rowan College at Burlington County Barons Department of Athletics

Eligibility Checklist

All prospective student-athletes must apply and be accepted prior to being considered by Athletics. Barons student-athletes must submit the following documents prior to participation. Please make a copy of all documents for your records, and submit originals to the Department of Athletics no later than August 1 for fall sports, and September 1 for winter and spring sports.

o Eligibility Affidavit o Proof of identification - Copy of birth certificate, driver’s license or passport o Permanent resident card if applicable o Official high school transcripts, with final grades and graduation date, from all high schools

attended. All transcripts must be signed and stamped by a school administrator. All high school transcripts from schools outside of the United Stated must be translated and evaluated by World Education Services (https://www.wes.org/).

o NJCAA Amateurism o Authorization for the Release of Information o Pre-Participation Physical Evaluation Form o Sudden Cardiac Death Pamphlet Sign-Off Sheet o Student-Athlete Concussion Information Acknowledgement Form o Inherent Risk of Injury/An Agreement to Participate o Parent/Guardian/Student-Athlete Insurance Information Form, with copy of insurance card o Athletic Injury Insurance Policy Acknowledgement o BCC registration form showing proof of payment of BCC Student Insurance, if applicable o FAFSA Completion Page o Student-Athlete Participation Fee Agreement – to be distributed by coach by the end of

September o Social Media Acknowledgement o Barons Student-Athlete Statement of Commitment

Transfers – applies to all student-athletes who have been registered at any other College, regardless of number of credits completed o All previous college transcripts – official transcripts preferred; unofficial acceptable for initial

eligibility evaluation o Transfer tracking form o Transfer waiver, if applicable

Please understand that falsified or omitted information can make a student-athlete ineligible for ALL future competition in compliance with the National Junior College Athletic Association Eligibility Rules.

NJCAA ELIGIBILITY AFFIDAVITInformation on this form will be used to determine eligibility for participation on a NJCAA sponsored athletic team. Accuracy of your answers is paramount

to the reputation and safekeeping of the history of athletics at Rowan College at Burlington County (RCBC).

Today’s Date: _____________________________________ Sport: _________________________ ID Number: _________________Name: ___________________________________________________________________________ DOB: ______________________Home Address: _________________________________________________________________________________________________City:________________________________________________ State:_______________ County: ______________________________Email Address: ____________________________________ Cell Phone: _________________________________________________

Student/Athlete Signature: _________________________________________________________ Date: ______________________

Coach Signature: __________________________________________________________________ Date: ______________________

I understand that falsified or omitted information can make me ineligible for ALL future college competition in compliance with the National Junior College Athletic Association Eligibility Rules.

Year(s) Name of School Country How was tuition paid?

(Parent coach, etc)Graduation

DateWhere did you live?

HIGH SCHOOL EDUCATIONDid you attend more than one high school? Yes ________No _______Name high school(s) you attended. Please include city, state and country.9th Grade ____________________________________________________________________________________________________10th Grade ___________________________________________________________________________________________________11th Grade ___________________________________________________________________________________________________12th Grade ___________________________________________________________________________________________________What high school did you graduate from? ________________________________________________________________________(Please enclose a final transcript; transcript must show graduation date, be signed, and sealed.) Graduation Date: _________Were you homeschooled? Yes________ No________ Did you graduate? Yes________ No________

(Enclose a copy of diploma and all other pertinent information.)If you did not complete high school, did you pass a State Department of Education approved High School Equivalency Test? Yes________ No________ Equivalency Test date earned: ___________________________(Enclose a certificate with test scores.)

***** If you have not attended a U.S. high school for your last three (3) years, please submit a high school diploma and proof of age (a birth certificate, passport or driver’s license). *****

ADDITIONAL EDUCATION WHILE IN HIGH SCHOOLDid you take any college credit classes while in high school? Yes________ No________If YES, please list college(s): _____________________________________________________________________________________

(You MUST provide transcript(s) from each college attended.)

ATHLETIC PARTICIPATION WHILE IN HIGH SCHOOL

Freshman, Junior Varsity, Varsity

Are you a United States Citizen? Yes________ No________ (U.S. Citizen must provide birth certificate/drivers license.)

A Permanent Resident? Yes________ No________(Permanent Resident must supply card.)

OR


Coach Signature: __________________________________________________________________ Date: ______________________

COLLEGE EDUCATION & ATHLETIC PARTICIPATIONCollege/University Education: List all full-time and part-time enrollment.

College: __________________________________________________ Dates: ____________________________________FT or PT



1. Have you ever signed a Letter of Intent Form with any college/university? Yes________ No________

If YES, specify the college/university: _________________________________________________ Date: ____________________

2. Have you ever participated in practices, scrimmages, and/or games for a college/university team other than RCBC? Yes________ No________ If YES, name the school: _______________________________________________________________

Sport: ____________________________________________________________________________ Date: ____________________

If YES, describe the situation: _________________________________________________________________________________

3. Have you ever been red-shirted for a season? Yes________ No________

If YES, list dates of that season, name the school and describe the situation: ________________________________________

___________________________________________________________________________________________________________

4. Have you ever files for a Medical Hardship? Yes________ No________

If YES, list dates of that season, name of college/university, and describe the situation: _______________________________

___________________________________________________________________________________________________________

5. Have you ever played on a sanctioned club team at a college/university that has competed against other colleges?

Yes________ No________ If YES, name the school: ___________________________________________________________

RECRUITING INFORMATION

6. How did you learn about RCBC? _______________________________________________________________________________

7. How were you contacted (e.g. by email, letters, telephone calls, in-person visits, etc.) and who encouraged you to attend this institution? _____________________________________________________________________________________________

8. Please list all official visits taken: _______________________________________________________________________________

9. Did you or someone on your behalf ever utilize a recruiting service or another individual to assist you in finding this institution or assist you in obtaining an athletic scholarship? Yes________ No________ I don’t know________

If YES, who assisted you? Explain: ______________________________________________________________________________

___________________________________________________________________________________________________________

Additional Clarifications: If you were not attending college full time following high school graduation, itemize this period from your graduation to the present. This should include employment, unemployment, military history, internships, and other activities/work. This is a requirement of the NJCAA. This is mandatory if you did not enroll full time and attend RCBC the semester following your high school graduation. Please include specific months and years when referring to dates.


Activity City, State Start Date Stop Date

NJCAA RECRUITING AND AMATEURISM QUESTIONNAIRE

Please be advised that this is a questionnaire used in the recruiting process in order to help the institution determine your eligibility under NJCAA eligibility rules. Please be honest with your answers.

ATHLETICS PARTICIPATION AFTER THE AGE OF 19

1. Do you currently play or did you play on any other sports teams (USAV, city recreational leagues, AAU, indoor soccer) after you turned the age of 19 while you were registered as a full-time student? Yes __________No ___________ If yes, please provide the name of the team, location and dates of participation:

2. Did you sign any type of agreement to participate on any of the teams you mentioned above? Yes __________No ___________ If YES, please indicate for which team and provide a copy of the agreement. ________________________________________ 3. Have you ever participated on a sports team in a country other than the United States? Yes __________No ___________ If YES, please list the sport(s): ________________________________________ and country: _____________________________ List the dates and explain the circumstances: ____________________________________________________________________ 4. Have you ever received money beyond expenses for participating in any athletic event? (Example: a salary, bonus spending money) Yes __________No ___________ If YES, describe the situation: __________________________________________________________________________________ 5. Have you ever received, directly or indirectly, a salary, reimbursement of expenses, or any other form of financial assistance from a professional sports organization based on your athletic skills or participation? Yes __________No ___________ 5a. Have you ever accepted any benefits not listed on this form from anyone other than your parents? Yes __________No ___________ 6. Have you or your parents/guardians ever accepted any benefits from an agent or anyone associated with an agent? Yes __________No ___________ 7. Did you accept a promise of pay-to-play even if this payment was to be received following completion of intercollegiate athletic participation? Yes __________No ___________ 8. Did any member of your team receive money beyond expenses for their participation on any of the teams on which you participated? Yes __________No ___________ I don’t know________________ If YES, indicate what was received and which teams(s) provided the payment to your teammate: ______________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 9. Did any of the teams or tournaments you participated in call themselves semi-professional or professional? Yes ___________ No ___________ I don’t know ___________ If YES, which team(s): _________________________________________________________________ 10. Have you ever competed on a professional athletic team or on a team where any member of the team was considered professional, even if no payment or other compensation for expenses was received? Yes __________No ___________

Team Name Team Contact Info League Affiliation Participation Dates # of Contests Played Expenses Received



11. Have you ever entered a professional draft? Yes __________No ___________12. Have you ever participated in a professional tryout? Yes __________No ___________ If yes, where and when? ______________________________________________________________________________________13. Have you ever been involved in an advertisement or promotion? Yes __________No ___________14. Have you ever participated in a non-sponsored showcase for your sport? Yes __________No ___________ If yes, where and when? ______________________________________________________________________________________15. Did you have a written or verbal agreement with an agent/agency to represent you while you were participating in athletics? Yes __________No ___________16. Did you ever sign a contract or commitment of any kind to play professional athletics regardless of its legal enforceability or any compensation received? Yes __________No ___________ If YES, provide a copy of the document.17. Did you win any money as a result of your participation in a foul shooting contest, bowling contest, golf outing, tennis tournament, road race, or any other athletic contest where money or prizes were awarded to the winner (you)? Yes __________No ___________ If YES, please explain:

TENNIS ONLYHave you participated in any tennis tournaments that awarded prize money? Yes _____ No _______If YES, please explain: __________________________________________________________________________Have you ever received accumulated compensation for participation in competition thatexceeds $2,500 for ALL events and dates of completion? Yes _____ No _______

College Major _____________________________________

What best depicts what you want to accomplish while at RCBC? List most important first 1-5 (1 most important):

____ Transfer to a four-year college to pursue a BA/BS degree prior to graduation ____ Transfer to a four-year college after graduation from RCBC ____ Basically to compete ____ To compete with the hope for possible professional scouting opportunities ____ Graduate RCBC with an associates degree and seek employment ____ Other (please specify):__________________________________________________________________________________

Date of Competition Name/Type of Competition Money/Prize Received Expenses

AR2959 08/15

Rowan college at Burlington County DEPARTMENT OF ATHLETICS

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Please complete all sections of this form. This form is not valid until complete. Name __________________________________________ Student ID#______________________________________ I, __________________________________, hereby request and authorize the release of any and all of my academic records, health‐related information, and photographs to the following identified parties: Please identify the parties you are authorizing to receive information. ___ All parties ___ Coach ___ Insurance Carrier ___ Media ___ Faculty ___ Trainer ___ Doctor ___ Recruiters ___ Hospital ___ NJCAA ___ NJCAA Region XIX ___ GSAC ___ Parent/Guardian (please identify) ____________________ ___ Other (please identify) ____________________ Expiration of Authorization: This authorization will remain effective for twelve (12) months from the date of signature unless you specify a different date or an event that will cause the expiration to expire. I authorize the release of the above information. Signature: _________________________________ Date: _________________ Signature of Parent/Guardian: _________________ Date: _________________ (If under the age of 18) Printed Name: ______________________________

■ Preparticipation Physical EvaluationHISTORY FORM(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep a copy of this form in the chart.)

Date of Exam ___________________________________________________________________________________________________________________

Name __________________________________________________________________________________ Date of birth __________________________

Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports forany reason?

2.Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes InfectionsOther: _______________________________________________

3. Have you ever spent the night in the hospital?

4.Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?

6.Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during exercise?

8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:

High blood pressure Aheart murmurHigh cholesterol Aheart infectionKawasaki disease Other: _____________________

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected during exercise?

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No

13. Has any 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)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No

17. Have you ever had an injury to a bone, muscle, ligament, or tendonthat caused you to miss a practice or a game?

18. Have you ever had any broken or fractured bones or dislocated joints?

19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture?

21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)

22. Do you regularly use a brace, orthotics, or other assistive device?

23. Do you have a bone, muscle, or joint injury that bothers you?

24. Do any of your joints become painful, swollen, feel warm, or look red?

25. Do you have any history of juvenile arthritis or connective tissue disease?

MEDICAL QUESTIONS Yes No

26. Do you cough, wheeze, or have difficulty breathing during orafter exercise?

27. Have you ever used an inhaler or taken asthma medicine?

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

30. Do you have groin pain or a painful bulge or hernia in the groin area?

31. Have you had infectious mononucleosis (mono) within the last month?

32. Do you have any rashes, pressure sores, or other skin problems?

33. Have you had a herpes or MRSA skin infection?

34. Have you ever had a head injury or concussion?

35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

36. Do you have a history of seizure disorder?

37. Do you have headaches with exercise?

38. Have you ever had numbness, tingling, or weakness in your arms orlegs after being hit or falling?

39. Have you ever been unable to move your arms or legs after being hitor falling?

40. Have you ever become ill while exercising in the heat?

41. Do you get frequent muscle cramps when exercising?

42. Do you or someone in your family have sickle cell trait or disease?

43. Have you had any problems with your eyes or vision?

44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

46. Do you wear protective eyewear, such as goggles or a face shield?

47. Do you worry about your weight?

48. Are you trying to or has anyone recommended that you gain orlose weight?

49. Are you on a special diet or do you avoid certain types of foods?

50. Have you ever had an eating disorder?

51. Do you have any concerns that you would like to discuss with a doctor?

FEMALES ONLY

52. Have you ever had a menstrual period?

53. How old were you when you had your first menstrual period?

54. How many periods have you had in the last 12 months?

Explain “yes” answers here

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 (if under age of 18) _____________________________________________________ Date _____________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410

New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

ATTENTION: The preparticipation physical examination (page 3) must be completed by a health care provider who has completedthe Student-Athlete Cardiac Assesment Professional Development Module.

■ Preparticipation Physical EvaluationTHE ATHLETE WITH SPECIAL NEEDS:SUPPLEMENTAL HISTORY FORM

Date of Exam ___________________________________________________________________________________________________________________


Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________

1. Type of disability

2. Date of disability

3. Classification (if available)

4. Cause of disability (birth, disease, accident/trauma, other)

5. List the sports you are interested in playing

Yes No

6. Do you regularly use a brace, assistive device, or prosthetic?

7. Do you use any special brace or assistive device for sports?

8. Do you have any rashes, pressure sores, or any other skin problems?

9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?

11. Do you use any special devices for bowel or bladder function?

12. Do you have burning or discomfort when urinating?

13. Have you had autonomic dysreflexia?

14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

15. Do you have muscle spasticity?

16. Do you have frequent seizures that cannot be controlled by medication?


Please indicate if you have ever had any of the following.

Yes No

Atlantoaxial instability

X-ray evaluation for atlantoaxial instability

Dislocated joints (more than one)

Easy bleeding

Enlarged spleen

Hepatitis

Osteopenia or osteoporosis

Difficulty controlling bowel

Difficulty controlling bladder

Numbness or tingling in arms or hands

Numbness or tingling in legs or feet

Weakness in arms or hands

Weakness in legs or feet

Recent change in coordination

Recent change in ability to walk

Spina bifida

Latex allergy


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 (if under age of 18) _________________________________________________ Date __________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

■ Preparticipation Physical EvaluationPHYSICAL EXAMINATION FORM


PHYSICIAN REMINDERS1. 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 seat belt, use a helmet, and use condoms?

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

EXAMINATION

Height Weight Male Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Y NMEDICAL NORMAL ABNORMAL FINDINGSAppearance• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excava tum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)Eyes/ears/nose/throat• Pupils equal• HearingLymph nodesHeart a

• Murmurs (auscultation standing, supine, +/- Valsalva)• Location of point of maximal impulse (PMI)Pulses• Simultaneous femoral and radial pulsesLungsAbdomenGenitourinary (males only) b

Skin• HSV, lesions suggestive of MRSA, tinea corporisNeurologic c

MUSCULOSKELETALNeckBackShoulder/armElbow/forearmWrist/hand/fingersHip/thighKneeLeg/ankleFoot/toesFunctional• Duck-walk, single leg hop

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 recommenda tions 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 preparticipation 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 parents. If conditionsarise 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).

_________________________________________________ __ Date ________________

Address __________________________________________________________________________________________________________ Phone _________________________

_____________________________________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.HE0503 9-2681/0410New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

NOTE: The preparticiaption physical examination must be conducted by a health care provider who 1) is a licensed physician, advanced practiciannurse, or physician assistant; and 2) completed the Student-Athlete Cardiac Assessment Professional Development Module.

Signature of physician, APN, PA

Name of physician, advanced practice nurse (APN), physician assistant (PA) (print/type)

■ Preparticipation Physical EvaluationCLEARANCE FORM

Name ___ ____________________________________________________ Sex M F Age _________________ Date of birth _________________

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 preparticipation 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 parents. 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).

___________________________________________________________ Date _______________

Address

Name of physician, advanced practice nurse (APN), physician assistant (PA)

_________________________________________________________________________________________ Phone _________________________

Signature of physician, APN, PA _______________________________________________________________________________________________________

Completed Cardiac Assessment Professional Development Module

Date___________________________ Signature

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Other information _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71

HCP OFFICE STAMP PHYSICIAN:

Reviewed on ______________________________________________

Approved _______ Not Approved _______

Signature: _________________________________________________

(Date)

SUDDEN CARDIACDEATHINYOUNG ATHLETESThe Basic Facts onSudden Cardiac Deathin Young Athletes

SUDDEN CARDIAC DEATH IN YOUNG ATHLETES

Sudden death in young athletesbetween the ages of 10and 19 is very rare.

What, if anything, can bedone to prevent this kind oftragedy?

What is sudden cardiac deathin the young athlete?

Sudden cardiac death is theresult of an unexpected failure of properheart function, usually (about 60% of thetime) during or immediately after exercisewithout trauma. Since the heart stopspumping adequately, the athlete quicklycollapses, loses consciousness, andultimately dies unless normal heart rhythmis restored using an automated externaldefibrillator (AED).

How common is sudden death in youngathletes?

Sudden cardiac death in young athletes isvery rare. About 100 such deaths arereported in the United States per year.The chance of sudden death occurringto any individual high school athlete isabout one in 200,000 per year.

Sudden cardiac death is morecommon: in males than in females;in football and basketball than inother sports; and in African-Americans thanin other races and ethnic groups.

What are the most common causes?

Research suggests that the main cause is aloss of proper heart rhythm, causing theheart to quiver instead of pumpingblood to the brain and body. This is calledventricular fibrillation (ven- TRICK-you-lar fib-roo-LAY-shun). The problem is usually causedby one of several cardiovascular abnormalitiesand electrical diseases of the heart that gounnoticed in healthy-appearing athletes.

The most common cause of sudden death inan athlete is hypertrophic cardiomyopathy(hi-per-TRO-fic CAR- dee-oh-my-OP-a-thee)also called HCM. HCM is a disease of the heart,with abnormal thickening of the heartmuscle, which can cause serious heart rhythmproblems and blockages to blood flow. Thisgenetic disease runs in families and usuallydevelops gradually over many years.

The second most likely cause is congenital(con-JEN-it-al) (i.e., present from birth)

abnormalities of the coronaryarteries. This means that theseblood vessels are connected to

the main blood vessel of theheart in an abnormal way. This

differs from blockages that mayoccur when people get older

(commonly called “coronary arterydisease,” which may lead to a heart

attack).

� Sudden Death in Athleteshttp://tinyurl.com/m2gjmvq

� Hypertrophic Cardiomyopathy Associationwww.4hcm.org

� American Heart Association www.heart.org

Collaborating Agencies:American Academy of Pediatrics New Jersey Chapter3836 Quakerbridge Road, Suite 108Hamilton, NJ 08619(p) 609-842-0014(f ) 609-842-0015www.aapnj.org

American Heart Association1 Union Street, Suite 301Robbinsville, NJ, 08691(p) 609-208-0020www.heart.org

New Jersey Department of EducationPO Box 500Trenton, NJ 08625-0500(p) 609-292-5935www.state.nj.us/education/

New Jersey Department of HealthP. O. Box 360Trenton, NJ 08625-0360(p) 609-292-7837www.state.nj.us/health

Lead Author: American Academy of Pediatrics, New Jersey ChapterWritten by: Initial draft by Sushma Raman Hebbar,MD & Stephen G. Rice, MD PhD

Additional Reviewers: NJ Department of Education,NJ Department of Health and Senior Services,American Heart Association/New Jersey Chapter, NJ Academy of Family Practice, Pediatric Cardiologists,New Jersey State School Nurses

Revised 2014: Nancy Curry, EdM; Christene DeWitt-Parker, MSN, CSN, RN; Lakota Kruse, MD, MPH; Susan Martz, EdM; Stephen G. Rice, MD; Jeffrey Rosenberg, MD, Louis Teichholz, MD; Perry Weinstock, MD

Website Resources

STATE OF NEW JERSEYDEPARTMENT OF EDUCATION

Other diseases of the heart that can lead tosudden death in young people include:

� Myocarditis (my-oh-car-DIE-tis), an acuteinflammation of the heart muscle (usuallydue to a virus).

� Dilated cardiomyopathy, an enlargementof the heart for unknown reasons.

� Long QT syndrome and other electricalabnormalities of the heart which causeabnormal fast heart rhythms that can alsorun in families.

� Marfan syndrome, an inherited disorderthat affects heart valves, walls of majorarteries, eyes and the skeleton. It isgenerally seen in unusually tall athletes,especially if being tall is not common inother family members.

Are there warning signs to watch for?

In more than a third of these sudden cardiacdeaths, there were warning signs that werenot reported or taken seriously. Warningsigns are:

� Fainting, a seizure or convulsions duringphysical activity;

� Fainting or a seizure from emotionalexcitement, emotional distress or beingstartled;

� Dizziness or lightheadedness, especiallyduring exertion;

� Chest pains, at rest or during exertion;

� Palpitations - awareness of the heartbeating unusually (skipping, irregular orextra beats) during athletics or during cooldown periods after athletic participation;

� Fatigue or tiring more quickly than peers; or

� Being unable to keep up with friends dueto shortness of breath (labored breathing).

What are the current recommendationsfor screening young athletes?

New Jersey requires all school athletes to beexamined by their primary care physician(“medical home”) or school physician at leastonce per year. The New Jersey Department ofEducation requires use of the specific Prepar-ticipation Physical Examination Form (PPE).

This process begins with the parents andstudent-athletes answering questions aboutsymptoms during exercise (such as chestpain, dizziness, fainting, palpitations orshortness of breath); and questions aboutfamily health history.

The primary healthcare provider needs toknow if any family member died suddenlyduring physical activity or during a seizure.They also need to know if anyone in thefamily under the age of 50 had anunexplained sudden death such asdrowning or car accidents. This informationmust be provided annually for each exambecause it is so essential to identify those atrisk for sudden cardiac death.

The required physical exam includesmeasurement of blood pressure and a carefullistening examination of the heart, especiallyfor murmurs and rhythm abnormalities. Ifthere are no warning signs reported on thehealth history and no abnormalitiesdiscovered on exam, no further evaluation ortesting is recommended.

Are there options privately available toscreen for cardiac conditions?

Technology-based screening programsincluding a 12-lead electrocardiogram (ECG)and echocardiogram (ECHO) arenoninvasive and painless options parentsmay consider in addition to the required

PPE. However, these procedures may beexpensive and are not currently advised bythe American Academy of Pediatrics and theAmerican College of Cardiology unless thePPE reveals an indication for these tests. Inaddition to the expense, other limitations oftechnology-based tests include thepossibility of “false positives” which leads tounnecessary stress for the student andparent or guardian as well as unnecessaryrestriction from athletic participation.

The United States Department of Healthand Human Services offers risk assessmentoptions under the Surgeon General’s FamilyHistory Initiative available athttp://www.hhs.gov/familyhistory/index.html.

When should a student athlete see aheart specialist?

If the primary healthcare provider or schoolphysician has concerns, a referral to a childheart specialist, a pediatric cardiologist, isrecommended. This specialist will performa more thorough evaluation, including anelectrocardiogram (ECG), which is a graph ofthe electrical activity of the heart. Anechocardiogram, which is an ultrasound testto allow for direct visualization of the heartstructure, will likely also be done. Thespecialist may also order a treadmill exercisetest and a monitor to enable a longerrecording of the heart rhythm. None of thetesting is invasive or uncomfortable.

Can sudden cardiac death be preventedjust through proper screening?

A proper evaluation should find most, but notall, conditions that would cause sudden deathin the athlete. This is because some diseasesare difficult to uncover and may only developlater in life. Others can develop following a

normal screening evaluation, such as aninfection of the heart muscle from a virus.

This is why screening evaluations and areview of the family health history need tobe performed on a yearly basis by theathlete’s primary healthcare provider. Withproper screening and evaluation, most casescan be identified and prevented.

Why have an AED on site during sportingevents?

The only effective treatment for ventricularfibrillation is immediate use of an automatedexternal defibrillator (AED). An AED canrestore the heart back into a normal rhythm.An AED is also life-saving for ventricularfibrillation caused by a blow to the chest overthe heart (commotio cordis).

N.J.S.A. 18A:40-41a through c, known as“Janet’s Law,” requires that at any school-sponsored athletic event or team practice inNew Jersey public and nonpublic schoolsincluding any of grades K through 12, thefollowing must be available:� An AED in an unlocked location on school

property within a reasonable proximity tothe athletic field or gymnasium; and

� A team coach, licensed athletic trainer, orother designated staff member if there is nocoach or licensed athletic trainer present,certified in cardiopulmonary resuscitation(CPR) and the use of the AED; or

� A State-certified emergency servicesprovider or other certified first responder.

The American Academy of Pediatricsrecommends the AED should be placed incentral location that is accessible and ideallyno more than a 1 to 11/2 minute walk from anylocation and that a call is made to activate 911emergency system while the AED is beingretrieved.

S U D D E N C A R D I A C D E AT H I N Y O U N G AT H L E T E S

State of New JerseyDEPARTMENT OF EDUCATION

Sudden Cardiac Death Pamphlet

Sign-Off Sheet

Name of School: ______________ _________________________________________________________

I/We acknowledge that we received and reviewed the Sudden Cardiac Death in Young Athletes pamphlet.

Student Signature: _____________________________________________________________________

Parent or GuardianSignature: _________________________________________________________________

Date:____________________________

New Jersey Department of Education 2014: pursuant to the Scholastic Student-Athlete Safety Act, P.L. 2013, c.71

E14-00395

(if under age of 18)

Athletic Training and Sports Medicine Concussion Guideline and Management Plan

Student-Athlete Concussion Information Acknowledgement Form

In keeping in line with the NCAA guidelines, the NJCAA requires that all student-athletes sign a statement where they acknowledge, understand, and accept the responsibility for reporting any/all signs and symptoms of a concussion to the Rowan College at Burlington County Athletic Training Staff.

A concussion is described as a violent shaking or jarring action to the brain, usually as a result of impact with a person, object or ground. A concussive head injury can result in acute clinical symptoms and typically result in a functional disturbance and /or impairment. A concussion may or may not involve loss of consciousness, but physical, cognitive and emotional symptoms may be present. If you have suffered a head injury during competition, practice or any life event, the symptoms of a concussion can present themselves or worsen as time passes. Here are some of the signs and symptoms that may indicate you have sustained a concussion: If your mild headache gets worse If you are restless, irritable, or experience a drastic change in emotional control Mental confusion or disorientation that gets progressively worse Memory loss or other memory problems Feeling “dazed” or in a “fog” Loss of appetite Drowsiness, or increased sleepiness Unequal or dilated pupils Blurred vision Sensitivity to light or noise Ringing in the ears Bleeding and or clear fluid from the nose or ears Persistent or increasing nausea and or vomiting Change in breathing patterns Dizziness or unsteadiness when walking or standing Difficulty speaking or slurred speech

I agree to inform the Rowan College at Burlington County Athletic Training Staff if I experience any of these signs and symptoms of a concussion during the academic year. My signature below indicates that I have read this entire document, understand it completely and agree to be bound by its terms. Name: ________________________________________ Date: ____________________ Signature: _____________________________________ Sport: ___________________ Signature of Parent/Guardian: ___________________ Date: ____________________ (If under the age of 18) Printed Name: _________________________________

Rowan County at Burlington County

Barons Department of Athletics Inherent Risk of Injury

An Agreement to Participate

I am aware that playing in any sport can be a dangerous activity involving risks, including injury. I understand that the dangers and risks of playing or practicing in any sport include, but are not limited to: death, serious neck and spinal cord injuries which may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system and serious injury or impairment to other aspects of my body, general health and well being. I especially acknowledge that contact sports can involve even a greater risk of injury than some other sports. Because of the dangers of participating in the named sport(s), I recognize the importance of following the coach’s instructions regarding playing techniques, training, rules of sport, and other team rules and obeying such instructions. In consideration of the College permitting me to practice, play or try out for the College’s team(s) and to engage in all activities related to the team, including practicing, playing, and traveling, I hereby voluntarily assume all risks associated with participation and agree to exonerate and save the harmless College, their agents, servants and employees, the athletic staff of the College, the physicians and other practitioners of the healing arts treating me from any and all liability, claims, causes of action or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the College sports team(s). The terms hereof shall serve as a release and as an assumption of risk for my heirs, estates, executor, administrator, assignees, and all members of my family. I hereby agree to submit any disputes that may arise between myself and the College, its agents, its servants and employees, the athletic staff of the College, the physicians and other practitioners of the healing arts treating me, in connection with my activities at the College, to binding arbitration before three arbitrators, in accordance with the Rules of the American Arbitration Association. ▪ I will not knowingly attempt to harm or injure an opponent through the use of proper or improper techniques. ▪ I will properly maintain any equipment in good working order issued to me and report any defects to the coaches, athletic trainer, or equipment coordinator. ▪ I understand that the administrators, coaches and medical staff hold my health and safety first and foremost in their minds. Name: ________________________________________ Date: ____________________ Signature: _____________________________________ Sport: ___________________ Signature of Parent/Guardian: ___________________ Date: ____________________ (If under the age of 18) Printed Name: _________________________________

Please provide the requested information below regarding the student–athlete’s primary insurance plan. o I am currently covered by an accident or other medical/hospitalization insurance. o I am NOT currently covered by any accident or other medical/hospitalization insurance.

PRIMARY INSURANCE HOLDER

Name: _____________________________________________________________________________________________________Address: ___________________________________________________________________________________________________Home Phone #: _________________________________________ Work Phone #: ________________________________________Employer Name: _____________________________________________________________________________________________Employer Address: ___________________________________________________________________________________________Name of Insurance Company: __________________________________________________________________________________Insurance Company Phone #: __________________________________________________________________________________Policy #: ______________________________________________ Group #:_____________________________________________Plan #: _______________________________________________ ID #: ________________________________________________Expiration of Policy: ____________________________________Is your dependent son/daughter covered under the above policy? o Yes o NoDoes your insurance require pre-authorization for services? o Yes o NoDoes your insurance require referrals? o Yes o NoIs the company or plan listed above considered a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO)?

HMO: o Yes o No PPO: o Yes o No

** PLEASE ATTACH A COPY OF BOTH SIDES OF INSURANCE CARD **

STUDENT–ATHLETE

Name: _______________________________________________________________ SS#: _________________________________Address: ___________________________________________________________________________________________________Home Phone #: _________________________________________ Cell Phone #: _________________________________________Insurance ID #: _________________________________________Primary Physician: ___________________________________________________________________________________________Address: ___________________________________________________________________________________________________City: ______________________________________ State: _________________________________ Zip: ____________________Phone #: _______________________________________________ Fax #: _______________________________________________

I hereby authorize Rowan College at Burlington County to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays and any other data covering this and/or previous confinements and/or disabilities. A photo copy of this autho-rization shall be deemed as effective and valid as the original.

I hereby certify that the answers provided are true, complete, and correct to the best of my knowledge.

Signature of Student-Athlete: _________________________________________________________ Date: ___________________ Printed Name: ______________________________________________________________________

Signature of Parent/Guardian: ________________________________________________________ Date: ___________________ Printed Name: ______________________________________________________________________

Signature of Policy Holder: ___________________________________________________________ Date: ___________________ Printed Name: ______________________________________________________________________

PARENT/GUARDIAN/STUDENT–ATHLETE INSURANCE INFORMATION FORM

FORM 44500-025 REV 06/18

Student–Athlete Name: _____________________________________________________________________________Student–Athlete ID #: ______________________________ Sport: __________________________________________

As of July 1, 2013, RCBC will provide all student-athletes a comprehensive Athletic Injury Insurance Policy. The policy is a fee that is covered for all student-athletes who are covered under a current NJCAA Letter of Intent. For student- athletes who are not on a Letter of Intent, the policy will cost $50.00*.

It is important to understand that this policy is specific to injuries and accidents that result only from RCBC sanctioned department/team events and activities. All other illnesses and injuries resulting from activities outside the team’s sanctioned events are not covered under this policy.

Personal health coverage remains the primary coverage in the event of an athletic injury. This accident coverage is an excess policy that will provide coverage if an athlete lacks primary coverage or if their primary coverage needs to be supplemented in any way. There is no deductible with this Athletic Injury Insurance Policy. Student-athletes may be responsible for a portion of the costs associated with procedures/treatments above and beyond the normal usual and customary limits.

It is imperative that when a student-athlete is injured, they contact the Department of Athletics’ Athletic Trainer to complete and forward the necessary claim form to the respective doctor. The claims form will have the insurance company name, address, contact information, policy number, as well as the RCBC Student-Athlete information.

All claims should be submitted to the college’s insurance company in a timely fashion. Lack of notification of injury and related medical bills may result in a lack of coverage. It is required that all claims be presented to the college no later than 90 days following the date of injury or by May 31 of the academic year, whichever comes sooner.

By signing below, I am verifying that I have read and understand the information presented above regarding the Student-Athlete Athletic Injury Insurance Policy.

*Students attending a team tryout are required to pay a $25.00 non-refundable fee to be covered under the Athletic Injury Insurance Policy during the time of the tryouts. If the student-athlete is added to the program’s roster, they will then be responsible for the remaining $25.00 of the fee, prior to any further participation with the program.

Signature of Student-Athlete: __________________________________________________ Date: _________________ Printed Name: _______________________________________________________________

Signature of Primary Policy Holder: ____________________________________________ Date: _________________ Printed Name: _______________________________________________________________ Relationship to Student–Athlete: ________________________________________________

Signature of Parent/Guardian: _________________________________________________ Date: _________________ (If under the age of 18)Printed Name: _______________________________________________________________

ATHLETIC INJURY INSURANCE POLICY ACKNOWLEDGEMENT

FORM 44500-028

I, _____________________________________, acknowledge that as a Barons Student–Athlete, it is my

responsibility to read, abide by, and respect the guidelines set forth in the Barons Student–Athlete Guide.

In the event that I am not clear about any of the concerns in the guide, I understand that I have a responsibility

to seek clarification from my coach or other member of the athletic administration staff.

Signature of Student-Athlete: __________________________________________ Date: _______________

Printed Name: _______________________________________________________

Sport: ______________________________________________________________

BARONS STUDENT–ATHLETE STATEMENT OF COMMITMENT FORM

FORM 44500-026

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