NPS SPORTS PHYSICAL DOCUMENTS

CENTRAL HIGH SCHOOL

These documents must be filled out completely prior to the examination.

Hand in completed packets directly to the School Nurse.

CHANGING HEARTS AND MIND TO VALUE EDUCATION

NEWARK PUBLIC SCHOOL ATHLETICS

PERMISSION & EMERGENCY INFORMATION FORM (ALL LINES MUST BE FILLED OUT COMPLETELY IN INK)

LAST NAME, FIRST NAME, MI BIRTHDATE AGE SEX SPORT(S)

GRADE HOMEROOM# & TEACHER STUDENT EMAIL ADDRESS

HOME ADDRESS HOME PHONE# STUDENT CELL PHONE#

MOTHER/GUARDIAN’S FULL NAME HOME ADDRESS HOME PHONE #

MOTHER/GUARDIAN’S BUSINESS NAME & PHONE# MOTHER EMAIL ADDRESS MOTHER CELL PHONE #

FATHER/GUARDIAN’S FULL NAME HOME ADDRESS HOME PHONE #

FATHER/GUARDIAN’S BUSINESS NAME & PHONE FATHER EMAIL ADDRESS FATHER CELL PHONE #

FAMILY PHYSICIAN ADDRESS BUSINESS PHONE#

IN CASE OF EMERGENCY, CONTACT: (OTHER THAN PARENT/GUARDIAN) RELATIONSHIP WORK PHONE #

ADDRESS HOME PHONE# CELL PHONE #

Medical Conditions/Medications/Allergies:

Insurance Information (PLEASE ATTACH A COPY OF YOUR INSURANCECARD) OR

(IF YOU HAVE NO INSURANCE PLEASE INDICATE NONE ON THE INSURANCE COMPANY LINE)

Insurance Company Name, Address & Phone #:

Name of Insured (parent/guardian) Insured Birthdate

Policy # Group #

**All information listed is complete and accurate. By signing this document, I hearby authorize medical treatment in case of

hospitalization and the billing of my insurance company to cover any injuries suffered by my child in the event of an

emergency. If my child does not have insurance coverage, I will apply for free or reduced medical care at the hospital. I

understand that the Newark Public Schools’ Secondary Insurance Plan will only cover medical costs after these measures have

been take n.**

Parent/Guardian Signature Date:

Physical Date: Nurse’s Signature: Today’s Date

Boys’ Baseball Basketball Cheerleading Cross Country Football

Girls’ Golf Ice Hockey Track Soccer Softball

Co-ed Swimming Tennis Volleyball Winter Guard Wrestling

Bowling Lacrosse Pep Squad Indoor Track Other

Student-Athlete’s Signature

NEWARK PUBLIC SCHOOLS ATHLETICS AND SPORTS MEDICINE MEDICAL CONSENT AND PERMISSION FORM OR ATHLETIC COMPETITION

Please complete this form in ink.

I/we the parent/legal guardian of , request that our child be permitted to participate

in as carried out in the school, including practice sessions and contests with other schools. In consideration of such permission, it is represented and agreed as follows:

1.That said child is physically able to participate in said sport.

2. I/we realizing that such activity involves the potential for injury, which is inherent in all sports, acknowledge that even with the best coaching, use of the most protective equipment and strict observance of rules, injuries are still a possibility. I/we understand that the dangers and risks include, but are not limited to, death, serious head, neck and spinal injuries, paralysis, injuries or impairment to the musculoskeletal system, or other aspects of the body, general health, and well-being. I/we acknowledge that I/we have read and understand this warning, and have discussed these thoroughly with our child.

3. That said child issued equipment and supplies, which must be returned on demand or replaced if lost or stolen. It is understood that I am not to be

charged for any damage due to wear and tear through legitimate use. The student may use school facilities to store equipment , but is responsible for

equipment once it has been issued. It may be taken home for cleaning and storage.

4. FOOTBALL PLAYERS ONLY: That I/we acknowledge and understand the following warning: no helmet can prevent all head or neck injuries

that a player might receive while participating in football. A helmet must not be used to butt, ram or spear an opposing player. This is a violation of

the football rules and such use can result in severe head or neck injuries, paralysis or death and possible injury to the opp onent as well.

5. I/we authorize Athletic Staff to communicate electronically with my son/daughter as it relates to school-related business, athletics, and/or injures.

6. I/we authorize the athletic trainers to provide necessary medication or treatment to my/our child if injured or ill, and if it is deemed necessary to have my/our child admitted and treated (including medication) in a hospital until the arrival of a family member or the family physician.

7. I further consent to allow said physician(s)or health care provider(s)to share appropriate information concerning my child that is relevant to participation in athletics and activities with athletic trainers, coaches and other school personnel as deemed necessary.

8. I/we also authorize the Newark Public School Athletic Trainers to render to our son/daughter any preventive measures for injuries, first aid,

treatment, rehabilitation, or emergency treatment that they deem reasonable and necessary, the health and well-being of our child. This includes all

practices, competitions and team travel.

9. I/we realize that I/we are expected to report all injuries/illnesses that may have been sustained during periods of official, organized athletic participation (including all regularly scheduled practices and competitions) to the athletic director, athletic trainer, and coach.

10. That neither the Newark Public Schools nor any of its employees shall be liable to the undersigned or to the pupil for any claims arising out of or during, such participation, said claims be hereby waived, and the undersigned releases the said Newark Public Schools, its employees, teachers, and principal from any and all liability claims for personal injury to said pupil, expenses, or property damage.

11. That said child has hospital and medical surgical insurance coverage. If said child is not covered by health insurance, I/we take responsibility for

applying for and obtaining free/reduced medical care coverage at the hospital. I/we understand that the school insurance plan is for excess insurance

coverage only. I/we acknowledge receipt of the Certificate of Insurance, which describes the benefits, and conclusion of the insurance program in

force for the athletes and other participants in the athletic office.

12. Because of the dangers of participating in sports, I/we recognize the importance of following the instructions of the ath letic department personnel

regarding playing techniques, training, rules of the sport/team equipment, and to obey such rules. I/we also acknowledge that some sports are

classified as violent sports involving an even greater risk of injury than other sports.

DECLARATION OF AGREEMENT

I/we certify that the undersigned student is an amateur and is eligible to compete under the rules of the New Jersey State Athletic Association. He/she requests to be enrolled as a candidate for a place on the school team in the above-specified sport. He/she acknowledges the fact that physical hazards may be encountered and waives all claims against the Newark Public Schools and its employees for damages to themselves or other persons in their behalf for personal injuries that occur during participation in the sport. I/we will be responsible for the safe return of all athletic equipment issued by the school to my/our child. By signing below, I/we are acknowledging that I/we understand the above terms.

Parent/Guardian’s Signature Date

PEsch-md parent consent

Newark Public Schools

Central High School

Office of Health Services Request/Consent for Medical Examination

By the School Physician

Name Birth Date Grade/Room

Parent/Guardian Phone (work)

(home)

I understand that the laws of the New Jersey Departments of Education and Health require that each student

must be examined upon entry into the school district.

I am requesting that my child be examined by the School Physician.

Therefore, I give my consent to the Newark Public Schools’ School Physician to provide a physical

examination for my child. I will be notified of any abnormal findings, and will be responsible to seek further

medical care.

Family Physician/Primary Health Care Provider Medical Examination

My child has a medical care provider, , who shall provide the physical

examination for my child. I am responsible for submitting the completed physical examination form to the

school nurse within 60 days.

I understand that it is highly recommended that all students have a medical examination at least once up to 3

rd grade, once between 4

th and 8

th grades, and once between 7

th and 12

th grades.

Parent/Guardian Signature Date

, Dear Parent/Guardian

Central High School is currently implementing an innovative program for our student-athletes.

This program will assist our team physicians/athletic trainers in evaluating and treating head

injuries (e.g., concussion). In order to better manage concussions sustained by our student-

athletes, we have acquired a software tool called ImPACT (Immediate Post Concussion

Assessment and Cognitive Testing). ImPACT is a computerized exam utilized in many

professional, collegiate, and high school sports programs across the country to successfully

diagnose and manage concussions. If an athlete is believed to have suffered a head injury during

competition, ImPACT is used to help determine the severity of head injury and when the injury

has fully healed. The computerized exam is given to athletes before beginning contact sport practice or

competition. This non- invasive test is set up in “video-game” type format and takes about 15-20

minutes to complete. It is simple, and actually many athletes enjoy the challenge of taking the

test. Essentially, the ImPACT test is a preseason physical of the brain. It tracks information such

as memory, reaction time, speed, and concentration. It, however, is not an IQ test. If a concussion is suspected, the athlete will be required to re-take the test. Both the preseason

and post-injury test data is given to a local doctor or, to help evaluate the injury. The

information gathered can also be shared with your family doctor. The test data will enable these

health professionals to determine when return-to-play is appropriate and safe for the injured

athlete. If an injury of this nature occurs to your child, you will be promptly contacted with all

the details. I wish to stress that the ImPACT testing procedures are non-invasive, and they pose no risks to

your student- athlete. We are excited to implement this program given that it provides us the

best available information for managing concussions and preventing potential brain damage that

can occur with multiple concussions. The Central High School administration, coaching, and

athletic training staffs are striving to keep your child’s health and safety at the forefront of the

student athletic experience. Please return the attached page with the appropriate signatures. If

you have any further questions regarding this program please feel free to contact the Head of

Athletics or the Athletic Trainer.

w w w . i m p a c t t e s t . c o m

Consent Form

For use of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), I have read the attached

information. I understand its contents. I have been given an opportunity to ask questions and all questions have

been answered to my satisfaction. I agree to participate in the ImPACT Concussion Management Program.

Printed Name of Athlete

Sport

Signature of Athlete Date

Signature of Parent Date

w w w . i m p a c t t e s t . c o m

The Newark Public Schools 2 Cedar Street, Newark, NJ 07102

PARENTAL CONSENT FORM

This form is for media interviews with students for publications and programs. Parent’s permission must be

obtained prior to television, film, video or print publication interviews. This also applies to photographs and

footage of students taken for the various media.

I, the parent of

(Parent’s/guardian’s name) (Student’s name)

at NEWARK CENTRAL School, do grant my permission for my son/daughter

(Name of school)

to appear in an article/photograph/televised news program produced by

(Name of individual or company)

(Street address, city and state)

Date of Interview/Taping: Time:

I understand that this interview/taping is designed to showcase my son/daughter’s participation in an academic

setting and is not for a profit venture. Therefore, said organization, individual or company will not pay any fees

to me or my child.

(Date)

(Parent’s/guardian’s signature)

(Street address, city and state

Please return this form to the Athletic Director.

SPORT/TEAM___________________________

CHANGING HEARTS AND MINDS TO VALUE EDUCATION

State of New Jersey

DEPARTMENT OF EDUCATION

Sign-Off Sheet

Name of School District: Newark Public Schools

Name of Local School: Central High Schools

I/We acknowledge that we received and reviewed the following pamphlets (Check all received):

Sudden Cardiac Death in Young Athletes

Sports-Related Concussion and Head Injury Fact Sheet

Sports-Related Eye Injuries: An Educational Fact Sheet for Parents

Student Signature:

Parent or Guardian

Signature:

Date:

New Jersey Department of Education 2014: pursuant to the Scholastic Student-Athlete Safety Act, P.L. 2013, c71

E14-00395

1161 Route 130, P.O. Box 487, Robbinsville, NJ 08691 609-259-2776 609-259-3047-Fax

NJSIAA STEROID TESTING POLICY

CONSENT TO RANDOM TESTING

In Executive Order 72, issued December 20, 2005, Governor Richard Codey directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying for championship games.

Beginning in the Fall, 2006 sports season, any student-athlete who possesses, distributes,

ingests or otherwise uses any of the banned substances on the attached page, without written prescription by a fully-licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA’s sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition. The NJSIAA will test certain randomly selected individuals and teams that qualify for a state championship tournament or state championship competition for banned substances. The results of all tests shall be considered confidential and shall only be disclosed to the student, his or her parents and his or her school. No student may participate in NJSIAA competition unless the student and the student’s parent/guardian consent to random testing.

By signing below, we consent to random testing in accordance with the NJSIAA steroid

testing policy. We understand that, if the student or the student’s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances.

Signature of Student-Athlete Print Student-Athlete’s Name Date

Signature of Parent/Guardian Print Parent/Guardian’s Name Date

State of New Jersey Department of Education

HEALTH HISTORY UPDATE QUESTIONNAIRE

Name of School

To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose

physical examination was completed more than 90 days prior to the first day of official practice shall provide a

health history update questionnaire completed and signed by the student’s parent or guardian.

Student Age Grade

Date of Last Physical Examination Sport

Since the last pre-participation physical examination, has your son/daughter:

1. Been medically advised not to participate in a sport? Yes

No

If yes, describe in detail

2. Sustained a concussion, been unconscious or lost memory from a blow to the head? Yes No

If yes, explain in detail

3. Broken a bone or sprained/strained/dislocated any muscle or joints? Yes No

If yes, describe in detail

4. Fainted or “blacked out?” Yes No

If yes, was this during or immediately after exercise?

5. Experienced chest pains, shortness of breath or “racing heart?” Yes No

If yes, explain

6. Has there been a recent history of fatigue and unusual tiredness? Yes

7. Been hospitalized or had to go to the emergency room? Yes

No

No

If yes, explain in detail

8. Since the last physical examination, has there been a sudden death in the family or has any member of the family

under age 50 had a heart attack or “heart trouble?” Yes

9. Started or stopped taking any over-the-counter or prescribed medications? Yes

If yes, name of medication(s) _________________________________________________________

Date:__________________________ Signature of parent/guardian

No ___