SLAM! Apollo Beach SPORTS / LEADERSHIP / ARTS / MANAGEMENT

Home of the Sharks! 5150 N US HWY 41 • Apollo Beach, FL 33572 • Phone: 813-773-4560

SHARKS

ATHLETICS

Hello SLAM Apollo Families,

We are excited that your child wants to participate in Athletics here at SLAM Apollo. Student information

needs to be updated each academic year. Prior to participating in any sport, student athletes must provide the

following documents to the SLAM Apollo Athletic Department:

Purchase of SLAM School Insurance via the Shark Store

FHSAA Pre-Participation Physical (EL-2) Template Provided

Accident Waiver, Release of Liability, and Media Form

Hillsborough County Medical Release Form (must be notarized)

*Notary is available at SLAM Apollo. Please inquire with the front office for hours.

Athletics Student Participation Agreement

Completion of Required Video Links (Print certificate after done and turn in)

All documents and payments can be accessed from the Athletics page on the school website. If you have any

questions, please email our Athletic Coordinator, Coach Wise at pwise@slamapollo.com

EL2 Revised 05/18 Florida High School Athletic Association

Preparticipation Physical Evaluation (Page 1 of 3)

This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.

This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.

– 1 –

Part 1. Student Information (to be completed by student or parent)

Student’s Name: Sex: Age: Date of Birth: / /

School: Grade in School: Sport(s):

Home Address: Home Phone: ( )

Name of Parent/Guardian: E-mail:

Person to Contact in Case of Emergency:

Relationship to Student: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( )

Personal/Family Physician: City/State: Office Phone: ( )

Part 2. Medical History (to be completed by student or parent). Explain “yes” answers below. Circle questions you don’t know answers to.

1. Have you had a medical illness or injury since your last

check up or sports physical?

2. Do you have an ongoing chronic illness?

3. Have you ever been hospitalized overnight?

4. Have you ever had surgery?

5. Are you currently taking any prescription or non-

prescription (over-the-counter) medications or pills or

using an inhaler?

6. Have you ever taken any supplements or vitamins to

Yes No 26. Have you ever become ill from exercising in the heat?

27. Do you cough, wheeze or have trouble breathing during or after

activity?

28. Do you have asthma?

29. Do you have seasonal allergies that require medical treatment?

30. Do you use any special protective or corrective equipment or

medical devices that aren’t usually used for your sport or position

(for example, knee brace, special neck roll, foot orthotics, shunt,

retainer on your teeth or hearing aid)?

Yes No

help you gain or lose weight or improve your

performance?

7. Do you have any allergies (for example, pollen, latex,

medicine, food or stinging insects)?

8. Have you ever had a rash or hives develop during or

after exercise?

9. Have you ever passed out during or after exercise?

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

32. Do you wear glasses, contacts or protective eyewear?

33. Have you ever had a sprain, strain or swelling after injury?

34. Have you broken or fractured any bones or dislocated any joints?

35. Have you had any other problems with pain or swelling in muscles,

tendons, bones or joints?

If yes, check appropriate blank and explain below: 10. Have you ever been dizzy during or after exercise?

11. Have you ever had chest pain during or after exercise?

12. Do you get tired more quickly than your friends do

during exercise?

13. Have you ever had racing of your heart or skipped

heartbeats?

Head

Neck

Back

Chest

Shoulder

Upper Arm

Elbow

Forearm

Wrist

Hand

Finger

Foot

Hip Thigh

Knee

Shin/Calf

Ankle

14. Have you had high blood pressure or high cholesterol?

15. Have you ever been told you have a heart murmur?

16. Has any family member or relative died of heart

problems or sudden death before age 50?

17. Have you had a severe viral infection (for example,

myocarditis or mononucleosis) within the last month?

18. Has a physician ever denied or restricted your

participation in sports for any heart problems?

36. Do you want to weigh more or less than you do now?

37. Do you lose weight regularly to meet weight requirements for your

sport?

38. Do you feel stressed out?

39. Have you ever been diagnosed with sickle cell anemia?

40. Have you ever been diagnosed with having the sickle cell trait?

41. Record the dates of your most recent immunizations (shots) for:

19. Do you have any current skin problems (for example,

itching, rashes, acne, warts, fungus, blisters or pressure sores)?

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

21. Have you ever been knocked out, become unconscious

Tetanus:

Hepatitus B:

FEMALES ONLY (optional)

Measles:

Chickenpox:

or lost your memory?

22. Have you ever had a seizure?

23. Do you have frequent or severe headaches?

24. Have you ever had numbness or tingling in your arms,

hands, legs or feet?

25. Have you ever had a stinger, burner or pinched nerve?

42. When was your first menstrual period?

43. When was your most recent menstrual period?

44. How much time do you usually have from the start of one period to

the start of another?

45. How many periods have you had in the last year?

46. What was the longest time between periods in the last year?

Explain “Yes” answers here:

We hereby state, to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida

Statutes, and FHSAA Bylaw 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic

tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.

Signature of Student: Date: / / Signature of Parent/Guardian: Date: / /

EL2 Revised 05/18 Florida High School Athletic Association

Preparticipation Physical Evaluation (Page 2 of 3)

This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.

This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.

– 2 –

Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physi-

cian, licensed physician assistant or certified advanced registered nurse practitioner).

Student’s Name: Date of Birth: / /

Height: Weight: % Body Fat (optional): Pulse: Blood Pressure: / ( / , / )

Temperature: Hearing: right: P F left: P F

Visual Acuity: Right 20/ Left 20/ Corrected: Yes No Pupils: Equal Unequal

FINDINGS NORMAL ABNORMAL FINDINGS INITIALS*

MEDICAL

1. Appearance

2. Eyes/Ears/Nose/Throat

3. Lymph Nodes

4. Heart

5. Pulses

6. Lungs

7. Abdomen

8. Genitalia (males only)

9. Skin

10. Neurological

11. Psychiatric

MUSCULOSKELETAL

12. Neck

13. Back

14. Shoulder/Arm

15. Elbow/Forearm

16. Wrist/Hand

17. Hip/Thigh

18. Knee

19. Leg/Ankle

20. Foot

* – station-based examination only

ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER

I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):

Cleared without limitation

Disability: Diagnosis:

Precautions:

Not cleared for: Reason:

Cleared after completing evaluation/rehabilitation for:

Referred to

For:

Recommendations:

Name of Physician/Physician Assistant/Nurse Practitioner (print):

Address:

Date: / /_

Signature of Physician/Physician Assistant/Nurse Practitioner:

EL2 Revised 05/18 Florida High School Athletic Association

Preparticipation Physical Evaluation (Page 3 of 3)

This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.

This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.

– 3 –

Student’s Name:

ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable)

I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s):

Cleared without limitation

Disability: Diagnosis:

Precautions:

Not cleared for:

Cleared after completing evaluation/rehabilitation for:

Recommendations:

Name of Physician (print):

Address:

Reason:

Date:

/ /_

Signature of Physician:

Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopae-

dic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.

Student’s Name (print)_____________________________________

Accident Waiver, Release of Liability, and Media Form

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTITIVIES ASSOCIATED

WITH SLAM ACADEMY OF APOLLO BEACH SHARKS ATHLETIC PROGRAM, including by way of

example and not limitation, any risks that may arise from negligence or carelessness on the part of the

persons or entities being released, from dangerous or defective equipment or property owned, maintained,

or controlled by them, or because of their possible liability without fault. I certify that I am physically fit, have

sufficiently prepared or trained for participation in the activity, and have not been advised to not participate

by a qualified medical professional, I certify that there are no health-related reasons or problems which

preclude my participation in this activity. I acknowledge that this Accident Wavier and Release of Liability

Form will be used by Slam Academy of Apollo Beach, event holders, sponsors, and organizers of activities

in which I may participate, and that it will govern my actions and responsibilities at said activities. In

consideration of my application and permitting me to participate in Slam Academy at Apollo beach, I hereby

take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, REALEASE, AND DISCHARGE from any and all liability, including but not limited to, liability

arising from the negligence or fault of the entities or persons released, for my death, disability, personal

injury, property damage, property left, or actions of any kind which may hereafter occur to me including my

traveling to and from this activity. THE FOLLOWING ENTITIIES OR PERSONS: SLAM! Academy at Apollo

Beach and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity

holders, sponsors, and volunteers; (B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the

entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of

participation in the activity, whether caused by negligence of release or otherwise. I acknowledge that

SLAM! Academy at Apollo Beach and their directors, officers, volunteers, representatives, and agents are

NOT responsible for the errors, omissions, acts, or failures to act of any party of entity conducting a specific

activity on their behalf. I acknowledge that this activity may involve a test of a person’s physical and mental

limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are

not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment,

vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants,

volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants, but

are also present for volunteers. I hereby consent to receive medical treatment which may be deemed

advisable in the event of injury, accident, and/or illness during this activity. I understand while participating

in this activity, I may be photographed. I agree to allow my student(s) and/or myself to be in a photo, video,

or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors,

Home of the Sharks!

5150 N US HWY 41 • Apollo Beach, FL 33572 • Phone: 813-773-4560

organizers, and assigns. The Accident Waiver and Release of Liability Form shall be construed broadly to

provide and release and Waiver to the maximum extent permissible under applicable law. Participation in

athletic activities and the use of athletic equipment and/or facilities involves a risk of accidental injury despite

all safety precautions. We (I) assume all risk and hazards incidental to these activities, and release SLAM,

its officers, directors, independent contractors, volunteers and all employees, for any illness or injury to my

child occurring during participation in any activity or use of any facility conducted by SLAM! Academy of

Apollo Beach and/or the Sharks Athletic Program. I CERTIFY THAT I HAVE READ THIS DOCUMENT

AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY

AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

______________________________ _____________________ __________________

Student’s Signature

DOB Grade

__________________________________ _________________ _______ ______

Street Address

City State Zip code

______________________________________ _____________________________

Parent/Guardian Name

Contact Number

___________________________________________ _______________________

Parent Signature

_________________________________________

Email

Date

___________________________________________ ____________________________

Additional Emergency Contact Number Contact Number

Home of the Sharks!

5150 N US HWY 41 • Apollo Beach, FL 33572 • Phone: 813-773-4560

PART II (ONLY COMPLETE PART I OR PART II)

As parent or guardian of the athlete listed above, I do not desire to sign the medical and surgical release form above.

Signature of parent or guardian: Date: (Do not sign both parts. This form does not need to be notarized if Part II is signed.)

School District of Hillsborough County

MEDICAL RELEASE FORM

STATE OF FLORIDA, COUNTY OF HILLSBOROUGH SUBSCRIBED AND SWORN TO BEFORE ME A NOTARY PUBLIC, THIS DAY OF 20 .

My Commission expires:

Notary Public:

Name of Student:

Name of Parent:

Parent home phone: Parent business phone: Parent cell phone:

PART I (ONLY COMPLETE PART I OR PART II ) The undersigned as the parents and/or legal guardians of do hereby consent to any

and all medical and surgical treatments, including anesthesia and operations that may be deemed advisable by any qualified physician selected by agents or officials of the Hillsborough County School Board. The intention hereof is to grant authority to administer and to perform all and singularly any examination, treatments, anesthetics, operations, and diagnostic procedures that may now or during the course of the patient's care, be deemed advisable or necessary by any qualified physician. No action will be taken until an attempt is made to contact me at the phone number(s) listed above.

IN WITNESS of our consent and agreement to the matters stated above, we have subscribed our signature below.

Signature of parent or guardian: Date:

Please list any medical conditions or allergies:

SLAM Academy of Apollo Beach www.slamapollo.com

Meredith Williamson Principal

SLAM Academy of Apollo Beach www.slamapollo.com

Meredith Williamson Principal

SLAM Academy at Apollo Beach

5150 N. US Hwy. 41 Apollo Beach, FL 33572

www.slampollo.com (p): 813-773-4560

2020-2021 SLAM Athletics Program Agreement We (I) give permission for my child _______________________________________ Grade _________ to participate in the SLAM interscholastic ___________________________ team. We (I) assume all responsibility for any medical cost that may result from injury. My medical insurance carrier is _____________________________________. My policy number is: _________________________________________. PLEASE BRING INSURANCE CARD FOR OFFICE TO MAKE A COPY Physician Information – Name: _________________________________________________________ Phone: ____________________________ Address: ________________________________________________ Daytime parental contact number is: _______________________________ Emergency contact: __________________________________ Relationship to student: ___________________ Phone: ________________________________ IN ADDITION, we require that all Athletes purchase school insurance as a supplement at $20 for the entire school year. Parent (Guardian) Signature X ____________________________________________ Date: ________________ Printed Name: _______________________________________ SLAM ATHLETICS: PERMISSION FOR TRANSPORTATION We (I) hereby give permission for my child: ____________________________________ Grade ____ to travel by the schools designated transportation as part of the after school Interscholastic Athletic Program. We (I) understand that it is my responsibility to pick up my child (children) at the SLAM campus upon the athlete’s return from competitions. Return times will be posted and pick up must be within fifteen minutes of return time. Any late pick up will result in a charge of five dollars per fifteen minutes and each fifteen minutes thereafter. If picking the athlete(s) up at the competition venue, the Head Coach and/or Athletic Director must be informed in advance. When taking the athlete from a competition venue, the parent must sign the athlete out on the coach (es) transportation list. Parent (Guardian) Signature X ____________________________________________ Date: ________________ Printed Name: _______________________________ Student Name: _____________________________ Grade_______

SLAM Academy of Apollo Beach www.slamapollo.com

Meredith Williamson Principal

SLAM Academy at Apollo Beach

5150 N. US Hwy. 41 Apollo Beach, FL 33572

www.slampollo.com (p): 813-773-4560

2020-2021 SLAM ATHLETICS CONTRACT Student Athlete’s Name (Printed): _____________________________________________ Grade: __________ Signing this letter states that I, the parent/guardian of the above-named student, and my child has, read and understands the SLAM Athletics Handbook and do agree to be held to all the policies, rules and consequences as stated. I also understand the T.E.A.M. philosophy that everyone participates in practice. I understand that by participating in the athletic extra-curricular program, I grant the right to allow SLAM to drug-test my child participating in extra-curricular activities. I also understand the fact that there might be a need for tryout and cuts. It is the family’s responsibility to update SLAM of any change to the insurance information. I have read and understand the SLAM Athletic Contract, physical examination, hold harmless form, transportation form, activity and uniform fee (all uniforms are rented and must be returned), and know that all forms must be filled out in their entirety and turned in to the Head Coach before my child may participate with the team. The last day to turn this information in is the day before the first day of practice for each sport. MANDATORY ATHLETIC FEE Each student athlete is required to pay a non-refundable, mandatory Athletic Fee, per sport played, before the first game of each season. Failure to complete this requirement will render the athlete ineligible to play. The amount due is listed below and is used to cover the basic expenses of the school’s athletic program such as referees/officials’ fees, transportation, field rentals, required on-site security and emergency medical personnel, training staff equipment, etc. In order to participate, athletes must meet all team fundraising goals set forth by the head coach and approved by the administration. Without this fee and fundraisers, we would not be able to offer an athletics program. MANDATORY INSURANCE FEE Each student athlete is required to purchase school insurance as a supplement to any personal insurance at $20 for the entire school year. Insurance fee must be paid online via the Athletics Page. Insurance fee must be paid prior to try-outs. Fees for Middle School: - $100 - Middle School - $50 - Elementary School - Make a full payment before the first game of the season or the student will not be cleared to play. “Sibling Discounts” will not be made.

The mandatory athletic fee requirement must be fulfilled before the first game of the team’s season or the student will not be cleared to play. Other team or school fundraising activities and/or donations to the team or school will NOT count towards the Athletic Fee requirement, only the options above will satisfy the Athletic Fee. Athletic fee is non-refundable if a student is dismissed/suspended from a team by the school administration die to disciplinary and/or academic issues. It is also non-refundable if the student quits the team

SLAM Academy of Apollo Beach www.slamapollo.com

Meredith Williamson Principal

SLAM Academy at Apollo Beach

5150 N. US Hwy. 41 Apollo Beach, FL 33572

www.slampollo.com (p): 813-773-4560

on his/her own merit. Refunds for students deemed medically unfit to participate, after having been initially cleared, will only be considered after a letter from a medical professional, stating that the student is not able to participate, has been presented and verified. The amount of the refund will vary depending on the amount of time the student was listed on the team’s roster as part of the team and will be determined by the Athletic Director and Administration. No Refunds past half way through the season. Future participation in the school’s athletic program by a student previously deemed medically unfit to participate will only be considered after the student presents a new letter confirming they are fit to participate, in the particular sport, from a medical professional. Refunds will not be issued due to a perceived lack of playing time. All pending financial obligations must be satisfied before an athlete can participate in any competitions. In case of emergency, I/we do authorize the SLAM athletic staff and its volunteers to seek emergency medical care should the need arise. I/we hereby release and save harmless the school, its agents and its volunteerism from any and all liability that may occur during this athletic season. X ___________________________________________ Student Signature Student Printed Name X ___________________________________________ Parent or Guardian Signature Parent or Guardian Printed Name Date: _________________