Carson Valley Middle School. Physical Packet. Dear Parent or Guardian:

Transcription

1 Carson Valley Middle School Physical Packet Dear Parent or Guardian: The goal of this physical and health history is to determine if it is safe for your student to participate in sports and related activities. Please complete the following paperwork to the best of your ability, and have a doctor or practitioner complete the physical worksheet. Our goal is to be sure that all students are healthy enough to participate. Please make an appointment with your health provider to complete the physical. Please have a talk with your student about their academics, citizenship, and behavior. Students who have two (2) or more D s, or one (1) or more F s will be disqualified from playing until their grades improve. Students with two (2) or more needs improvement, or one (1) or more unacceptable marks in their class citizenship will also be disqualified until the marks are improved. Grades and citizenship checks will be done on Tuesday, and students and the coach will be notified of disqualifications. This packet and physical are good from 6 th grade until the end of 8 th grade. Packets brought to the office with physicals older than 6 months will need to have the physical retaken. Students will need to have another physical to participate in sports at the high school. Thank you for your interest in Carson Valley Middle School Sports and Activities!! GO TIGERS!! Thank you, Carson Valley Middle School **Please keep this letter for your records

2 CARSON VALLEY MIDDLE SCOOL EXTRACURICULAR AND CO-CURRICULAR ACTIVIY CONTRACT AND PHYSICAL PACKET Student Name: Date: As a participant in extracurricular and/or curricular activities, you represent the students of Carson Valley Middle School and Douglas County School District. It is expected that all participants conduct themselves in a sportsmanlike manner and abide by the rules and regulations set forth by the coach, and school officials. The items in this contract are necessary to ensure the greatest potential for success and a rewarding experience for you and your teammates. By signing this contract, you and your parents/guardians are making a commitment that you will contribute 100% to your academics, citizenship, and the program for which you are a member. Please read the following carefully. ELIGIBILITY Participants in extracurricular and co-curricular activities must be full-time CVMS students. Home-schooled students may participate in sports or extra/co-curricular programs if space allows. MEDICAL INSURANCE NPAIP will be providing to all Member School Districts an Excess Student Accident insurance policy through Gerber Life Insurance Company. The Student Accident insurance provides coverage during the hours and days when school is in session, while participating in school sponsored and supervised activities. PHYSICAL All participants must have the enclosed physical packet completed by a qualified medical doctor, practitioner, or RN. The physical may not be older than six (6) months when delivered to the office. ACADEMIC ELIGIBILITY Academic eligibility for participation in extracurricular or co-curricular activities includes current academic and conduct grades. Students will be ineligible to participate if their grades

3 reflect one (1) F, two (2) D s, or if the student s citizenship grades reflect two (2) needs improvement (N), or one (1) unacceptable (U). Grades will be checked weekly, and may bar the student from games, meets, and practice. Students can return to regular status when grades/citizenship marks improve. UNIFORMS Participants are responsible for all uniforms and equipment issued to them and agree to return them to the school promptly at the end of the season or pay for missing/damaged items. BEHAVIOR Anywhere the student is representing their team and CVMS, they are expected to behave according to the school rules and standards. Anyone who violates this standard may be suspended from participation after being given due process as set forth in the Administrative Regulation to Board Policy No Coaches and advisors will have specific training regulations for their teams. Students are expected to follow their coach and advisors rules per Board Policy No DRUGS/ALCOHOL/TOBACCO The use or possession of alcohol or controlled substance is prohibited. Any violation on or off campus will result in loss of eligibility for a period of one (1) calendar year. If the student and parent agree to have a drug/alcohol assessment, the ineligibility period may be reduced to include the remainder of the activity season or six (6) months if the violation occurred during the non-season. If the violation occurs on school property, additional disciplinary action will be taken. Students are encouraged to come forward if they have knowledge of such abuses, and will not be subject to disciplinary action. Any other violations of DCSD policy, law, or school rules will also be grounds for disciplinary action and ineligibility, after given due process as set forth in the Administrative Regulation to Board Policy No Students may not participate in extracurricular or co-curricular activities while they are suspended from school. I AGREE THAT I HAVE READ AND WILL ADHERE TO THE ABOVE INFORMATION PARENT: DATE: STUDENT: DATE:

4 Student Accident Insurance Coverage School Year NPAIP will be providing to all Member School Districts an Excess Student Accident insurance policy through Gerber Life Insurance Company. The Student Accident insurance provides coverage during the hours and days when school is in session, while participating in school sponsored and supervised activities. Coverage includes participation in Interscholastic Sports; including Football, Religious Education Classes, One Day Field Trips and Overnight Field Trips* (no more than 7 consecutive nights). This includes travel directly (uninterruptedly) to and from a regularly scheduled activity with other members as a group. The travel must be supervised by a person authorized by the school. This policy should replace any policy that is currently being purchased or offered to schools and students. Schedule of Benefits: Maximum Benefit $10,000 Deductible $250 Coinsurance None Inpatient Room & Board: Intensive Care: Hospital Miscellaneous: Surgery: Assistant Surgeon: Anesthetist: Registered Nurse: Physician's Visits: Pre admission Testing: based on data provided by Ingenix, at the 80th percentile. Outpatient Surgery: based on data provided by Ingenix at the 80th percentile. Day Surgery Miscellaneous: (Usual and Customary Charges for Day Surgery Miscellaneous are based on the Outpatient Surgical Facility Charge Index.) Assistant Surgeon: Anesthetist: Outpatient Misc. Benefit: Physician's Visits: Physiotherapy:

5 Medical Emergency: Diagnostic X Rays: Laboratory: Tests & Procedures: Prescription Drugs: Other Ambulance: Durable Medical Equipment: Dental (Benefits paid on Injury to Sound, Natural Teeth only.) 100% Usual and Customary Charges. Replacement of eyeglasses, hearing aids or contact lenses damaged during a covered Injury, if medical treatment is also received for the covered Injury: 100%Usual and Customary Charges This is a highlight of benefits and all claims payments are subject to the term of the policy. HOWBENEFITS ARE PAID (Excess Coverage) Excess Coverage: If an Injury to the Insured Person results in incurring Covered Medical Expenses for any of the services specified in the Schedule of Benefits, the Company will pay the Covered Medical Expenses incurred subject to the Deductible Amount and Coinsurance Percentage (if any), that are in excess of Covered Medical Expenses payable by any other valid and collectible insurance. Covered Medical Expenses excludes amounts not covered by the primary carrier due to penalties imposed on the Insured for failing to comply with policy provisions or requirements. NOTICE OF CLAIM Written notice of claim must be given to the Company within 90 days after the occurrence or commencement of any loss covered by this policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Named Insured to the Company, with information sufficient to identify the Named Insured shall be deemed notice to the Company. Written proof of loss must be furnished to the Company at its said office within 90 days after the date of such loss. Treatment must begin 180 days after the date of Injury and is received within 12 months after date of injury. In the event of an Accident, students should: 1. Secure treatment at the nearest medical facility of their choice. 2. Obtain a receipt (if payment of any bills were made) and itemized copy of charges from the provider of medical services and send copies of their itemized bills, primary insurance Explanation of Benefits and the fully completed and signed accident claim form to the claims office mail all correspondence to: WEB TPA, P.O. Box 2415, Grapevine, TX Call with any Claims questions.

6 NIAA PRE-PARTICIPATION HISTORY FORM STUDENT NAME: GRADE: GENDER: AGE: DOB: SCHOOL: ADDRESS: PHONE: PHYSICIAN: PHONE: EMERGENCY CONTACT: PHONE: 1. Do you have a chronic medical condition (asthma, diabetes, etc.)? Yes No 2. Have you ever been hospitalized overnight? Yes No 3. Are you taking any medications? Yes No 4. Do you have any allergies? Yes No 5. Have you ever passed out or become dizzy with exercise? Yes No 6. Have you ever had chest pains while exercising? Yes No 7. Have you ever had a relative that died from cardiovascular disease younger than 50 years of age? Yes No 8. Do you have a diagnosed heart condition? Yes No 9. Has a physician ever denied or restricted your participation in sports? Yes No 10. Do you have any current skin diseases or issues? Yes No 11. Have you ever had a head injury? Yes No 12. Have you ever been knocked unconscious or had memory loss? Yes No 13. Have you ever had a seizure? Yes No 14. Do you have frequent or severe headaches? Yes No 15. Have you had numbness of tingling in your extremities? Yes No 16. Have you ever become ill while exercising in the heat? Yes No 17. Do you cough, wheeze, or have trouble breathing during activity? Yes No 18. Do you use protective or corrective equipment while exercising? Yes No 19. Are you missing an eye, kidney, testicle or ovary? Yes No 20. Do you have a vision problem or wear corrective lenses? Yes No 21. Have you ever had a back or neck injury? Yes No 22. Are your immunizations up to date? Yes No If you answered YES to any questions above, please provide an explanation. Parent Signature: Date: Student Signature: Date:

7 NIAA PRE-PARTICIPATION PHYSICAL EVALUATION PHYSICAL EXAMINATION Date of Examination: Name: Date of Birth: Height: Weight: %Body Fat (optional): Pluse: BP: / ( /, / ) Vision:R20/ L20/ Corrected: Y / N Pupils: Equal Unequal MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Lungs Abdomen Genitalia (Males Only) Skin CARDIOVASCULAR NORMAL/A BSENT ABNORMAL FINDINGS EXPLAIN INITIALS Murmur that Increases From Supine to Standing Systolic Murmur Greater Than II/VI Any Diastolic Murmur Radial & Femoral Pulses MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot Stigmata of Marfan s Syndrome CLEARANCE CLEARED: Cleared after completing evaluation/rehabilitation for: NOT CLEARED FOR: REASON: Recommendations: Name of Physician (Print/Type): Phone: Address: Street City State Zip Code I, herby certify that I am a licensed, qualified to perform NIAA Pre-Participation Evaluations, and that on the date set forth below I performed all aspects of the NIAA Pre-Participation Evaluation on the above student. This student meets all physical examination requirements for participation in INIAA sanctioned sports. Signature of Health Practitioner License Number Office Phone Number Date Revised

8 Carson Valley Middle School Athletic Emergency Information Form Student s Name: Grade: Age: Address: City: State: Zip: Parent Name: Phone: Parent Name: Phone: Emergency Contact: Phone: Emergency Contact: Phone: Parent Signature: Date: