17. Have you ever had an injury, like a sprain, muscle or

ligament tear or tendonitis that caused you to miss a practice or game? (if Yes, circle below) 18. Have you had any broken or fractured bones or dislocated joints? (if Yes, circle below) 19. Have you ever had a bone or joint injury that required x-rays, MRI, CT, surgery, injections rehabilitation, physical therapy, a brace, a cast or crutches? Head Neck Shoulder Upper arm Elbow Calf Hand Chest Upper back Lower back Forearm Thigh Knee Ankle Foot Toes

ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM

Medical History - Parent/Guardian please fill out prior to examination

HISTORY

Name:_________________________________________________________________________ Age: ____________ Grade: _______ DOB:______

(Please Print) Last First Middle

Place of Birth: ______________________________________________ Last School Attended: _________________________________________ City State School City State

Mailing Address: _______________________________________________________________________________ Home Phone: ______________ Street City State Zip

Name of Parent/Guardian: _____________________________________________________ Work/Cell Phone: _____________________________

Explain “YES” answers below

1. Has a doctor ever denied or restricted your

participation in sports for any reason? 2. Do you have an ongoing medical condition (like asthma or diabetes)? 3. Are you currently taking any prescription or

nonprescription medications or pills? 4. Do you have allergies to medicines, pollens, foods, or stinging insects? 5. Have you ever become dizzy or passed out

during or after exercise? 6. Have you ever had chest discomfort, pain or

pressure during or after exercise? 7. Do you get more tired than your friends during

exercise? 8. Has doctor ever told you that you have:

(check all that apply) High Blood Pressure Heart Murmur

Heart Infection High Cholesterol

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

10. Has anyone in your family ever died for no apparent reason?

11. Does anyone in your family have a heart condition starting under the age of 50? 12. Has a family member or relative died of heart

problems or sudden death before the age of 50? 13. Have any relatives ever had one of the following

conditions? Hypertrophic, cardiomyopathy, Marfan’s syndrome, Long QT syndrome or a significant hear arrhythmia.

14. Have you ever had racing of your heart or skipped heart beats?

15. Have you ever spent the night in a hospital? 16. Have you ever had surgery?

20. Have you ever had a stress fracture?

YES NO

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

22. Do you regularly use a brace or assistive device? 23. Has a doctor ever told you that you have asthma

or allergies? 24. Do you cough, wheeze, or have difficulty

breathing during or after exercise? 25. Is there anyone in your family with asthma? 26. Have you ever used an inhaler or taken asthma

medicine? 27. Were you born without or are you missing a

kidney, an eye or testicle, or any other organ? 28. Have you had a sever viral infection such as

infectious mononucleosis (mono) or myocarditis in the last month?

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

30. Have you had a herpes infection? 31. Have you had a head injury or concussion? 32. Have you been hit in the head and been

confused or lost your memory? 33. Have you ever had seizure? 34. Do you have headaches with exercise? 35. Have you ever had numbness or tingling or

weakness in your arms or legs? 36. Have you ever been unable to move your arms

or legs after being hit or fallen? 37. When exercising in the heat, do you have severe

muscle cramps or become ill? 38. Has a doctor told you that you or someone in

your family has sickle cell trait or sickle cell disease?

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

40. Do you wear glasses or contacts? 41. Do you wear protective eyewear such as goggles

or a face shield? 42. Are you unhappy with your weight? 43. Are you trying to gain or lose weight? 44. Has anyone recommended you to change your

weight or eating habits? 45. Do you limit or carefully control what you eat? 46. Do you have concerns that you would like to

discuss with the doctor/health care provider? FEMALES ONLY: 47. Have you ever had a menstrual period? 48. How old were you when you had your first

menstrual period? 49. How many periods have you had in the last 12

months? Explain “Yes” answers here:

YES NO

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS VALID AND CORRECT:

Student-Athlete Signature Parent or Court Appointed Legal Guardian Signature Date

I VERIFTY THAT I HAVE REVIEWED THE ABOVE INFORMATION

Physician Signature Date

ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM

Student MAY participate in the following types of sports (CHECK ALL THAT APPLY):

ALL FORMS OF SPORTS CONTACT/COLLISION NON-CONTACT/STRENUOUS LIMITED CONTACT NON-CONTACT/NON-STRENUOUS STUDENT CLEARED FOR PARTICIPATION PENDING (explanation)

STUDENT NOT CLEARED FOR PARTICIPATION (explanation)

PHYSICAL EXAMINATION

MEDICAL NORMAL ABNORMAL FINDINGS/COMMENTS

Appearance

(any physical finding of Marfan’s syndrome)

Eyes/Ears/Nose/Throat (if indicated)

Hearing (if indicated)

Murmurs

Pulses

Lungs: Auscultation

Abdomen:

Genitourinary (only if indicated)

Skin

MUSCULOSKELETAL

Neck

Back

Shoulder/Arm

Elbow/Forearm

Wrist/Hand/Fingers

Hip/Thigh

Knee

Leg/Ankle

Foot/Toes

Name of Physician/Provider (print/type)________________________________________________ Date___________

Signature of Physician/Provider______________________________________________________________________

Student’s Primary Physician/Provider (for follow up, if necessary):_________________________________________

NOTES:_________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Athlete’s Name________________________________________________ Gender______________ DOB___________

Height: _____ Weight: _____ Pulse: _____ Blood Pressure: _____/_____, (_____/_____, _____/_____)

Vision: R20/_______ L20/_______ Corrected: Y_____ N_____ Pupils: Equal_______ Unequal_______

HEART (auscultation should be done supine and standing-abnormal findings require referral for further evaluation)

ALL PARTS OF THE FOLLOWING FORM MUST BE

COMPLETELY FILLED OUT BEFORE

YOUR SON/DAUGHTER MAY PARTICIPATE

The New Mexico Activities Association (NMAA) and the Alamogordo Public School’s

regulations require that all students must have accident/medical insurance which covers all

activities that the student is participating in and have on file the parent’s statement regarding

insurance before he/she is eligible to participate in athletics.

Alamogordo Public Schools will make accident/medical insurance available through an

insurance company. The insurance company, coverage types and cost of premiums will be

made available during the summer.

1. I do not wish school insurance for my son/daughter because he/she is covered at home by

the following policy:

Insurance Company ___________________________________________________________

Policy Number ______________________________ Group Number ____________________

2. I will not hold the Alamogordo Public Schools responsible or liable for the cost of any

medical or ambulance services. Date _________________ Signature___________________________________________ Parent/Guardian

3. I hereby give my consent for my son/daughter to participate in interscholastic athletics at

Alamogordo Public Schools and authorize the Alamogordo Public Schools to provide the information on this form to the New Mexico Activities Association.

Date _________________ Signature___________________________________________ Parent/Guardian

4. I hereby give my consent for my son/daughter to receive services provided under the direction of the Certified and Licensed Athletic Trainer and Team Physician. The services can include preventative taping and bracing, evaluation, first aid, and rehabilitation of injuries incurred while participating in athletics.

Date _________________ Signature___________________________________________ Parent/Guardian

5. I hereby agree to inform the Certified and Licensed Athletic Trainer of any pre-existing conditions, new conditions, and medication that my son/daughter is being treated for under the care of a physician. I understand that this information will be kept in my son/daughter’s confidential medical file and be viewed only by the school’s medical staff and administration.

Date _________________ Signature___________________________________________ Parent/Guardian

ALAMOGORDO PUBLIC SCHOOL DISTRICT

VOLUNTARY ACTIVITIES PARTICIPATION AND

ACKNOWLEDGEMENT AND ASSUMPTION OF POTENTIAL RISK FORM

_____________________________ wishes to participate in the Alamogordo Public School District (Print Students Name)

activities of _____________________________________________________________________

I understand and acknowledge that these activities by their very nature, pose the potential risk of serious injury/illness to individuals who participate in such activities. Some of these activities may include, but are not limited to:

BASEBALL BASKETBALL CHEERLEADING CROSS COUNTRY RUNNING

FOOTBALL GOLF SOCCER SOFTBALL

SWIMMING TENNIS TRACK/FIELD VOLLEYBALL

I understand and acknowledge that some of the injuries/illnesses which may result from participating in these activities include, but are not limited to, the following:

I understand and acknowledge that participation in these activities is completely voluntary and as such is not required by the Alamogordo Public School District.

I understand and acknowledge that in order to participate in these activities. I agree to assume liability and responsibility for any and all potential risks which may be associated with participation in such activities.

I understand that due to the unique hazards posed by some activities, claim exposure could be mitigated by showing that the participant was aware of the risks yet put himself/herself “in harms way” and by participating in spite of the risks, should therefore be considered comparatively negligent.

I understand, acknowledge , and agree that the Alamogordo Public School District, its employees, officers, agents, or volunteers, shall not be liable for any injury/illness suffered by me which is incident to and/or associated with preparing for and/or participating in this activity.

I acknowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATION AND ASSUPMTION OF POTENTIAL RISK FORM and I understand and agree to its terms.

_________________________________________________________________________________ Student Signature Date

_________________________________________________________________________________ Parent/Guardian Signature Date

A signed VOLUNTARY ACTIVITIES PARTICIPATION/ASSUMPTION OF RISK FORM must be on

file with the Alamogordo Public School District before a student will be allowed to participate in extra

curricular/co-curricular activities.

1. Sprains/Strains

2. Fractured bones

3. Unconsciousness

4. Head and/or Back injuries

5. Paralysis

6. Loss of eyesight

7. Communicable Diseases

8. Death

Printed name of Student-Athlete

Printed name of Parent/Guardian

ALAMOGORDO PUBLIC SCHOOL ATHLETIC DEPARTMENT

CONCUSSION MANAGEMENT ACKNOWLEDGEMENT

A concussion is a disturbance in brain function that can be caused by a blow to the head or body, causing the head and neck to “whiplash”, and may occur in any sport or activity. Effects of a con-cussion may include a variety of symptoms (i.e., headache, nausea, dizziness, memory loss, balance problems) with or without a loss of consciousness. I/we understand APS Athletic de-partment has a concussion management protocol established that includes care and return to play criteria. I also understand, and my signature confirms, that I/my child will be required to adhere to that policy. Student-Athlete Signature Date

Parent/Guardian Signature Date

By signing below, I acknowledge that I have received and reviewed the attached NMAA’s Return to Play Guidelines Under New Mexico Senate Bill 38 (2017). I also acknowledge and I understand the risks of brain injuries associated with participation in school athletic activity, and I am aware of the State of New Mexico’s Senate Bill 38; Concussion Law. Student-Athlete Signature Date Parent/Guardian Signature Date

Name___________________________________________________________

(print)

READ THOROUGHLY AND COMPLETELY

Whereas, I am about to participate upon my own initiative in interscholastic football with the

Alamogordo Public School District. I understand that there are risks associated with the said sport. I

have read the following warning and fully understand its meaning. These, or similar warnings, are

attached to all helmets at APSD.

WARNING

Do not strike an opponent with any part of this helmet or face mask. This is a violation of football rules and may cause you to suffer severe brain or neck injury, including paralysis or death. Severe brain or neck injury may also occur accidentally while playing football.

No helmet can prevent all such injuries.

You use this helmet at your own risk.

On some of our helmets, the warning reads:

Do not use this helmet to butt, ram or spear an opposing player. This is in violation of the football rules and can result in serious head, brain, or neck injury, paralysis or death to you and possibly injury to your opponent. There is a risk these injuries may also occur as a result of accidental contact without intent to butt, ram or spear. No helmet can prevent all such injuries. I also understand that the observance of the above or similar warnings may still not prevent the occurrence of a severely debilitating injury. Physical impairment may occur by means other than those described above and not contemplated within this warning. The risk of physical impairment such as paraplegia, quadriplegia, brain injury, etc. is assumed whenever one is involved in the sport of football. We do hereby declare that we have read the above statement and fully understand its meaning.

Signature (Athlete)______________________________________ Date___________________

Signature (Parent/Guardian)_______________________________ Date___________________

FOOTBALL ATHLETES ONLY!!

ALAMOGORDO PUBLIC SCHOOLS

ATHLETIC TRAINING/SPORTS MEDICINE

Alamogordo Public Schools Concussion Management

Return to Play Protocol

Returning to play following a concussion involves a stepwise progression once the individual is

symptom free.

There are many risks to premature return to play including:

A greater risk for a second concussion due to a lower concussion threshold

Second impact syndrome (abnormal brain blood flow that can result in death)

Exacerbation of any current symptoms

Increasing the risk of injury due to alteration in balance

No student-athlete should return to play while symptomatic

Students are prohibited to returning to play the day the concussion is sustained

“If there is any doubt—Sit them Out”

Once a student-athlete is symptom free at rest for 24 hours and has signed a release by the treating

clinician, she/he may begin the return to play progression below:

Stage 1: Light Cognitive Activity (patterns, simple addition, memory drills)

Stage 2: Light Aerobic Activity (walking or stationary bike, no resistance training)

Stage 3: Sport-specific Activity (running—resistance training may begin)

Stage 4: Non-contact Training Drills (Skill Drills)

Stage 5: Full Contact Practice

Stage 6: Return to Play

Each step should take 24 hours so that an athlete would take approximately 10 days (in accordance

with NM SB 38) to proceed through the full rehabilitation protocol once they are asymptomatic at rest

and with provocative exercise. If any post-concussion symptoms occur while in the stepwise

program, then the student should drop back to the previous asymptomatic level and try to progress

again after a further 24-hour period of rest has passed.