ANNUNCIATION CATHOLIC SCHOOL ATHLETIC PROGRAM 2017 - 2018

Dear Parents/Guardians,

If your child is in Grades 5 through 8 and interested in playing sports, this is for you!

All student athletes trying out for any sports team must have the attached forms filled out and returned to the school office prior to the sports season which starts in September. **This is mandatory and required by the Archdiocese. There will be no exceptions. **Simply, these forms must be on file or your child will not be able to try out for a team. **Note: The HRS Form 3040(yellow) is not accepted as clearance for sports. When you go for your physical, take the attached Athletic Pre-participation Physical Evaluation form with you. The doctor must fill it out, sign it and date it. ** All sports physicals must be dated after July 1st for the new school year. Attached you will find: Athletic Pre-participation Physical Evaluation form. Page 1 is to be completed and signed by parent or guardian. Page 2 is to be filled out and signed by the physician. Archdiocese of Miami Athletic Consent and Release from Liability Certificate - to be filled out and signed by parents or guardians. We are required by the ABCC (All Broward Catholic Conference) to have these forms on file for all student athletes who try out for any sports team. Thank you for your cooperation.

Basketball & Cheerleading seasons will begin September 18th thru October 20, 2017. There is a change this year. Basketball game will no longer be played at the Chaminade Gym. We will be playing after school either 3:30pm or 4:30pm. The location will be determined by the ABCC and will be included with the schedule. CLINIC—September 9th. CHEER EXHIBITION - October 14th, 2017.

Coed Soccer: November 6th thru December 15th, 2017. All games are played after school. Game time 3:30 PM. We travel to our Home field and our opponents Home field.

Girls Basketball: November 6th thru December 15th, 2017. All games are played after school. Game times are 3:30 or 4:30 PM. We travel for all games.

Boys Volleyball: January 22nd thru February 23rd, 2018. All games are played after school. Game time is 3:30 PM. We travel to our opponents court or field.

Girls Volleyball: March 12th thru April 27, 2018. All games are played after school. Game time is 3:30 PM. We travel to our opponents court.

COACHES ARE NEEDED! If you could share your time and talents to help coach, please contact Mrs. Thomas - 954-989-8287 or thomas@annun.org. REMINDER: The Archdiocese requires all coaches and volunteers to have fingerprints on file and to have attended the 3 hour Virtus Program and to keep current on the monthly Virtus training bulletins online. For more information please contact Mrs. Thomas.

Thank you for your interest in our Athletic Program and in your child’s desire to play sports. I look forward to an exciting season and hearing from you! Sincerely,

Mrs. Barbara Thomas, Athletic Director

Archdiocese of MiamiDeparlment of Schools

'Ath letic Pre-participatio nIhis completed form must be

Physical Evaluatibn (Page 1 of 2)l<epi on file by the school

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<,cchool:

Name:

Student lnformation 1to bc comptet"O fly tf.," p"runfi

Sex: Age Daie of ginh- l--l

Grade in School Sport(s) expectecj to n l:r rr

Home Phonc (Home Addrcss:

Name of ParenUGuardian:

Person lo Contacl in Case of'Emeroencv:

Relaiionship to Student: iionro Phone; (

Personal Family Physician: Cily/Siate:

Part 2. Medical History (to bc completec, by parent). Explain ,,yes,' answe rs bolow.

Ytrs Nol. Has child Ilad a medical iililess or iniury sincc lhs Iasi circc\ up or

sporls physical?

2, Ooss ciilld havo an ongoing clvonjc lllness?

3. Ha5 ciriid cvcr beon hDspilJlizcLJ ovciltiglrt?

.:. HJ5 child cvcr hDd surocry?

5. ls child curenuy taking aoy prosc;i;JUon or nonircscripticn (ovcr tirccountcr) mcdications or p;ll or usiig ril ithalcr?

G. Ha: child cvcr ttkgn s1)y supl)luillools o, vit!mir)5 to l)clp !{in or lo joweight or improvc Dcr.,arnarrce.?

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chitd havc any allergics (tor exJnlplc to poilcn. ntcdjcine, food orstioging insecls)?

L Has chiid cvci prsscd ou( durlng or allc; cxorci:c?

10. l-ias child evo,. bcen di?zy during or after exercisc?

I 1. Ha3 chi(d e{erhad chest pain during orallercxcrcise?

i2. Docs clriid geuircd more qulckt' illail triends duriilg excrcisc?

13. l-ias chitC evcr had rac;ng olthe llertl of skippcd l)eanbcals?

l,l. Has child had high btood pics5urc or higlr cholesteioi?

15. Has child evcf beco told lte/shc lras i lteei ntuirnual

Circle questions for vrhich you do not know thc answcr

Yosilas chiid cver become ill irom c:crcisin! ,n ihc hcat?

Does child cough. whacrc or havc i.ioublc Urcathlng tJuring or allcractivjly?

?C. .lccs clrlld lravo U5l.hma? __ _

?9. Oces chlid llavc soasonal Jllcrgiss llr!t ruquiru mcdlcal trgJlmeJ)i?

30. Coes Child lravg s11y spccial proicctivo oa corrcctivc oquipmclt ordcviccs lh3I arcn't usually used foi your sport or posi(ion (lor cxamplc,kncc br:rcc, .spccial nock roll. loot o;lhotics. rcliiner on your tcclf).hearing aid)?

gl. fies cnitd had any problcms with l)is/hcr cycs or vision?

32, Ooss child weor glasscs, conlacts, or ptolcctivc cle wcal?

3i. Has chikJ brokonorlraciurcd any Uonc3 ordlslocJted anyjoints?

35. l-ias child had any o(hcr prob(ems wilh pai^ or slyclling ii musctcs.tcr'dons, boncs, or joints?

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.n", cvor llad fash or ilvcs ctcvclop durirrg or o/lor cxcrcisc? j3. Has clilld evcr had a sprain, sirain, or svrelling allar injury?

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i6. Has any family membc; or relarivo dicd ol hcarl prolrlcms or suddefldeath belorc age 50?

i7. Has child hod severe viral inlcction (fo, cxaorptc, myocardit;s ornc:turruciu)si!i trilii,i lirs ;d5l i,:o,,ii,l

Has a physician ever dcnicd or restrictcd child.s l)articiitrtion in sporlstor Jny head problcrns?

Ooes child have any currcnt skirr problcrns (lor e:amclc, itching,rashes. acnc, wal(s, lungus. ot IJlisters)?

i"ias child cvcr had a herd injury or concujsion?

Has child ever bocjl knocked out. bccorne unconscious, cr losl his/,hcrmcmory'l

22. Has chitd ever hatj a seizure?

?3. Docs clild havc frcqvcnl or sBvcre llcadachos?

?4..Hal cltild ever had nrmbncss or lirgling in hjs,ihcr arms, hands, lcAs,or Ieul?

child ever had a slingcr. br.JrnCr. or pinchcd r)crve?

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36. Does child rvenl lo lrcigh rnofe or lcss then cl)ild.rciglrs rotf?

3i, Coes clrild losc vr'cighi rcguian),lo mecl y/cight ft:rluiicrnofllj for asporl?

0ocs child leol sircsscd out?

Record the datcs oi lis/most rcceni immunizrtjons (sllots) for:

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@Archdiocese of Miami

Department of Schools

Athletic Pre-participation Physical Evaluation (Page 2 of 2\

This completed form must be kept on file by the school

Pilt 3, Physical Examination (to be completod by physiclan)'

oate of Birth---- --! -_----t ------

Student Name

Heightr

-

weight:

----

% Body Fat (optionat):--- Pulse;------ Blood Pressure: ---l-_' (-*--l---- ' -_*.-l---'..-)

visual Acuity: Right 2ol--- Left2ol_.._ corrected: Yes No Pupils: Eq!al*----- Un6qual-------

M EDICAL

1. Appearance

2. Eyes/Ears/NosefThroat

3. Lymph I{odes

4. Hearl

5. Pulses

6. Lungs

7. Abdomen

L Skin

M U SCU LOSKELETAL

9, Neck

10.8ack

11. Shoulder/Arm

'12. Elbow/Forearm

13. WrisYHand

14. Hip/Th'gh

15. Knee

16. Leg/Ankle

17. Foot

'- Station-based examrnation only

ASSESSMENT OF EXAMINING PHYSICIAN

.-Cleared wilhout lim itationRea son_----

Nor cl!ared fot

Cleared after compleling evaluation/rehabilitation for:

Referr!d to

R ecom m end a llon

Name of PhYSlcian (Print or tYPe):...-.___

Ad d ress:-_ , MD, OO. DC, ARNP

Signature of PhYsician:

i;;rs** di ,rtt,",o, ,o *ro* *rrtl*t? (,t "1r,,o"0,., . ., ,,,r, . ,, ,. ,aa:,..::.,;;;jiii;;'ii;;i;A;;;;j;;i;;t;j

I hareby cedify that the examination(s) for which ,rfrrr"d n""/*"EGEGid by mysay or an individual undet my direct supetvtstt

--_Cleared without lim itatron

ReasonNot cleered tot

-Clealed

atter

Referred to

Cleared atter sompleting evaluation/rehabilitation for:

Reco

Dat!

Name of PhYsic'an (Print or lYPe)

Address:__--- MD, DO, DC, ARNP

Signatu16 ol PhYsici!n

Based on recomm!ndations deveroped by rhe American Academy ol Family physicians, Ameilaan Academy of Pedialrics, American Medical society lot sports MEdicine' American

Odhopaedic Society tor spods Msdicina and American Osteopathic Academy fot sporls Medicine'

Archdiocese of Miami

Department of Schools

Athletic Consent and Release from Liability CertificateThis completed form must be kept on file by the school

Student Name__________________________________________________________

School________________________________________________________________

Sports in which student plans to participate:___________________________________

_____________________________________________________________________

A. I/we hereby give consent for child/ward to participate in the interscholastic sports

that I have listed above.

B. I/we know of and acknowledge that my child/ward knows of the risks involved in

athletic participation, understands that serious injury, and even death, is possible

in such participation and choose to accept any and all responsibility for his/her

safety and welfare while participating in athletics. With full understanding of the

risks involved, I/we release and hold harmless my child’s/ward’s school, the

schools against which it competes, the contest officials and the Archdiocese of

Miami of any and all responsibility and liability for any injury or claim resulting

from such athletic participation and agree to take no legal action against my

child’s/ward’s school, the schools against which it competes, the contest officials

and the Archdiocese of Miami because of any accident or mishap involving the

athletic participation of my child/ward. I further authorize emergency medical

treatment for my child/ward should the need arise for such treatment while my

child/ward is under the supervision of the school.

C. Insurance Information

My/our child is covered under our family health insurance plan which has limits of not

less than $25,000

Company________________________________ Policy Number:_________________

I/WE HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE:

Date: __________ Signature of Parent/Guardian:_____________________________

Date:___________ Signature of Parent/Guardian:_____________________________