Konsos Stote High School Activities Association

PRE.PARTICIPATION PHYSICAL EVATUATION INSTRUCTIONSSTUDENTS/PARENTS

1. I Complete the History Form (pages 1 & 2) portion PRIOR to your appointment with your healthcare provider.2. I Sign the bottom of the History Form (page 2).

3. I Sign the boffom of the Medical Eligibility Form (page 4) AFIER the pre-participation evaluatlon is complete and PRIOR toturning in the completed PPE to the school.

4. f Review the Student Eligibility Checklist (page 5) AND SIGN the bottom of the page PRIOR to turning in the completed PPEto the school.

5. f Review and sign the Concussion and Head lnjury Release Form provided by the school.

HEALTHCARE PROVIDERS

1 . I Review the History Form (pages 1 & 2) with the student and his/her parent/guardian as part of the pre-participation physicalevaluation.

2. I Complete the Physical Examination Form (page 3) AND SIGN the bottom of page 3.

3. I Complete the Medical Eligibility Form (page 4) AND S|GN page 4.

NOTE: Two signatures are required by the healthcare provider!

SCHOOT ADMINISTRATORS

1. I Collect the completed PPE forms with the appropriate signatures on pages 2 - 5.

2. f] Based on your school's policy, determine who is responsible to review and disseminate the studenfs medical informationprovided on the form.*

3. I Complete the Shared Emergenry lnformation section on the Medical Eligibility Form (page 4).

4. I Provide copies of the Medical Eligibility Form to appropriate staffwith supervisory responsibility of extracurricular activities(coaches, sponsors, etc.).

5. []CollecttherequiredConcussionandHeadlnjuryReleaseFormsignedbythestudentandparent/guardian.* Schools are encouraged ta have policies in place identifying who has access to a student's complete private health information

found onthe PPE form. The Medical Eligibility Form can be used independentlyto share with staff who may not need completeaccess to the private health information found on the PPE.

The annual history and the physical examination shall not be taken earlier than May 1 preceding the school year for which it isapplicable. The KSHSAA recommends completion of this evaluation by athletes/cheerleaders at least one month prior to the flrstpractice to allow time for correction of deficiencies and implementation of conditioning recommendations.

ffi Kansos State High School Activities Association

PRE.PARTICI PATION PHYSICAL EVATUATIONPPE is required onnually and shall not be token earlier thon Msy 7 precedint the school year lor which it is opplicable.

HISTORY FORM @oges 1 & 2 should be fitled out by the student ond parenttgudrdian prior to the physicol examinotion)Name Age Dare of birth

PPE

Grade SchooI Sport(s)

Home Address Phone

Personal physician Parent Email

List past and current medical conditions:

Have you ever had surgery? lfyes, list all past surgical procedures:

Medicines and Allergies:Please list all ofthe prescription and over-the-counter medicines, inhalers, and supplements (herbal and nutritional)thatyou are currentlytaking:

I No Medications

Doyouhaveanyallergies? [ves I No lfyes,pleaseidentifyspecificallergybelow.

Dl'aedicines-Elpollens-[rood-flstingingtnsect5-Whar was the reaction?

Explain 'Yes" answeE at the end of this form. circle questions if you don't know the answer.

'1. Do you have any concerns that you would like to discuss with your provider? tr tr2. Has a provrder ever denied or restrided your pardcipation in sports for any reason? tr u3. Do you have any ongoing rnedical issues or recent illness? n D

5. Have you ever passed out or nearly passed out during or after exercise?

4. Have you ever spent the night in the hospital? trrtl trEE5. Have you ever had discomfort, pain, tightness or pressure in your chest during exercise? n n7. Does your hean ever race, flutter in your chest, or skip beats (irregular beats) during exercise? tr tr8. Has a doctor ever told you that you have any hean problems? n u9, Has a doctor ever requested a test for your heartT For example. electrocardiography (ECG) or echocardiotraphy. tr tl

'1 0. Do you get light-headed or feel shofter of brearh than your friends during exercise? tr tr

1 2- Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (inciud-ing drowning or unexplained car crashf

1 1 . Have you ever had a seizure? fftr&

1 3. Does anyone in your family have a genetic hean problem such as hypertrophic cardiomyopathy (HCM), N4arfan syndrome, arrhythmogenicright ventricular cardiomyoparhy (ARVC), long QT syndrome (LQTS), shon QT qyndrome {SQTS), Brugada syndrome, or catecholamrnergcpolyrnorphic ventricular tachycardia (CPVlf u

1 5. Have you ever had a stress fracture or an inJury tc a bone, muscle, ligarnent, joint, or tenCon that caused you ro miss a practice or game?

14. Has anyone in your family had a or an implanted defibrillator before age 35?

1 5. Have you ever had any broken or fra.tured bones or dislocated joints? tr E:I1 7. Have you ever had an injury that required x-rays, N,lRl. CT scan, injections or therapy? n u'1 8. Have you ever had any injuries or conditions involving your sptne irervical, thoracic, lumbarp tr tr1 9. Do you regularly use, or have you ever had an injury rhat required the use of a brace, crutches, cast, orthotics or other assistive device? tr tr20. Do you have a bone, muscle. ligament, or joint injury that bothers you? tr tr2'1 . Do you have any history ofjuvenile arthritis, other autoimmune disease or other congenital genetic conditions {e9., Downs Syndrome or

Dwarfism)? u DKansasStateHighSchoolActivitiesAssocialion,6alSWCommercePlocelPOBox49SlTopeko,KS6660llTS5-273-5329

1Rev.3/2020

GENERAL QUESTIONS: YES NO

HEART HEALTH QUESTIONS ABOUT YOU:

HEART HEALTH QUESTlONS ABOUT YOUR FAMILY:

utr

BONE AND JOINT QUESTIONS: YES NO

22. Do you cough, wheeze, or have difficulty brearhing during or after exercise? _l tr23. Have you ever used an inhaler or taken asthma medicine? tr rl24. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organs? l tr25. Do you have groin or testicle pain, a bump, a painful bulge or hernia in the groin area? l tr26. Have you had infectious mononucleosis (mono)? l tr27. Doyou have any recurringskin rashes or skin infection that come and go, including herpes or methicillin-resistant Staphylococcus aureus

(MRSA)?

28. Have you had a concussion or head 'njury

that caused confusion, a prolonged headache, or memory problems? fl trlfyes, how many?

Whar is rhe longest time it took for full recovery?

When were you last reieased?

29. Do you have headaches with exercise? l n30. Have you ever had numbness, ringlins weakness in your arms (including stingers/burners) or legs, or been unable to move your arms or legs

after being hit or falling?

31 . Have you ever becorne ifl while exercising in the heatT l u32. Do you get frequent muscle cramps when exercising? l u33. Do you or does someone in your famlly have sickle cell trait or disease? l tr34. Hsve you ever had or do you have any problems with your eyes or vision? n tr35. Do you wear protective eyewear, such as goggles or a face shield? -l tr35. Do you worry about your weight? l n37. Are you trying to or has anyone recommended that you gain or lose weight? l fl38. Are you on a special diet or do you avoid certain types of foods or food groups? f tr39. Have you ever had an eating disorder? f tr40. How do you curremly identify your gender? trM [F L]other41. Over the last 2 week, how often have you been bothered by any ofthe followingproblerfi* (check box) NOT AT ALT SEVERAL

DAYSOVER HAtFTHE DAYS EVERY DAV

NEARLY

Feeling nervous, anxious, or on edge oD rI ,E 3ENot being able to stop or control worling DE 1fl ,El 3ELittle interest or pleasure in doing things 0fl rI 2fl 3EFeeling down, depressed, or hopeless OEI 1E ,E 3fl(A sum of 3 or more is cansidered positive on either subscole [questions 1 ond 2, or questions 3 and 4] for screening purposes)Patient Heolth Questionnoire Version 4 (PHQ4)

42. Haveyou ever had a menstrual period,2

43. lfyes, are you experiencing any problems or changes with athletic participation (i.e., irregularity, pain, etc.)? l tl44. How old were you when you had your first menstrual period?

45. When was your most recent menstrual period?

46. How many menstrual periods have you had in the pasr 1 2 rnonths?

MEDICAL QUESTIONS: YES NO

FEMALES ONLY YES NO

I XSXSRR PRE-PARTICIPATION PHYSICAL EVALUATION

Explain all Yes answers here

I herehy state that, to the best of my knowledge, my answers to the above questions are complete and correct.lt1sitnatureof5tudent.athletesignatureofparenUguardian-Date-

KansasStakHighSchoolActivitiesAssociation,5}lsWCommercePlare | PoBox495 | Topeko,KS66601 | 785-273-5j29

mercial, educatiooal purposes with acknowledgment. 2Rev.3/2020

t-t n

I XSXSAA PRE.PARTICTPATION PHYSICAL EVATUATION

PHYSICAL EXAMINATION FORMName Date of birthDate of recent immunizations: Td Tdap Hep B varicella HPV Meningococcal

PHYSICIA.N REMINDERS1. Consid€r additional questions on more sensitive issues

- Do you feel stressed out or under a lot of pressure?- Doyou everfeel sad, hopeless, depressed, or anxious?- Do you feel safe at your home or residence?- Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?- During the past 30 days, did you use .hewing tobacco, snuff, or dip?

Do you drink alcohol or use any other drugs?Have you ever taken anabolic steroids or used any other performanceenhancing supplement?Have you ever taken any supplements to help you gain or lose weight orimprove your performance?Do you wear a seat belt, use a helmet and adhere to safe sex pradices?

2. Consider reviewing questions on cardiovascular symptoms (questions 5-14 of History Form).3. Per Kansas statute. any school athlete who has sustained a concussion shall not return to competition or practi(e until the athlete is evaluated by a

healthcare provider and the healthcare provider (MD or DO only) provides such athlete a written clearance to return to play or practice,

I acknowledge I have reviewed the preceding patient history pages and have performed the above physical examination on the student named on this form.Name of healthcare provider (prinvtype) Date

1sign"trr" ot healthcare provider ./-' MD, DO, DC. FA.E. APRN(plee$e clrcle o1e)

Address Phone

Heofthcore Providers: You must complete the t/ledicol Eligibility Form on the fiollowing pageKansas State High school Activities Association,5ql Sw Commerce Plsce I PO Box 495 | Topeko, KS 66601 | 785-27i-5329

mercial, educational purposes with a(knowledgm€nt. nev. ltZOZ3O

HeiSht Weight Male ! Female Z BP(rqerence$nder/height/agechart)**** / ( )Pulse

Appearan(e- Marfan stigmata (kyphoscoliosis, high-arched palate, pectusmyopia, mitralvalve prolapse [MVP], and aortic insufficienry)

Vlsion R 20l L20t Correfled:Yes tr No ll

excavalum, arachnodactyly, hyperlaxity,

Eyes/ears/nose/throat- Pupils equal, Gross Hearing

Lymph nodes

Murmurs (auscultation standin& auscultarion supine, and t Valsalva maneuver)Heart r

Simultaneous fenioral and radial pulsesPulses

Lungs

Abdomen

Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant S,aphylococcrs aureus (MRSA),or tinea corporis

Skin

Neurological++*

Genirourinary (optional-males only)*+

Neck

Back

Shoulder/arm

Elhrow/forearm

Wrist/hand/flngers

Hip/thigh

Knee

Leg/ankle

Foot/toes

e.g. double-leg squat tesr, single-leg squat Ie$, and box drop or srep d.op testFunctional

EXAMINATION

MEDICAL NORMAL ABNORMAL FINDINGS

MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS

I XSNSEI PRE.PARTICIPATION PHYSICAL EVALUATIONMEDICAL ELIGIBILITY FORMName

f tr/edically eligble for all sports without restriction

fl Medically eligible for all sports Wthout restriction with recommendations for further evaluation or treatment of

Dete of binh

I vedically eligible for certain sports

f] Not medically eligible pending further evaluation

[] Not medically eligible for any spofts

Recommendations:

I have examined the studenr named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical conrraindications topractice and can participate in the sport(s) as ourlined on this form, except as indicated above. lf conditions arise after the athlere has been cleared for participation, the

NameofheallhCareproVider(printortype):Date:

Xsrgn t rr. ocheatthcare provider , MD. DO, DC, orPA{,APRNAddress:

Allergies:

Phone:

SHARED EMERGENCY I N FORMATION

lvledications;

Other information:

Emergency contacts:

Parent or Guardian ConsentTo be eligible for participation in interscholastic athleticslspirit groups, a student must have on file with the superintendent or principal, a signed statement by aphysician, chiropractor, physi€ian's assistant who has been authorized to perform the examination by a Kansas licensed supervising physician or an advanced practiceregistered nurse who has been authorized to perform this examination by a Kansas licensed supervising physician, certifying the student has passed an adequatephysical exami-nation and is physically fit to participate (5ee KSHSAA Handbook, Rule 7). A complete history and physical examination must be performed annuallybefore a student participates in KSHSAA interscholastic athletics/cheerleading.

I do not know of any existing physical or any additional health reasons that would preclude participation in activities. I certify that the answers to the questions in theHISTORY part ofthe Prepartiripation Physical Examination {PPE}, are true and accurate. I approve participation in activities. I hereby authorize release to the KSHSAA,school nurse, certified athletic trainer (whether employee or independent contractor of the school), school administrators, coach and mediral provider of informationcontained in this document. Upon written request, I may receive a copy of th;s document for my own personal health care records.

I acknowledge that there are risks of participating, including the possibility of catastrophic injury. I hereby give my consent for the above student to compete in KSHSAAapproved adivities, and to accompany school representatives on school trips and receive emergenry medical treatment when necessary. lt is understood that neitherthe KSHSAA nor the school assumes any responsibility in rase of accident. The undersigned agrees to be responsible for the safe return of all equipment issued by theschool to the student.

ItI Signatureofparent/guardian Date_

/v-

The parties to this document agree that an electlonic signature is inteded to make this writing ettective and binding and to have lhe same torce and effect as the use of amanual signature.

Kansas Stite High School ActMti€s Asso.ialion,601 SW Commerce Place I PO Sox 495 | Topeko, KS 66601 | 785"27j-5329

mercial, educatjonal purposes with acknowledgment. 4Rev. 3/2020

I RrrtrvrlON PARENTS AND STUDENTS: KSHSAA ELIGIBILITY CHECKLIST

NOTE: Transfer Rule 18 states in part, a student is eligible transfer-wise if:BEGINNING SEVENTH GRADER-A seventh grader, at the beginning of his or her seventh grade year, is eligible under the Transfer Rule at any school he or she maychoose to attend. ln addition, age and academic eligibility requirements must also be met.

BEGINNING NINTH GRADERS lN ATHREE-YEARJUNIOR HIGH SCHOOL-So that ninth graders ofa threeyearjunior high are treated equallyto ninth graders ofa four-yearsenior high school, a student who has successfully completed the eighth grade ofa two-yearjunior high/middle school. maytransferto the ninth grade ofa three-yearjunior high school at the beginning ofthe school year and be eligible immediately under the Transfer Rule. Such a ninth grader must then, as a tenth grader, attend thefeeder senior high school oftheir school system. Should they attend a different school as a tenth grader, they would be ineligible for eighteen weeks.

ENTERING HIGH SCHOOL FOR THE FIRST TIME-A senior high school student is eligible under the Transfer Rule at any senior high school he or she may choose to attendwhen senior high is entered for the first time at the beginning of the s€hool year. ln addition, age and academic eligibility requirements must also be met.

For Middle{unior High and Senior High School Students to Retain EligibilitySchools may have stricter rules than those pertaining to the questions above or listed below. Contact the principal or coach on any matter of eligibility. A studenteligible to participate in interscholastic activities must be certified by the school principal as meeting all eligibility standards.

All KSHSAA rules and regulations are published in the official (5HSA,4 Hondbookwhich is distributed annually to schools and is available atwww.kshsoa.arg.

Below Arc gfiel Summaries Ol Selected Rules. Please See Your Pfincipai For Complete lntormation.Rule 7 Physical Evaluation - Parental Consent-Students shall have passed the attached evaluation and have the written consent of their parents or legal

guardian.Rule'14 Bona Fide Student-Eligible students shall be a bona fide undergraduate member of his/her school in good standing.Rule 15 Enrollm€nt/Attendance-Students must be regularly enrolled and in attendanre not later than Monday of the fourth week of the semester in which

they participate.Rule 16 Semester Requirements-A student shall not have more than two semesters of possible eligibility in grade seven and two semesters in grade eight. A

student shall not have more than eight consecutive semesters of possible eligibility in grades nine through twelve, regardless ofwhether the ninth gradeis included in.junior high or in a senior high school.

Rule '17 Age Requirements-Students are eligible if they are not '19 years of age (16, 15 or 14 for junior high or middle school student) on or before August 1 ofthe school year in which they compete.

Rule 19 Undue lnfluenc€-The use of undue influence by any person to secure or retain a student shall cauEe ineligibility. lf tuition is charged or reduced, itshall meet the requirements of the K5H5AA.

Rules 20121 Amateur and Awards Rules-Studen6 are eligible if they have not competed under a false name or for money or rnerchandise of intrinsic value, andhave observed all other provisions ofthe Amateur and Awards Rules.

Rule 22 Outside Competition-Students may not engage in outside competition in the same sport during a season in which they are representing their school.NOTf Consult the coach, othletic director or principal biore participating individuolly or on a teom in ony game, trdining session, contest, or t4lout conductedby on outside orgonizotion.

Rule 25 Anti-Fraternity-Students are eligible if they are not members of any fraternity or other organization prohibited by law or by the rules of the KSHSAA.

Rule 26 Anti-Tryout and Private lnstruction-Students are eligible if they have not participated in training sessions or tryouts held by colleges or other outsideagencies or organizations in the same sport while a member of a school athletic team.

Rule 30 Seasons of Sport-Students are not eligible for more than fcur seasons in one sport in a four-year hi8h school, three seasons in a three-year high schoolor two seasons in a two-year high school,

For Middle{unior High and Senior High School Students to Determine Eligibility When EnrollingIf a negative response is given to any of the following questions, this enrollee should contact hislher administrator in charge of evaluating eligibility. This should bedone before the student is allowed to attend his/her first class and prior to the first activity practice. lf questions still exist, the school administrator should telephonethe KSHSAA for a final determination ofeligibiliry. fschools sholl process a Certificdte ofTronsfer Form T-E on all transfer students.)

Are you a bona fide student in good standing in school? (lfthere is a question, your principal will make that determination.)Did you pass at least five new subjects (those not prwiously passed) last semester? (The KSHSAA hos o minimum regulation which requires youto poss ot leost frve subjects of unit weight in your last semester of attendonce-)

Are you planning to enroll in at least five new subje€tr {those not prevlously pass€d) of unit weight this coming semester?(he KSHSAA hos d minimum regulotion which requiresyou to enroll ond be in ottenddn& in ot leastlive subjeLts af unitweight.)Did you attend this school or a feeder school in your district last semester? (lfthe answer is "no" to this question, pleae onswer Sections o ond b.)

a. Do you reside with your parents?

b. lfyouresidewithyourparents,havetheymadeapermanentandbonafidemoveintoyourschoolsattendancecenter?

YEs NOrI n2fl n3[] tr4.8 trtrtrtrtr

The above named student and I have read the KSHSAA Eligibility Checklist and how to retain eligibility information listed in this form. The student/parentauthorizes the school to release to the KSHSAA student records and other pertinent doruments and information for the purpose of determining studenteligibility,The student/parent also authorizes the school and the KS}|SAAto publish the nameand picture ofstudent as a result ofparticipating in or attendingextra-currlcular activities, school events and IGHSAA activities or €vents.

Student's Name oLEAsE INNT ILEARLr,

Signature of parent/guardian Date _ftSitnatureofstudent Birth Date Grade Date_

The parties to this document ogree thot on electronic signoture is intended to moke this writing elfective and binding ond to hove the some force ond eIled os the use oI o monudlsignoture.

5Rev.3/2020

KansasStateHighS(hoolA.tivitiesAsso(iation,6015WComnercePldcelPOBax495lTopeko,K56660ll785-273-5329

!f lur! llrinli yorn'clrikl has suffered a concglslqn

Any athlete even suspscted of suffering a concussion should be removed from the game or practice immediately. No athletemay return to activity after sustaining a concussion, regardless of how mild it seems or how quickly symptoms clear, withoutwritten medical clearance from a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO). Close observation of theathlete should continue for several hours. You should also inform your child's coach if you think that your child may havea concussion Remember it is better to miss one game than miss the whole season. When in doubt, the athlete sits out!

Cosnitive Re.st & Return to Learn

The first step to concussion recovery is cognitive rest. This is essential for the brain to heal. Activities that requireconcentration and attention such as trying to meet academic requirements, the use of electronic devices (cornputers,tablets, video games, texting, etc.), and exposure to loud noises may worsen symptoms and delay recovery. Students mayneed their academic workload modified while they are initially recovering from a concussion. Decreasing stress on thebrain early on after a concussion may lessen symptoms and shorten the recovery time. This may involve staying homefrom school for a few days, followed by a lightened school schedule, gradually increasing to normal. Any academicmodifications should be coordinated jointly between the student's medical providers and school personnel. Noconsideration should be given to returning to physical activity until the student is fully integrated back into the classroomsetting and is syrnptom free. Rarely, a student will be diagnosed with post-concussive syndrome and lrave symptoms thatlast weeks to months. In these cases, a student may be recommended to start a non-eontact physical activity regimen, butthis will only be done under the direct supervision of a healthcare provider.

Ret_ur4 to Practice and Comnetition

The Kansas School Sports Head Injury Prevention Act provides that if an athlete suffers, or is suspected of havingsuffered, a concussion or head injury during a competition or practice, the athlete must be immediately removed from thecompetition or practice and cannot return to practice or competition until a Health Care Professional has evaluated theathlete and provided a written authorization to return to practice and competition. The KSHSAA recornmends that anathlete not return to practice or competition the same day the athlete suffers or is suspected of suffering a concussion. TheKSHSAA also recommends that an athlete's return to practice and competition should follow a graduated protocol underthe supervision of the health care prcvider (MD or DO).

For current and upto-date information on concussions you can go to:!t! I p:/hr' wu.rrlc.eot'/j.!Illri//* * n"t]l]rllrsrorrr:us:;iun.ord

For concussion information and educational resources collected by the KSHSAA, go to:h t I p://rvrvrr. hsh*ua.oreillu hlic/GencraUConcussionGuidelines.cfm

Student-athlete Name Printed Student-athlete Signature Date

Parent or Legal Guardian Printed Parent or Legal Cuardian Signature Date

Revised 04114

Lansing School DistrictMedical Consent and Insurance Form

Student Athlete: Grade:

In the event of an emergency, when I (the parent or guardian) or an emergency contactcannot be reached, permission is hereby given to the attending physician to proceed with anymedical or minor surgical treatment x-ray examinations and immunizations for the above namedstudent. I understand that an attempt will be made to contact me in the most expeditious waypossible. [f the attending physician is not able to communicate with me, the emergencytreatrnent necessary for the best interest of the student may be given.

I verify that this student is covered by some type of accidental medical-hospital insurancethat will cover him/her while attending school in this district and participating in activitiessponsored by the school district.

Should the student require medic,al attention or hospitalizatian as a result of participationin any school sponsored activities, the school or sponsor will not be liable for the medical orhospital costs incurred. The student's insurance will cover the cost of such accidents, and we donot wish to purchase insurance offered by the school.

DateSi gnature of Parent/Custodian

Phone number where parents can be reached:

Home:Cellular:

Name of Insurance Company

Allergies:

Offrce:Other:

Phone:

Phone:

Policy Number

Last Tetanus Shot:

Emergency Contact:

Family Physician:

Serious Medical Condition: No Yes_ (copy of physical to be attached)