Sports Participation Record Sheet by mzq79210

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									                                              Sports Participation Record Sheet

                                               For: _________________________
Player's Information:
Last Name:                                                        Parent 1:

First Name:                                                       H. Phone:

Birth date:                                                       Emergency#:

Grade:                                                            P1 Occupation:

Street Address:                                                   Parent 2:

City, State, Zip:                                                 H. Phone:

M. School:                                                        Emergency#:

Height:                                                           P2 Occupation:

Weight:                                                           Insurance On File:

Jersey#                                                           Birth Certificate:

Classification:                                                   Consent Form:

                                                                  Contact Email:


Equipment Issued                                                  Fee Payment Schedule

Equipment                   Size/Number     Issued     Returned     Date                       Event Schedule     Amount              Paid




                                                                  Status               Paper Work Completed        Date

                                                                           Birth Certificate

                                                                           League Waiver

                                                                           Jr Falcon Weiver

                                                                           Physical Exam

                                                                           Proof of Insurance
Total               $   -                                                  Proof of Residency



Guardian signature that all Information is current and true.




                                                                                                                6:33 PM - 1/31/2010
                                          Permission, Medical Release and Waiver
                                               Of Transportation Liability

I understand that the PEBBLEBROOK JR. FALCONS ASSOCIATION is no way connected to Pebblebrook High School. Neither
Pebblebrook High School nor anyone acting in the capacity of an employee of Pebblebrook High School is responsible for the safety
or supervision of athletes, coaches or any other involved in the program. Questions or concerns about the PEBBLEBROOK JR.
FALCONS ASSOCIATION should be directed to the officials of that program and not to the faculty or staff of Pebblebrook High
School.


Signature of Parent/
Legal Guardian _________________________________________Date:_________________

I hereby certify that I have knowledge of my child’s physical condition and state of health and give my consent and permission for my
son/daughter, as identified, to engage in the active sports program of the AMATEUR ADVOCATE ASSOCIATION INC. and the
PEBBLEBROOK JR. FALCONS ASSOCIATION. I do further certify that my son/daughter has no physical condition and he/she is
allowed to take an active part in this program.

I further state that I shall not hold any person, firm or corporation backing any team, nor any of the coaches of the AMATEUR
ADVOCATE ASSOCIATION INC. and the PEBBLEBROOK JR. FALCONS ASSOCIATION responsible or liable for injuries
during practice sessions, practice games, regularly scheduled games or while being transported to and from same.

I further certify that by placing my signature on this document I have been served with notification that the PEBBLEBROOK JR.
FALCONS ASSOCIATION and the AMATEUR ADVOCATE ASSOCIATION INC. do not carry any insurance on my child. As
parent/guardian, I am responsible for any medical bills incurred while my child participates in activities in the PEBBLEBROOK JR.
FALCONS ASSOCIATION and the AMATEUR ADVOCATE ASSOCIATION INC.

I further certify that by placing my signature in this document I have given permission to the PEBBLEBROOK JR. FALCONS
ASSOCIATION to transport my child to a medical facility and to secure treatment if necessary in my absence.

I hereby give my permission for a representative of the PEBBLEBROOK JR. FALCONS ASSOCIATION to secure immediate
medical treatment for my child _______________________________________ who is under the age of 18 (eighteen). I further give
my permission for a medical facility, chosen by a representative of the PEBBLEBROOK JR. FALCONS ASSOCIATION to provide
immediate medical treatment for the above named child. I understand this treatment is authorized in my absence and that my
signature below releases the medical facility and the PEBBLEBROOK JR. FALCONS ASSOCIATION from any liability regarding
treatment if I cannot be reached. I further understand that I will be considered the RESPONSIBLE PARTY for any charges incurred.

I herby certify that by placing my signature on this document that I grant full permission to use my name and my child’s name printed
above and any photographs, or record of me and my child participating in this programs events, for any publicity and/or promotional
purposes without obligation of liability to me or my child.

Cobb County Zero Tolerance Policy Regarding Fan Behavior:
Any negative cheering/yelling will result in a warning and/or removal from the site, whether it is for or against your team. Negative
cheering shall be defined as cheering/yelling that is profane or derogatory in nature or cheering/yelling that is deemed in the opinion
of the game officials, tournament/league director or his/her designee, to be an unnecessary disruption to the game. The
tournament/league director or his/her designee shall be empowered with the authority to make the final decision.

The undersigned, being a parent and/or guardian of the above-named student, has completed this
application truthfully and agrees to all the above written terms and participation.

Signature of Parent/
Legal Guardian _________________________________________Date:_________________



                                                                                                                             RWORO
Revised 7/1/05
Mandatory

Preparticipation Physical Evaluation                                                                                                                                                        HISTORY FORM

Date of Exam ___________________________


Name _________________________________________ Sex_________Age________Date of birth_________________

Grade_____School________________________________Sport(s)____________________________________________

Address_________________________________________________________________Phone_____________________

Personal Physician __________________________________________________________________________________

In case of emergency, contact:

Name _______________________Relationship______________Phone (H)_______________Phone(W)______________

 Explain "Yes" answers below.
 Circle questions you don't know the answers to.
                                                                                                Yes No                                                                                                                Yes No
  1. Has a doctor ever denied or restricted your participation                                                        24. Do you cough, wheeze, or have difficulty breathing
     in sports for any reason?                                                                                            during or after exercise?
  2. Do you have an ongoing medical condition                                                                         25. Is there anyone in your family who has asthma?
     (like diabetes or asthma)?                                                                                       26. Have you ever used an inhaler or taken asthma medicine?
  3. Are you currently taking any prescription or                                                                     27. Were you born without or are you missing a kidney,
     nonprescription (over-the-counter) medicines or pills?                                                               an eye, a testicle, or any other organ?
  4. Do you have allergies to medicines, pollens, foods, or                                                           28. Have you had infectious mononucleosis (mono)
     stinging insects?                                                                                                    within the last month?
  5. Have you ever passed out or nearly passed out                                                                    29. Do you have any rashes, pressure sores, or other
     DURING exercise?                                                                                                     skin problems?
  6. Have you ever passed out or nearly passed out                                                                    30. Have you had a herpes skin infection?
     AFTER exercise?                                                                                                  31. Have you ever had a head injury or concussion?
  7. Have you ever had discomfort, pain, or pressure in                                                               32. Have you been hit in the head and been confused
     your chest during exercise?                                                                                          or lost your memory?
  8. Does your heart race or skip beats during exercise?                                                              33. Have you ever had a seizure?
  9. Has a doctor ever told you that you have                                                                         34. Do you have headaches with exercise?
     (check all that apply):                                                                                          35. Have you ever had numbness, tingling, or weakness
         High blood pressure               A heart murmur                                                                 in your arms or legs after being hit or falling?
         High cholesterol                  A heart infection                                                          36. Have you ever been unable to move your arms or
 10. Has a doctor ever ordered a test for your heart?                                                                     legs after being hit or falling?
     (for example: ECG, echocardiogram)                                                                               37. When exercising in the heat, do you have severe
 11. Has anyone in your family died for no apparent reason?                                                               muscle cramps or become ill?
 12. Does anyone in your family have a heart problem?                                                                 38. Has a doctor told you that you or someone in your
 13. Has any family member or relative died of heart                                                                      family has sickle cell trait or sickle cell disease?
     problems or of sudden death before age 50?                                                                       39. Have you had any problems with your eyes or vision?
 14. Does anyone in your family have Marfan syndrome?                                                                 40. Do you wear glasses or contact lenses?
 15. Have you ever spent the night in a hospital?                                                                     41. Do you wear protective eyewear, such as goggles or
 16. Have you ever had surgery?                                                                                           a face shield?
 17. Have you ever had an injury, like a sprain, muscle or                                                            42. Are you happy with your weight?
     ligament tear, or tendinitis, that caused you to miss a                                                          43. Are you trying to gain or lose weight?
     practice or game? If yes, circle affected area below:                                                            44. Has anyone recommended you change your weight
 18. Have you had any broken or fractured bones or                                                                        or eating habits?
     dislocated joints? If yes, circle below:                                                                         45. Do you limit or carefully control what you eat?
 19. Have you had a bone or joint injury that required x-rays                                                         46. Do you have any concerns that you would like to
     MRI, CT, surgery, injections, rehabilitation, physical                                                               discuss with a doctor?
     therapy, a brace, a cast, or crutches? If yes, circle below:                                                     FEMALES ONLY
 Head      Neck           Shoulder        Upper        Elbow         Forearm       Hand/          Chest               47. Have you ever had a menstrual period?
                                          Arm                                      Fingers
 Upper     Lower          Hip             Thigh        Knee          Calf/         Ankle          Foot/               48. How old were you when you had your first menstrual period? ______
 Back      Back                                                      Shin                         Toes                49. How many periods have you had in the last 12 months?__________
 20. Have you ever had a stress fracture?                                                                             Explain "Yes" answers here:_________________________________
 21. Have you been told that you have or have you 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?                                                                                                    __________________________________________________________

  I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

 Signature of Athlete_________________________________Signature of Parent/Guardian________________________________Date_____________
  c 2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American
  Osteopathic Academy of Sports Medicine.
Preparticipation Physical Evaluation                                                                                                                  PHYSICAL EXAMINATION FORM


Name _______________________________________________________________Date of Birth___________________


Height_________Weight________% Body Fat (optional)________Pulse_______BP____ / ____ (____ / ____, ____/____)


Vision R 20/______ L 20/______                                      Corrected:               Y      N                    Pupils: Equal ______                          Unequal______




                                                    NORMAL                                                ABNORMAL FINDINGS                                                                                  INITIALS*
MEDICAL
Appearance

Eyes/ears/nose/throat

Hearing

Lymph nodes

Heart

Murmurs

Pulses

Lungs

Abdomen

Genitourinary (males only)+

Skin


MUSCULOSKELETAL
Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

*Multiple-examiner set-up only.
+Having a third party present is recommended for the genitourinary examination.



Notes: ____________________________________________________________________________________________________
__________________________________________________________________________________________________________


Name of physician (print/type)________________________________________________________________Date______________

Address__________________________________________________________________________Phone____________________

Signature of physician _______________________________________________________________________________, MD or DO

 c 2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American
 Osteopathic Academy of Sports Medicine.
Preparticipation Physical Evaluation                                                                                                                                                     CLEARANCE FORM

    Name______________________________________Sex__________Age________Date of birth___________________

               Cleared without restriction
               Cleared, with recommendations for further evaluation or treatment for:___________________________________
               ___________________________________________________________________________________________
               ___________________________________________________________________________________________
               ___________________________________________________________________________________________

               Not Cleared for                      All sports                   Certain sports: ________________________ Reason:__________________

    Recommendations:_________________________________________________________________________________
    ________________________________________________________________________________________________

    EMERGENCY INFORMATION

    Allergies ________________________________________________________________________________________

    Other Information _________________________________________________________________________________


    Name of physician (print/type) ____________________________________________________Date _______________

    Address ________________________________________________________________Phone ____________________

    Signature of physician _____________________________________________________________________, MD or DO

 c 2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American
Osteopathic Academy of Sports Medicine.




Preparticipation Physical Evaluation                                                                                                                                                     CLEARANCE FORM

    Name______________________________________Sex__________Age________Date of birth___________________

               Cleared without restriction
               Cleared, with recommendations for further evaluation or treatment for:___________________________________
               ___________________________________________________________________________________________
               ___________________________________________________________________________________________
               ___________________________________________________________________________________________

         Not Cleared for All sports  Certain sports: ________________________ Reason:__________________
    Recommendations:_________________________________________________________________________________
    ________________________________________________________________________________________________

    EMERGENCY INFORMATION

    Allergies ________________________________________________________________________________________

    Other Information _________________________________________________________________________________


    Name of physician (print/type) ____________________________________________________Date _______________

    Address ________________________________________________________________Phone ____________________

    Signature of physician _____________________________________________________________________, MD or DO


  c 2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American
Osteopathic Academy of Sports Medicine.

								
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