-'

Alhambra Unified School District

ALHAMBRA

HIGH SCHOOL

ATHLETIC CLEARANCE CHECKLIST

Date:

Student Last Name

Student First Name

ID Number

Sport

Sport

Sport

Grade

Please completely fill out all forms.

Please return all forms to the Alhambra HSAthletic Office.
ATHLETIC FORMS
__

Physical Form
Must be completed, dated and stamped by a California Licensed Doctor (MD).
Both student and parent must sign the History side of the Physical Form.

__

Emergency/Insurance Information Form

Please include insurance company name, policy number, date and parent signature.

__

Waiver of Liability and Release Form

Signed by parent.

Concussion Information Form

Keep the first page, signed and return the second page.

Code of Ethics - Athletes

Signed by both student and parent.

__

Parent /Guardian Code of Conduct

Signed by parent.

Any questions, please call the Athletic Office at (626) 625-8915

m~~~

HEALTH AND NURSING SERVICES

HISTORY FORM
Preparticipation

N~e

Physical

_ Date of Birth

Student 10 #

Address
Personal

Evaluation

Sex:

Sport(s)

Grade

School:

__ ---'

Physican

In case of emergency,

contact:

Name

Phone (H)

Relationship

(W)

Explain "Yes" answers below.

Circle questions you don't know the answers to,
Yes
1. Has a doctor ever denied or restricted your
participation in sports for any reason?
0
2. Do you have an ongoing medical condition (like
diabetes or asthma)?
0
3. Are you currently taking any prescription or
nonprescription (over-the-counter)
medications or
~?
0
4. Do you have any allergies to medicines. pollens.
foods, or stinging insects?
0
5. Have you ever passed out or nearly passed out
DURING exercise?
0
6. Have you ever passed out or nearty passed out
AFTER exercise?
0
7. Have you ever had discomfort, pain. or pressure in
your chest during exercise?
0
8. Does your heart race or skip beats during exercise? 0
9. Has a doctor ever told you that you have (check all
that apply):
High blood pressure
0 A heart murmur
High cholesterol
0 A heart infection
10.Has a doctor ever ordered a test for your heart?
(for example, ECG, echocardiogram)
0
11. Has anyone in your family died for no apparent reason? 0
t 2. Does anyone in your family have a heart problem? 0
13. Has any family member or relative died of heart
problems or of sudden death before age 50?
0
14. Does anyone in your family have Marfan syndrome';(J
15. Have you ever spent the night in a hospital?
0
16. Have you ever had surgery?
0
17. Have you ever had an injury, like a sprain, musde or
ligament tear. or tendinitis, that caused you to miss a
practice or game? If yes, circle affected area below:O
18. Have you had any broken or fractured bones or
dislocated joints? 11 yes, circle below:
0
19_Have you had a bone or joint injury that required xrays, MRI, CT. surgery. injections, rehabilitation,
physical therapy, a brace, a cast. or crutches? If
..yes, circle below:
0

No

o
o
o
o
o
o
o

o
o

Head

Neck

Upper
back

Lower
back

SllOulder
Hip

Upper
arm
Thigh

Elbow

Forearm

Knee

Caltl
shin

Handl

finqers
Ankle

20. Have you ever had a stress fracture?

0
21. Have you been told that you have or have you had
an x-ray for atlantoaxial (neck) instability?
0
22. Do you regularly use a brace or assistive device? 0
23_ Has a doctor ever told you that you have asthma or
allergies?
0
I hereby state that, to the best of my knowledge,
Signature of athlete

o
o
.0

o
o
o

o
o

o
o
Chest
t-oou
toes

Yes
24. Do you cough, wheeze, or have difficulty
breathing during or after exercise?
0
25. Is there anyone in your family who as asthma?
0
26. Have you ever used an inhaler or taken asthma
medicine?
0
27. Were you born without or are you missing a
kidney, an eye, a testicle. or any other organ?
0
28. Have you had infectious mononucleosis (mono)
within the last month?
0
29. Do you have any rashes, pressure sores, or other
skin problems?
0
30. Have you had a herpes skin infection?
0
31. Have you ever had a head injury or concussion?
0
32. Have you been hit in the head and been confused
or lost your memory?
0
33. Have you every had a seizure?
0
34_ Do you have headaches with exercise?
0
35. Have you ever had numbness, tingling, or
weakness in your arms or' legs after being hit or
falling?
0
36. Have you ever been unable to move your arms or
legs after being hit or falling?
0
37. When exercising in the heat, do you have severe
muscle cramps or become ill?
0
38. Has a doctor told you that you or someone in your
family has sickle cell trait or sickle cell disease?
0
39. Have you had any problems with your eyes or
vision?
0
40. Do you wear glasses or contact lenses?
0
41. Do you wear protective eyewear, such as
goggles or a face shield?
0
42. Are you happy with your weight?
0
43. Are you trying to gain or lose weight?
0
44. Has anyone recommended you change your
weight or eating habits?
0
45. Do you limit or carefully control what you eat?
0
46. Do you have any concerns that you would like to
discuss with a doctor?
0
FEMALES ONLY
47. Have you ever had a menstrual period?
0
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:

o
o

my answers t~the above ques!lorrscrr~

Signalu}e of parenUguardian

Date

No

o
o
o
o

o
o
o

o
o
o
o
o
o
o
o
o

o
o
o
o
o
o

Preparticipation Physical Evaluation

Name

----

Height: __

Weight

Vision R 20' __

Date ofbinh
% Body Fat (optional)

L 20'

Corrected:

Follow-Up Questions

PHYSICAL EXAMINATION
School:

Student ID #

BIP __

Pulse
Pupils: Equal

Unequal

<-' __.__I---.J

1
_

on More Sensitive Issues

1. Do you feel stressed out or under a lot of pressure?

2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities
a few days?

3. Do you feel safe?

4. Have you ever tried cigarette srnokinq,

FORM

even 1 or 2 puffs? Do you currently

5. During the past 30 days, did you use chewing tobacco, snuff, or dip?

Yes
0

No

0
0
0
0
0
0
0

0
0
0
0
0
0
0

for more than

smoke?
'

6. During the past 30 days, have you had a least 1 drink of alcohol?
7. Have you ever taken steroid pills or shots without a doctor's prescription?
8. Have you ever taken any supplements
to help you gain or lose.weiqht or improve your performance?
9. Questions from the Youth Risk Behavior Survey (http://www.cdc.gov/HealthyYouth/yrbslindex.htm)
on guns, seatbelts, unprotected sex, domestic violence, drugs, etc.
Not~:

',..:::.:-=.::..::..:.:..:
.:--': ~'...:..:-:::::- NORMAl.-- ...-.--......- ~-: ...=t':": ABNORMALFJNDINGS _.~- ..- .... -:-:- ..... .'INITIALS
.~.. ~ .
MEDICAL
Appearance
EyeslEarsINoselThroat
Hearing
Lymph nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary

(m.olesonlyY

Skin
MUSCULOSKELETAl
Neck
Back

Shoulder/arm
Elbow/forearm
Wrist/handlfingers
Hiplthlgh
Knee

Leg/ankle
Footltoes
'Mul!lple-examne<

sel-op

only.

Notes:

DOCTOR'S OFFICE STAMP REQUtRED_

Name of physician (print/type)

Date:

Addffi~,

Phone:

S~na~recl~y~cian.

_
_
~,MDmDO

Alhambra Unified Athletic Emergency and Insurance Information Form

High School:

Alhambra

Mark Keppel
(Please Circle One)

San Gabriel

Last

First

Schoollb

Address

City

Zip Code

School Attended Last year

F M Current Grade

Birthdate

Participated in Sport

(Please Circle One)

Sports/Activities Participating in this Year

(List all Sports)

1. Parent Consent: I hereby give consent for the above named student to compete in sports. I authorize the student to go with
and be supervised by a representative of the school on any trips. In the event this student I here by authorize an AUSD
Coach or Administrator to have an X-ray examinations, anesthetic, Medical or surgical diagnosis or treatment and
hospital care which is deemed advisable by anyone licensed under the provision of the "Medical Practice Act'.
2 Awareness of Risk: I have read the warnings to students and parents and understand it terms.
3. My son or daughter has permission to participate in the interscholastic athletic program and to be transported
to contests by school bus or designated private vehicle.
4. Certificate of Insurance: This to certify that there is in force an insurance policy which provides Medical and hospital expense benefit
and that such protection meets requirements of Section 32221 if the California Education Code. (Insurance applications available at school.

Insurance Company
Name of Insured

Policy Number
"'Myers Stevens
Y
N
(Please Circle One)
.(Alternative insurance plan offered for those non-covered)

-----------------------------

Doctors Name

Doctor Phone Number

HmlWk Phone Number

Father/Guardian Name

Cell Phone
HmlWk Phone Number

Mother/Guardian Name

Cell Phone
Non/Parent/Guardian Contact
or Emergency Contact

-----------------------------Name

Name of Parent/Guardian
FOR OFFICE USE ONLY
Academic Eligibility:
Health Clearance:

Signature

Eligible

Probation

----~--~~--~~-------Date of Physical

HmlWk Phone Number

Cell Phone

Date

Ineligible

Approved by
Revised 4/10/15

Alhambra

Unified School District Athletics

WAIVER OF LIABILITY AND RELEASE:

I hereby give my consent for the below-named student to compete and participate in the Alhambra
Unified School District approved activity program referenced on this form and to travel with the school
representative on authorized school trips, if applicable. I, the undersigned, hereby release and discharge
the Alhambra Unified School District, its officers, employees, agents, servants and volunteers (herein
collectively referred to as District) from any and all liability arising out of or in connection with the
above-described activity or all liabilities associated with any and all claims related to such activity that
may be filed on behalf of or for the above-named minor/student. For the purposes of this agreement,
liability is defined as all claims, demands, losses, causes of action, suits or judgments of any and every
kind that occurs during the above-described activity and that results from any cause including the active
or passive conduct and lor negligence of the District or its staff and personnel.
I also acknowledge on my behalf and on the behalf of the below-named minor/student that there are risks
that are inherent in the above described activity, including the risk of serious injury or death that may
occur through the conduct of the activity itself, participants, coaches, District, including conduct that may
not be part of the ordinary risks of the activity. Additionally, serious injury or death may occur through
conduct that is not authorized by the rules and regulations of the activity. This release and waiver as set
forth in the above paragraph shall also apply to all conduct and any resulting injury of death that occurs
thereby in whole or in part from any cause whatsoever.

I HAVE CAREFULLY READ THIS WAIVER AND FULLY UNDERSTAND THE WAIVER OF
LIABILITY AND RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS TERMS AND
CONDITIONS AND UNDERSTAND THAT BY SIGNING THIS DOCUMENT, I HAVE GIVEN
UP SUBSTANTIAL RIGHTS FOR MYSELF AND THE NAMED MINOR/STUDENT. I AM
AWARE THAT SERIOUS CATASTROPHIC INJURIES AND EVEN DEATH MAY RESULT IN
PARTICIPATION IN ANY ATHLETIC ACTIVITY.

Parent/Guardian

Student Name

April 3D, 2015

Signature

--------

Printed Name

Student ID #

--------------- Date -----Grade level

CIF Concussion Information Sheet

Why am I getting this information

sheet?

You are receiving this information sheet about concussions because of California state law AS 25 (effective January 1,
2012). now Education Code 49475:
1.
2.

3.

The law requires a student athlete whO may have a concussion during a practice or game to be removed from the
actMty for the remainder of the day.
~
Any athlete removed for this reason must receive a written note from a medical doctor trained in the management
of concussion before returning to practice.
Before an athlete can start the season and begin practice in a sport. a concussion information sheet must be
signed and retumed to the school by the athlete and the parent or guardian.

Every 2 years all coachesare .require.d.toreceive training about concussions (AS 1451).as well as certification
trainitlg; GPR, and AEDs (life-saving electrical devices that can be used during CPR).
.
What is a concussion

ill

First Aid

and how would I recognize one?

A concussion is a kind of brain injury. It can be caused by a bump or hit to the head, or by a blow to another part of the
body with the force that shakes the head. Concussions can appear in any sport, and can look differently in each person.
Most concussions get better with rest and over 90% of athletes fully recover. However, all concussions should be
considered serious. If not recognized and managed the right way, they may result in problems including brain damage
and even death.
Most concussions occur without being knocked out. Signs and symptoms of concussion (see back of this page) may show
up right after the injury or can take hours to appear. If your child reports any symptoms of concussion or if you notice
some symptoms and signs, seek medical evaluation from your team's athletic trainer and a medical doctor trained in the
evaluation and management of concussion. If your child is vomiting, has a severe headache, or is having difficulty staying
awake or answering simple questions, call 911 to take him or her immediately to the emergency department of your local
hospital.
On the elF website is a Graded Concussion Symptom Checklist. If your child fills this out after having had a
concussion, it helps the doctor, athletic trainer or coach understand how he or she is feeling and hopefully shows
improvement. We ask that you have your child fill out the checklist at the start of the season even before aconcussion
has occurred so that we can understand if some symptoms such as headache might be a part of his or her everyday life.
We call this a "baseline" so that we know what symptoms are normal and common for your child. Keep a copy for your
records, and turn in the original. If a concussion occurs, he or she should fill out this checklist daily. This Graded
Symptom Checklist provides a list of symptoms to compare over time (0 make sure the athlete is recovering from the
concussion.
What can happen if my child keeps playing with concussion
concussion?

symptoms or returns too soon after getting a

Athletes with the signs and symptoms of concussion should be removed from play immediately. There is NO same day
return to play for a youth with a suspected concussion. Youth athletes may take more time to recover from concussion
and are more prone to long-tenn serious problems from a concussion.
Even though a traditional brain scan (e.g., MRI or CT) may be "normal", the brain has still been injured. Animal and
human research studies show that a second blow before the brain has recovered can result in serious damage to the
brain. If your athlete suffers another concussion before completely recovering from the first one, this can lead to
prolonged recovery (weeks to months). or even to severe brain swelling (Second Impact Syndrome) with devastating
consequences.
There is an increasing concern that head impact exposure and recurrent concussions may contribute to long-term
neurological problems. One goal of this concussion program is to prevent a too early retum to play so that serious brain
damage can be p.revented.

Slurred speech
Shows a change in personality or way of acting
Can't recall events before or after the injury
Seizures or has a fit
Any change in typical behavior or personality
Passes out

Looks dizzy
Looks spaced out
Confused about plays
Forgets plays
Is unsure of game, score, or opponent
Moves clumsily or awkwardly
Answers questions slowly

Headaches
"Pressure
in head"

Nausea
or
throws up

Neck
pain

Has trouble standing or walking

Blurred, double, or fuzzy vision
.
,Bo~he.re~,bylight or~fI()i;>~,.
Feeling
sluggish
or
slowed
down

Feeling foggy or groggy

Drowsiness
Change in sleep patterns

.,

..

"

loss of memory
"Don'tfeel right'
Tired or low energy,.
Sadness
Nervousness or feeling on edge
Irritability
More emotional
Confused'
Concentration or memory problems
Repeating the same question/comment

What is Return to Learn?

Following a concussion, student athletes may have difficulties with short- and long-term memory, concentration and
organization. They will require rest while recovering from injury (e.g., avoid reading, texting, video games, loud movies),
and may even need to stay home from school for a few days. As they return to school, the schedule might need to start
with a few classes or a half-day depending on how they feel. If recovery from a concussion is taking longer than
expected, they may also benefit from a reduced class schedule and/or limited homework; a formal school assessment
may also be necessary. Your school or doctor can help suggest and make these changes. Student athletes should
complete the Return to Learn guidelines and return to complete school before beginning any sports or physical activities,
unless your doctor makes other recommendations. Go to the CIF website (cifstate.org) for more information on Return to
Learn.
How is Return toPlav (RTP) detennined?
Concussion symptoms should be completely gone before returning to competition. A RTP progression involves a gradual,
step-wise increase in physical effort, sports-specific activities and the risk for contact. If symptoms occur with activity, the
progression should be stopped. If there are no symptoms the next day, exercise can be restarted at the previous stage.
RTP after concussion should occur only with medical clearance from a medical doctor trained in the evaluation and
management of concussions, and a step-wise progression program monitored by an athletic trainer, coach, or other
identified school administrator. Please see cifstate.org for a graduated return to play plan. {AB 2127, a CaNfomia state
law effective 111115,states that return to play (i.e., full competition) must be no sooner than 7 days after the concussion
diagnosis has been made by a physician.]
Final Thoughts

for Parents and Guardians:

It is well knpwn that high school athletes will often not talk about signs of concussions, which is why this infonnation sheet
is so important to review with them. Teach your child to tell the coaching staff if he or she experiences such symptoms, or
if he or she suspects that a teammate has had a concussion. You should also feel comfortable talking to the coaches or
athletic trainer about possible concussion. signs and symptoms that you may be seeing in your child.
References:
American Medical Society for Sports Medicine position statement: concussion in sport (2013)
Consensus statement on concussion in sport: the 4th Intemational Conference on Concussion in Sport held in Zurich. November 2012
http:IAvww.c.qovlconcuSsionlHeadsUplyouth.html
OF5'2015
OFSfA1ECRJ

;", .

Concussion Information Sheet

Please Return this Page
I hereby acknowledge that I have received the Concussion Information Sheet from my school and I have read and
understand its contents. I also acknowledge that if I have any questions regarding these signs, symptoms and the
"Return to Learn" and "Return to Play" protocols I will consult with my physician.

Student-athlete

Patentor

Name Printed

LegalGuardian Printed'

Student-athlete

Signature

Parent or Legal Guardian Signature

Date

Date

109"32PineStntet

Telephone: 562-493-9500
Fax: 652-493$266

Los "AlllmitO$, .c'DllfomID$07-20.

Code of Ethics - Athletes

Athletics is an integral part of tbeschool's total educational program. All school actiVities, curricular and extracuiTicular, in the classtoomand on the playing field, must be congruent with the school's stated goals and
objectives established for the intellectual, physical, social and moral development ofits5tudents. It is within this
context that the following Code of Ethics is presented.
As an athlete, I understand that it is my responsibility to:
1. Place academic achievement as the highest priority.
2. Show respect for teamm ates, opponents, officials and coaches.
3. Respect the. integrity arid judgmeniof game officials.
4. Exhibit falr' play, sportsmanship and proper conduct on and off the playing field.
5. MaintaIn a high level of safety awareness.
6. Refrairi'fro'm the use of profanity, vulgarity and c(her offensive language and gestures.
7. Adhere to the established rules arid standards of the game to be played.
8. RespectalJ equipment and use it safely and appropriately.
9. Refrain'froiTitheuse of-alcohol, tobacco, iUegaland non-presCriptive drugs. anabolic steroids or
any.sob"staneeto increase physical deVelopmeritCir performartce that is.nc( approved by the
UriitedSlates.Food and Drug AdministratiOn. Surgeon General cifthe United States or American
Medical Association.
10. KnoW and follow allstate, section and school athletic rules and regulations as they pertain to
'eligibilityand sports participation.
11.\Mnwith character, lose With dignity.
As a conditiorYof membership in th'eCIF,all schools Shall adopt pOlicies prohibitingthe USeand abuse of
anqrogriic/anabolic.$t'i:!rolds. Allmernberschools.shall'have
panicipatingstiJdentsand their parents, legal
gtiarai~ntcar~glverag;'ee that.the athletewill not use steroids Withou!theWrltteiipreScription of a fully licensed
physIcian {as recognized by the AMA) to treat a medical condition (ArtiC/e'.523)~
Bysigning/;lelow;bofh the participating student athlete and the parents, legal guardianlcaregiverhereby agree
thatlhe .student .shaDnot use androgenic/anabolic steroidswithoufthe wriiten prescripfion of a fully licensed
physician (as recognized by theAMA) to treat a medical condition. We recognize that under CIF Bylaw
'202, there:could pe penalties for falseorfraudulent information.
We also understand that the
(schooVschool district name)
policy regarding the use of illegal drugs will be: enforced for any violations of these rules.

Printed Name of Student Athlete

Signature of Student Athlete

Date

Signature of Parent/Caregiver

Date

A copy of this form must be kept on lile in the athletic director's office at the local high school on an annual basis
and the Principal's Statement of Compliance must be on file at theCIF Southern Section office.
Revised 7/12

265

,-

---

Alhambra

Unified School District

Parent /Guardian Code of Conduct

The purpose of the Parent Code of Ethics is to develop parental support and positive role models in all
Alhambra Unified High'School athletic activities. Everyone involved in sports programs has a duty to
assure that the programs impart important

life skills and promote the development

Therefore we believe in the following and expect that as a parent/guardian

School District student/athlete

of good character.

of an Alhambra Unified

you will abide by the following:

Be a positive role model for my student, the school and the community.

Show respect for the opposing players, coaches, spectators and support groups.

Be respectful of all official's decisions.

Display a positive attitude and behavior.

Recognize and show appreciation

Assist in providing for student safety and welfare at all times.

Inform my student athlete of the dangers of using any illegal drug, alcohol, tobacco or steroids.

Do not confront or seek to conference with coaches or officials during or immediately

for an outstanding

play by either team.

game, except in cases of injuries or emergency medical treatment

after the

of their student.

Understand that playing time is not guaranteed in high school athletics.

Encourage my student athlete to attend school and excel academically.

Encourage my student to follow all guidelines in the athletic code of conduct.

Grievance Procedure

Grievances should not be addressed during or after a game or practice. If a situation arises where a
parent /guardian wishes to meet with a coach or address a specific issue, the following steps should be
followed:

Request a meeting at school with the coach.

If unresolved, arrange an appointment

with the athletic director.

If your problem is still unresolved, arrange an appointment

with the school administrator

in

charge of athletics.
We have read and agree to the policies stated in the Parent Code of Conduct regarding the conduct of
parents/guardians

of Alhambra

Unified School District students participating

below, we agree to abide to the Alhambra

Father/Guardian's

Grade:

Name (Please Print)

Name (Please Print)

By signing

Unified School District Parent Code of Conduct.

Students Name:

Mother/Guardian's

in athletics.

Mother/Guardian's

Father/Guardian's

Signature

Signature

ID #

Date

Date