SPORTS PHYSICAL PACKET

IF THE DATE OF THE PHYSICAL EXAM IS MORE

THAN 60 DAYS FROM THE FIRST PRACTICE

SESSION, A HEALTH HISTORY UPDATE FORM

MUST BE COMPLETED AND SIGNED BY THE

STUDENT AND PARENT.

CHECKLIST FOR NEW PHYSICALS

Health History Questionnaire,,

Physical Evaluation Form

Read Steroid Testing Form

Read Concussion Form

Read Sudden Cardiac Death in YoungAthletesSign Acknowledgement form that you haveread all 3 fact sheet/policies

.

Booster Club Membership Form

TAKE ENTIRE PACKET TO EMO FORSTAMP OF APPROVAL

*Put into the sports specific drawer on the

counter in the Main Office.

THIS PAC~T MUST BE APPROVED BY!

EMO PRIOR TO BEING TURNED IN. THISLETTER REMAINS WITH THE PHY$ICA__~L

NEW PROVIDENCE SCHOOL DISTRICT356 ELKWOOD AVENUE

NEW PROVIDENCE, N3 07974

PARENT NOTIFICATION LETTER

Date:

Dear Parent/Guardian:

This letter serves as written notification that your son!daughtercan/cannot (circle one) participate in spoils for the 2013-2014 school yea" pursuant toN,J.A.C. 6A: 16-2.2. Please be advised that this letter reflects the recommendationof the examining physician who completed and signed the Athletic Pre-Pa!"dcipationExamination Form (Parts A and B) submitted to the school on behalf of your son!daughter.

If your child is deemed unabte to participate based on an incomplete form, please ensurethat the origina! examining physMan completes the folm and returns it to the school to bereviewed for eligibility,

Thank you for your cooperation,

Sincerely,

School Physie, iardEMO Physician Name

School Physician/EMO Physician Signature

~MO ZS rOCA~ A~:3 69 SPRINGFIELD A VENUE

(908) 464-6700

New Jersey Department of EducationANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM

.Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining providerPart B: PHYSICAL EVALUATION FORM-Completed by examining licensed providerwith MD, DO, APN or PA

Today’s Date:.

Part A: HEALTH HISTORY QUESTIONNAIRE

Date af Last Sports Physical;

Student’s Name: Sex: M F (circle one)

Date of Birth: __/ /. . School:

spo.(si:Provider Name (Medical Home): Phone:

Age: __

District:

Home Phone: (~

Fax:

Grade:

EMERGENCY CONTACT INFORMATION

Name of parent/guardian:

Phone (work)t

Additional emergency contact:

Phone (work):

Phone (home):.

Phone (home):.

Relationship to student:

Relationship to student:

Phone (cell):

Phone (cell):

Directions’.. Please answer the following questions about the student’s medlcal history by C]RCUNG the correct response. Explain all"yes" responses on the lines below the questions, Please respond to all questions,

1. Have you ever had, or do you currently have:a. Restriction from sports for a health related problem? Y / N / Don’t Knowb. An iniury or illness since your last exam? Y / N / Don’t Knowc. A chronic or ongoir~g illness (such as diabetes or asthma)? Y / N / Don’t Know

(1.) An inhaler or other prescription medicine to control asthma? Y 1 N / Don’t Knowd. Any prescribed or over the counter medications that you take on a regular basis? Y / N / Don’t Knowe. Surgery, hospitalization or any emergency room visit(s)? Y 1 N / Don’t Knowf. Any allergies to medications? Y/N / Don’t Knowg. Any allergies to bee stings, pollen, latex or foods? Y / N / Don’t Know

(1.) If yes, check type of reaction:[] Rash [] Hives [] Breathing or other anaphylacttc reaction

(2.) Take any medication/Eplpen taken for allergy symptoms? (List below,) Y / N / Don’t Knowh. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Don’t Knowi. A blood relative who died before age 50? Y / N / Don’t Know

Explain all "yes" answers here (include relevant dates):

List all medications here:Medication Name Dosage

NID OE/APPEF 10/07Part APage 1 of 3

Use of this £onn is required by N,J.A.C. 6A:16-Programs to Support Student Development

2. Have you ever had, or do you currently have, any of the following head-relatedconditlons’.a, Concussion or head inju~ (including "bell rung" or ab. Memory loss?c. Knocked out?c. A seizure?d. Frequent or severe headaches (With or without exercise)?e, Fuzzy or blurry visionf. Sensitivity to light/noise

Explain all "yes" answers here (include relevant dates):

Y / N / Don’t KnowY l N / Don’t KnowY 1 N I Don’t KnowY/N/Don’t KnowY / N / Don’t KnowY f N l Don’t KnowY / N / Don’t Know

Have you ever had, or do you currently have, any of the following heart-~’elatedcondltions;a, Restriction from sports for heart problems? Y ! N t Don’t Knowb. Chest pain or discomfort? Y ! N l Don’t Knowc. Heart murmur? Y / N / Don’t Knowd. High blood pressure? Y ! N ! Don’t Knowe, Elevated cholesterol level? Y I N 1 Don’t Knowf. Heart infection? Y / N/Don’t Knowg. Dizziness or passing ouI during or after exercise wilhout known cause? Y ! N ! Don’t Knowh. Has a provider ever ordered a heart test ( EKG, echocardlogram, stress test, Halter monitor)? Y 1 N 1 Don’t Knowi. Racing or skipped heartbeats? Y / N I Don’t Knowj. Unexplained difficulty breathing or fatigue during exercise? Y ! N l Don’t Knowk, Any family member (blood relative): ,

(1 ,) Under age 50 with a heart condition? Y / N I Don’t Know(2,) With Marian Syndrome? Y t N / Don’t Know(3,) Died of e heart problem before age 50? If yes, at what ago? Y [ N ! Don’t Know(4,) Died with no known reason? Y I N I Don’t Know(5.) Died while exercising? If yes, was it during or after? (Circle one.) Y ! N t Don’t Know

Explain all "yes" answers here (include relevant dates):

Have you ever had, or do you currently have, any of the following aye, ear, nose, mouth or threat conditions;a, Vision problems? . Y 1 N/Don’t Know

(t ,) Wear contacts, eyeglasses or protect:lye eye wear? (Circle which type,)b, Hearing loss or problems?

(1,) Wear hearing aides or Implants?c, Nasal fractures or frequent nose bleeds?d, Wear braces, retainer or protective mouth gear?e, Frequent strap or any other conditions of the lhroet (e,g, tonsillitis)?

Y / N / Don’t KnowY 1 N 1 Don’t KnowY / N 1 Don’t KnowY ! N ! Don’t KnowY / N I Don’t KnowY / N 1 Don’t Know

Explain a!l "yes" answers hero (include relevant dates):

5. Have you ever had, or do you currently have, any of the following neuromuscular/orthopad/c cond/t/bn~a. Numbness, e "bu[ne¢’, "cringer or pinched nerve?b, A sprain?c. A strain?d. Swelling orpain In muscles, tendons, bones or joints?e, Dislocated joint(s)?f. Upper orfower backpain?g, Fracture(s), stress fracture(s), or broken bone(s)?h. Do you wear any protective braces or equipment?

Explain all (yes) answers here (include relevant dates):

Y / N / Don’t KnowY 1 N / Don’t KnowY / N / Don’t KnowY / N 1 Don’t KnowY / N / Don’t KnowY / N / Don’t KnowY 1 N 1 Don’t KnowY / N 1 Don’t Know

14ID OEIAPPEF 10/07Part A Page 2 of 3

of this fore; ~s required by N, £A,C, 6A: 16..Progra~ to Support

Have you ever had or do you currently have any of the following general or exercise related cond/tion~,e. Difficulty breathing?

(1,) During exercise?(2.) After running one mile?(3,) Coughing, wheezing or shortness of breath in weather changes?(4.) Exercise-induced asthma?

I. Controlled with medication? (specify .)l], Experience dizziness, passing out or feinting?

b. Vtral Infections (e.g. mona, hepatitis, coxsaclde virus)?c, Become tired more quickly than others?d. Any of the following skin conditions:

(1,} Cold sores/herpes, impetigo, MRSA, ringworm, warts?(2.) Sun sensitivity?

e. Weight gain/loss (of 10 pounds or more)?(1.) Do you want to weigh more or tess than you do now?

f. Ever had feelings of depression?g. Heat-related problems (dehydration, dizziness, fatigue, headache)?

(1.) Heat exhaustion (coo[, clammy, damp skin)?(2.) Heat stroke (hot, red, dry skin)?(3.) Muscle cramps?

h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)?

Explain all "yes" answers here (include relevant dates):

Y ] N / Don’t KnowY I N ! Don’t KnowY I N [ Don’t KnowY 1 N ] Don’t KnowY I N / Don’t KnowY / N / Don’t KnowY / N / Don’t KnowY I N I Don’t Know

Y / N t Don’t KnowY ! N / Don’t KnowY I N I Don’t KnowY ! N t Don’t KnowY 1 N 1 Don’t KnowY ! N / Don’t KnowY 1 N / Don’l KnowY ! N ] Don’t KnowY / N I Don’t KnowY t N I Don’t Know

7, Females only:Age of onset of menstruation:~ How many menstrual periods in the last twelve (12) months?

How many periods mtss~d In the last twelve: (12) months?

8. Males only:Have you had any swelling or pain In your testicles or groin? Y 1 N / Don’t Know

i certify that the information provided herein is accurate to the best of my knowledge as of the date of mysignature.

Signature, Parent/Guardian or Student Age 18 Date of Signature:

THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THEEXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.

N]DOE/APPE1~ 10/07Part A Page 3 of 3

Use ofth~s form is required by N,J,A,C, 6A:16.Programs to Sttpport Sttcdetff 1)evetopment

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORMPart B: Physical Evaluation Formo

(Completed by the examining licensed provider MD, DO, APN or PA)

-STUDENT INFORMATION-

Student’s Name:Sex: M F (circle one) Age;,Address:Clty./StateJZip;.Schooi:Peren~Guardlan’s Full Name:

Grsde;spot(s):

Date of Birth:

Home Phone:District:

- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATION-If conducted by school physician check hare EI

Name: Phone: Fs×:

Address: City/State/ZlpL

¯ - FINDINGS OF PHYSICAL EVALUATION

Height: Weight: Blood Pressure: ~/.~ PuIse: ~bpm,

Vision: R 20/..~ L 20/~

Ge~er~i_App_eara_nceHead/NeckEyes/S~:lera)PupJis ........Ears

Gross Hearing~N~se/.M~ outh/ThroatLYmph GIandsC a rdi ovascula r .,

Heart Rate......Rhythm .Murmur

ill m~rmur present

Corrected: Y / N

NORM,~L?

YES~ESrYESYESYESYE~ ..... t,YESYESYESYES....

ABSENT.:’.,.:’..’::’:,,::;?’:.:.::?.:~:’:’.:’:;i" ~~rna~es It: ~oud~er

F~mordi PulSes ......... YESL#ngs: Auscultation/P~rcussion ........ . YESChest Contour YESSkin YESAbdom~en (}iyer, sj~lee.n, m.a.sses_) ................. ~ES "Assessment of physic, a[ maturation or YESTanner ScaleTesticuler E-xam~Uales Only) ’Neck/Rack/Spine; _

. Range of Motion _ . .Scollosis

YESYESYES

ABSENTupper ~xtr~,~ni/le~: (RbM, ~St~rength, ............... ~ES -Stability) ,,Lower Extremities: (ROM, Strength, YESStability)Neurological: B~en~e’& Coordination YESHernia ABSENTEvidence of Marian Syndrome ABSEN~

Contacts’. Y / N Glasses: Y 1N

ABNORMAL FINDINGS/COMMENT8

Squatting makes it: LouderValsalve makes It: Louder

Softer8citerSofter

-No Chang#No Change ._

N.ff3QE/APPEF 10/07

Part B :Page i of 4

Use of this form is required by N,LA,C, 6A: 16.Programs go Support Student Development

Most recent immunizations and dates admtntsterod:

Medications currently prescribed, with dos_e add frec~uen, ~y:

_

Additional observations:

General Dlagnosis:

General Recommendations’,

THE HISTORY PREPARED BY THE PARENTISTUDENT MUST BE REVIEWED BYTHE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.

N~DOE/APPEF 10/07

Part B Page 2 of 4

Use of this form is require~[ by N, LA, C, 6A:16.Progratns to 8ttpport Stuarent Development

":i.:~l EARANCES: (See notes at bottom~or�on~ltio~S mq~JrJn~ a~te~iio~&nd~r a Jist o~~ ~;i&~ib~ (~~{&(~ii.i!iii;I

A, Student is cleared for participation in all sports without restriction.

B. Student is withheld clearance for participation in any sport until evaluation I treatment of:

C, Student is cleared for participation in llmited types of sports which exclude the following types of sportsco nta ct’, (CHECK ALL THAT APPLY) ..

CONTACTtCOLL1SIONLIMITED CONTACT

~ NON-CONTACT/STRENUOUS__ NON-CONTACT/NON-STRENUOUS

Due to:

HISTORY REVIEWED AND STUDENT EXAMINED BY:

Primary Care ProviderSchool Physician ProviderLicense Type’,

MDIDOAPNPA

Physician’s/Provider’s Stamp:

PHY$1C1AN~$/PROVtDER’8 SIGNATURE; Today’s Date:,

Date of Exam:

HISTORY REVIEWED BY:

Name Today’s Date:

SIGNATURE: Review Date:

NiID OE/APPBF 10/07

PartB Page 3 of 4

Use of this form is required by N, LA.C, 6A: [ 6-Programs to Support Student Development

Conditions requiring clearance before sports participation Include, but are not limited to the following:

Anaphylaxis; Atlantoaxial Instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmla; Mitral valve prolapse;Heart murmur; Cerebral palsy; Diabetes mel]itus; Eating disorders; Heat Illness history; One-kidney athletes; Hepatomegaly,Splenomegaly; Malignancy; Seizure Disorder; Marian Syndrome; History of repeated concussion; Organ transplant recipient; Cysticfibrosis; Sickle celt disease; andlor One-eyed,athletes or athletes with vision greater than 20140 in one eye,

Contact/Collision~:!:~#:.;!’;:.:.:::-:i i~;;i~;~.:.:i’:-bi ::" ¯ ::#:~-~;’Z:.::::’, ¯:

BasketballDiving

Field Hockey IFootball

Ice Hockey ,LacrosseSoccer

Wrestli~.

.,SAMPLES 6[= CLASSIFICATION O[= 8PORT8 BY CONTACTLimited Contact

i!~:.:-.~!~;’?..’.:;::~!.:~r~:,:":::’.:"::: ’:..::!~..’.!.!~:.i!!i~!~z.::,! ’~.!;i:i..:~i~!:’...:.’.":.:Baseball..............

Cheerleading,,, Feqc.lng

High JumpPole vault

....... Gymnastics ....I I Skiing .

SoftballVolleyball

Non-Contact,Strenuous

Discus.......JavellnShot putRowing

I Running/Cross CountryStrength Training ....

Swimming,TennisTrack

Non-strenuousBowling

Golf,

N.J.A.C. 6A:t6-2.2 requires the school physician to provide written notification to the parent/legal guardian statingapproval or disapproval of the student’s participation in athletics based on this physical evaluation. This evaluation andthe notification letter become part of the student’s school health record.

Effects of physiologic maneuvers on heart sounds:

Standing Increases murmur of HCMDecreases murmur of AS, MRMVP click occurs earlier in systole

Squatting Increases murmur of AS, MR, AIDecreases murmur of MCHMVP click delayed

Valsalva Increases murmur of HCMDecreases murmur of AS, MRMVP click occurs earlier in systole

HCM = Hypertrophic Cardio MyopathyAS = Aortic StenosisA1 = Aortic InsufficiencyMR = Mitral RegugitationMVP = Mitral Valve Prolapse

Physical Stigmata of Marian’s Syndrome

KyphosisHigh arched palatePectus excavatumArachnodactylyArm span > height 1.05:1 or greaterMitral Valve ProlapseAortic insufficiencyMyopiaLentlcula r dislocation

NJDOE/APPEF 10/07

Part B Page 4 of 4

Use of this form is required by N,LA,C, 6A: 16.Programs lo Support Student Development

416t Route 1,30, P,O, B9×487, Robbinsville, NJ 08691 609-259-2776 609-259-3047-Fax

NJSIAA’S STEROID TESTING POLICy

" Ir~ aeeot-dane ~ with-Ex~ eufi~¢~ O fd~t-72,- i a s~edb-y-th~-Go-v-em-or, gf:th~-St die ~ fNew-Jets ~y; Ri-eha~d .................J. Codey, on December 20, 2005, the NJSIAA will test a random selection of student athletes, whohave qualified, as individuals or as members of a team, for state championship competition.

1. ,General prohibition aeainst performance enhancin~ dru,~A. It shall be considered a violation of the NJSIAA"~ sportsmanship role for any

student-athlete to "possess, ingest, or otherwise use any substance on the list ofharmed substances, without mitten prescription by a fully licensed physician, asrecognized by the American Medical Association, to treat a medical condition.

B. Violations found as a result of NJSIAA’s testing shall be penalized in accordancewith this policy.

C. Violations found as a result of member school testing shall be penalized inaccordance with the school’s policy.

2. List of banned substances:

A list of banned substances shall be prepared annually by the Medical AdvisoryCommittee, and approved by the Executive Committee. (See list)

3. Consent form:

Before participating in interscholastic sports, the student-athlete and the student-athlete’sparent or guardian shall consent, in writing, to random testing in accordance with thispolicy.. Failure to sign the consent form renders the student-athlete ineligible.

4. Selection of athletes to be tested:

A. Tested athletes will be selected randomly from all of those athletesparticipating in championship competition.

B. Sixty percent of all tests shall be from football, wrestling, track & field,swimming, lacrosse and baseball. The remaining forty percent of all testsshall be from all other NJSIAA sports.

5. Administration of tests:

Tests shall be administered by a certified laboratory, selected by the Executive Directorand approved by the Executive Committee.

6. Testin~ methodolo~The methodology for taking and handling samples shall be in accordance with currentlegal standards.

7. Sufficiency of results:

10.

11.

12.

No test shall be considered a positive result unless the approved laboratory reports apositive result, and the NJSIAA’s medical review officer conftrms that there was nomedical reason for the positive result. A "B" sample shall be available in the event of anappeal.

Appeal process:If the certified laboratory reports that a student-athlete’s sample has tested positive, andthe medical review officer confirms that there is no medical reason for a positive result,a penalty shall be imposed unless the student-athlete proves, by a preponderance of theevidence;¢hat-he or she-bears--no =fault=or--~egligenoe ffor--the:violation~Appeals shall:be: " -- : ---: " "heard by a NJSIAA committee consisting of two members of the Executive Committee,the Executive Dkector/designee, a trainer and a physician. Appeal of a decision of theCommittee shall be to the Commissioner of Education, for public school athletes, and tothe superior court, for non-publio athletes. Hearings shall be held in accordance withNJSIAA By-Laws, Article XIII, "Hearing Procedure."

Penalties

Any person who tests positively in an NJSIAA administered test, or any person whorefuses to provide a testing sample, or any person who reports his or her own violation,shall immediately forfeit his or her eligibility to participate in NJSIAA competition for aperiod of one year from the date of the test. Any such person shall also forfeit anyindividual honor earned while in violation. No person who tests positive, refuses toprovide a test sample, or who reports his or her own violation shall resume eligibilityuntil he or she has undergone counseling and produced a negati~ve test result.

Confidentialit-v:,Results of all tests shall be considered confidential and shall only be disclosed to theindividual, his or her parents and his or her school.

,Compilation of results:

The Executive Committee shall annually compile and report the results of the testingprogram.

Yearly renewal of the steroid policy:,

The Executive Committee shall armually determine whether this policy shall be renewedor discontinued.

June 8, 2006

-2-

’~ ~ "~.~! :~" ’"¯

1t6t Route ~30, P.O. Box487, Robbinsville, NJ 08691 609.2~9-2776 609-259-3047-Fax

NJSIAA STEROID TESTING POLICY

CONSENT TO RANDOM TESTING

In Executive Order 72, issued December 20, 2005, Governor Richard Codeydirected the New Jersey Department of Education to work in conjunction with theNew Jersey State Interscholastic Athletic Association (NJSIAA) to develop andimplement a program of random testing for steroids, of teams and individualsqualifying for championship games.

Beginning in the Fall, 2006 sports season, any student-athlete who possesses,distributes, ingests or otherwise uses any of the banned substances on the attachedpage, without written prescription by a fully-licensed physician, as recognized by theAmerican Medical Association, to treat a medical condition, violates the NJSIAA’ssportsmanship rule, and is subject to NJSIAA penalties, including ineligibility fromcompetition. The NJSIAA will test certain randomly selected individuals and teamsthat qualify for a state championship tournament or state chain, pionship competitionfor banned substances. The results of all tests shall be considered confidential andshall only be disclosed to the student, his or her parents and his or her school. Nostudent may participate in NJSIAA competition ur~less the student and the student’sparent/guardian consent to random testing.

By signing below, we consent to random testing in accordance with theNJSIAA steroid testing policy. We understand that, if the student or the student’steam qualifies for a state championship tournament or state championshipcompetition, the student may be subject to testing fbrbanned substances.

PLEASE SIGN ON ACKNOWLEDGMENT FORM

(LAST PAGE)

June 8, 2006

Route130, P.O, Box4.87, .Robbinsville, NJ 08691 609-259-2776 609-2~9-3047-Fax

........................................ NJSIAA Banned-_Drug .Classes2006.2007

The term "related compounds" comprises substances that are included in the class by their pharmacological action andlor chemicalstructure. No substance belonging to the prohibited class may be used, regardless of whether it is specifically listed as an example.

Many nutritionalldietary supplements contain NJSIAA banned substances. In addition, the U. 8. Food and Drug Administration (FDA)does not strictly regulate the supplement industry; therefore purity and safety of nutritional dietary supplements cannot be guaranteed.impure supplements may lead to a positive NJSIAA drug test. The use of supplements is at the student-athlete’s own risk,,Student-athletes should contact their physician or athletic trainer for further information.

The following is a list of banned-drug classes, with examples of banned

(a) Stimulants (b) Anaboli¢ Agentsamiphenazole anabolfc steroids,amphetamine androstenediolbemigride androstenedionebenzphetarnine boldenonebromantan clostebolcaffeine1 (guorana) dehydrochlormethyl-chlorphentermine testosteronecocaine dehydroeplandro-cropropamide sterone (DHEA)crothetarnide dihydrotestosterone (DHT)diethylproplon dromostanolonedimethylarnphetarnine epltrenbolonedoxaprarn fluoxymesteroneephedrine gestrlnone

(ephedra, ma huang) mesterotoneetharnivan methandienoneethylamphetamine methenolonefencamfaminernec!ofenoxaternetharnphetamfne methyltestosteronernethylenedIoxymethamphetamine nandrolone

(MDMA, ecstasy) norandrostenediolrnethylphenldate norandrostenedionenikethamide norethandrolonepemoline oxandrolonepentetrazoi oxymesteronephendimetrazine oxymetholonephenmetrazine pregnelonephenterrnine stanozololphenylpropanolamfne (ppa) testosterone2picrotoxine tetrahydrogestrinonepipradol (THG)prolintane trenbolonestrychnine and related compoundssynephrine ,other anabollc a.qents,(citrus" aurantium, zhi shl, bitter clenbuterolorange)

and related compounds

substances under each class:

(c) Diureticsacetazolarnidebendroflurnethlazfdebenzhlazidebumetanldechlorothiazldechlorthalidoneethacrynic acidflumethiazldefurosemidehydrochlorothtazidehydroflumenthfazldemethyclothlazldemetolazonepolythiazidequinethazonesplronolaotonetriamterenetrrchlormethlazideand related compounds

(d) Peptide Horrnones& Analogues:cortlcotrophin (AOTH)human chorionio gonadotrophin (hCG)leutenizing hormone (LH)growth hormone (HGH, sornatotrophin)insulin like growth hormone (IGF-1)

All the respective releasing factorsof the above-mentioned substancesalso are banned:erythropoletin (EPO)darbypoetin.sermorelin

([e)’ Definitions of positive depends on the following;1 for caffeine - if the concentration in urine exceeds t~ micrograms/ml

2 for testosterone- if administration of testosterone or use of any othermanipulation has the result of increasing the ratio of the totalconcentration of testosterone to that of epitestosterone in the urineof greater than 6:1, unless there is evidence that this ratio is due to aphysiological or pathological condition.

June 8, 2006

Spor~s-Rehted Concussion ~nd ]le~d Injury F~c~ Shee~ andPareRffGu~rdi~n Acknowledgement Form

A concussion is a brain injm’y tha~ can be caused by a blow to the head or body tha~-disrupts normalfunctioning of the.braiu. Concussions are a type of Traumatic Brain Injury (TBI), which can range from mildto severe and c~n disrupt the way the brain normally functions. Concussions can cause signi~canl. ~ndsustained neuropsychological im!0a~zmen~ affeclkng problem solving, planning, memory, a~lention,concentr&lion, and behavior.

The Ce~srs for Disease Control and Prevention es~kna~es tha~ 300,000 concussions are susfained d~ring spor~srela~ed activities nationwide, and more than 62,~J00 concussions are sus~akied each year in hig~ school contact.spp~s. Sec.o. ~d-impact syndrome occurs when a person sustains a second concussion while slill experiencingsymptoms of a prg~bus co~gf~&’i~Y If ~ le-ad~b~~ewre" inipakmentandeven death of-the-Mclkn~ ........................

1Vfost concussions do not involve loss of consciousnessYou can sustain a concussion even if you do not hi~ your head7k blow elsewhere on the body can Irmusmi~ m~ "impulsivg" force to the braiu mud cause a concussio~

Signs of Concussions (Observed by Co~ch, Athletic Trainer,,Parenl/Guard~an)Appears dazed or sltmned

~ Forgols plays or demonslra~es shor~ term memo~ d~oulties (e.g. ~s~o ofg~e, opponcnl)E~bits d~oMfies with ba]~co, coor~afion, concen~afio~ ~d a~enfion

~ ~wers questions slowly or ~acc~a~ly¯ Demo~rales behaver or personaH~ ch~ges¯ Is ~ablo ~o rec~ events prior io oz ~er ~o ~ qr f~

Symptoms of Concussion (R~por~d by¯ Headache .¯ N’aus ea/vomiliug ’¯ BalanceprobIems or dizziness~ Double vision or changes in v~sion

Sensfiivity to Hght/soundFeeling of sluggishness or fogginessDif~culby with concentration, sho~memory, and/or confusion

What Should a Student-Athlete do if they ~hhk they have a concussion?, Don~ hide it. Tell your Afllledo Trgner, Coach, School N~s%¯ Repor~ it Don’~ re~ ~o competition or prac~ce ~ s~p~oms of a concussion or head hj~. The

soone~ you repoA 1% ~e sooner you mayTake ~e to recover. If you ~vo a concussion yo~ br~ nee~ ~e ~o he~. ~o yo~ br~ ishe~g you ~e much more ~ely io sus~ a second concision, Repea~ concussions c~ causepe~cn~ br~ ~j~.

conc~ss~oa?To reoover octave rest is j~ as ~mpo~l ~ physicN rest. Rea~g, te~g, testNg-even wale~gmovies c~ slow do~ a s~dent-atNefes recovery.8lay home ~om school ~th ~al menM ~d scorn st~Nafion ~t~ ~ symptoms have8~dents may need to ~e rest bre~% spend Nwer ho~s at schoo!, be Nven e~a ~e to comploloassi~ent% as well as behg offered o~er ~s~c~ion~ s~ate~es and classroom

Sbaden~-Athle~es who have susINn~d a concussion should com~leIe a ~raduated re~nrn-te-pla~r before,they may resume com~efition or ~racflce, accordin~

8te~ 1: Completion of a ~ day of norM co~dve ao~M~es (school day, s~dyNg for te~s, watc~gNac~oe, NleraotNg wi~ peers) wi~out reemergenc~ of ~yne~ day advmce.Step 2: Light Aerobic exerois% wMoh

he~Step 3: Spo~-speo~c exercise NcNdNg skaiNg, ~or ~g: no head ~p~c~ aotM~es. Theof~s step ~s to add movementS~ep 4: Non contact ~g drills (e,g, passNg ~s). S~dent-a~etg may ~date resist~ce ~a~g.S~e~ 5: Fo~owNg medical cle~oe (consNia~on be~een s&ool heM~ c~e perso~eI ~d s~dent-atNete’s physioi~), pmMpal[on N no~ ~a~g aotMfies. The objective of tNs step is to restorecovalence ~d assess ~odonNSt~N 6: Re~ ~o play ivolvNg no~N exe~on or g~e aciivi~,

fu~her ~fonnation on Sports-Related Concussions and other Head Injuries, pIease visi.k.w~, ode. gov/concussion/sportsBndex.ht-M .www’.n_fl~s,comvcww.ncaa, orgihealth-safe .ly www.bian.i.,.org , www.atsnj..org.

PLEASE SIGN ON ACKNOWLEDGMENT FORM

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NEW PROVIDENCE HIGH SCHOOLATHLETIC/HEALTH DEPARTMENT

35 PIONEER DRIVENEW PROVIDENCE, NJ 07974

To Parents of all athletes,

Please review the attached brochure on Sudden Cardiac Death in Youn~Athletes and sign b.elov~ indicating that you have received and reviewed thedocument. Please return this document to your child’s coach and keep thebrochure for your information. Thank you. ~

Robel~ Harmer, Athletic DirectorCarol McCabe, School Nurse

PLEASE SIGN ON ACKNOWLEDGMENT FORM

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rebsite Resources

Sudden Death in Athletes at;www’-su d d end eath athletes.orq

-Hypertrophic Cardiomyopathy Associationwww.4hcm.orq

American Heart Associationwww.heart.orq

ollaboratin_q Agencies:

~erican Academy of Pediatrics~W Jersey ChapterJ36 Quakerbridge Road, Suite 1mniRon, NJ 08619,) 609-842-0014~ 609-842-0615ww.aapnLor(~

medcan Heart AssociationUnion Street, Suite 301obbinsville, NJ, 086910 609-208-0020ww.heart.or~

ew Jersey Department o~ EducationO Box 500renton, NJ 08625-0500

609-292-4469~ww.state.ni.us/education{

ew Jersey Department of Health~d S eniorS~rVio. Box360 cos

renton, NJ 08625-0360609-292-7837

...ww.state.nLus/health

~.ad Authon American Academy of Pediatrics, New Jersey Chap[or

fritten by:. initial draft by Sushma Raman Hebbar, MD & ~tephen G.ice, MD FhO

evisions by; Zvi Marans, MD, Steven Ritz, MD, Pen7 Weinstoc~Louis Teichholz, MD; Jeffrey Rosenberg, MD, Sarah Klelnman

IPH, CHES; Susan Mariz, 15dMo

dditlonal Reviewers: NJ Department of Education, NJ DeparlmentF Health and Senior Services, American Hear Association/Newo.rsey Chapter, NJ Academy of Family PracSca, Pedia~c Cardiolo-ists, New Jersey State School Nurses AssocJalJon

inal edi[lng: Stephen G. Rice, ME}, PhD-January 2011

N&vJersey Chapter

American Heart ~°..

Association

Learn and Live

SUDDEN CARDIAC DEATH iN YOUNG ATHLETES

S udden death in young athletesbetween the ages of 10 and 19is very rare. What, it= anything,can be done to prevent thiskind of tragedy?

What is sudden cardiac death in theyoung athlete?

Sudden cardiac death is the result of anunexpected failure of proper heart func-tion, usually (about 60% of the time) dur-ing or immediately after exercise withou~trauma. Since the heart stops pumpingadequately, the" athlete quickly col-lapses, loses consciousness, and ulti-mately dies unless normal heart rhythmis restored using an automated externaldefibrillatorHow common is sudden death inyoung athletes?Sudden cardiac death in young athletesis very rare. About 100 such deaths arereported in the United States per year.The chance of sudden death occurringto any individual high school athlete isabout one in 200,000 per year.

Sudden cardiac death is more common:in males than in females; in football andbasketball than in other sports; and inAfrican-Americans than in other racesand ethnic groups.What are the most common causes?Research suggests that the main causeis a loss of proper heart rhythm, causingthe heart to quiver instead of pumping

blood to the brain and body. This iscalled, ventricular fibrillation (ven-TRICK-you-/arfib-roo-LA Y-shun). Theproblem is usually caused by one ofseveral cardiovascular abnormalitiesand electrical diseases of the heartthat go unnoticed in healthy-appearingathletes.The most common cause of suddendeath in an athlete is hypertrophic car-diomyopathy (hi-per-TRO-fic CAR-dee-oh-my-OP-a-thee) also calledHCM. HCM is a disease ofthe heart,with abnormal thickening of the heartmuscle, which can cause serious heartrhythm problems and blockages toblood flow. This genetic disease runsin families and usually develops gradu-ally over many years.The second most likely cause is con-genital (con-JEN-it-al) (i.e., presentfrom birth) abnormalities of the coro-nary arteries. This means that theseblood vessels, are connected to themain blood vessel of the heart in anabnormal way. This differs from block-ages that may occur when people getolder (commonly called "coronary ar-tery disease," which may lead to aheart attack).Other diseases of the heart that canlead to sudden death in young peopleinclude:= Myocardib’s (my-oh-car-DIE-tis), an

acute inflammation of the heartmuscle (usually due to a virus).

Dilated cardiomyopathy, an enlarge-ment of the hear for unknown rea-sons.Long QT syndrome and other elec-trical abnor-malities of theheart whichcause abnor-mal fast heartrhythms thatcan also run infamilies.Marfan syn-drome, an in-herited disor-der that affectsheart valves,walls of major arteries, eyes and theskeleton. It is generally seen in un-usually tall athletes, especially if be-ing tall is not common in other fam-ily members.

Are there warning signsto watch for?In more than a third of these suddencardiac deaths, there were warningsigns that were not reported or takenseriously. Warning signs are:o Fainting, a seizure or convulsions

during physical activity.

Fainting or a seizure from emotionalexcitement, emotional distress orbeing startledDizziness or lightheadedness, espe-cially during exertionChest pains, at rest or during exer-tion

Palpitations - awareness of the heartbeating unusually (skipping, irregularor extra beats) during athletics or dur-ing cool down pedods after athleticparticipation

¯ Fatigue or tiring more quickly thanpeers

¯ Being unable to k~ep up with friendsdue to shortness of breath

What are the current recommenda-tions for screening young athletes?New Jersey requires all school athletes tobe examined by their primary care physi-cian ("medical home") or school physicianat least once per year. The New JerseyDepartment of Education requires use ofthe specific Annual Athletic Pre-Participation Physical Examination Form.This process begins with the parents andstudent-athletes answering questionsabout symptoms during exercise (such aschest pain, dizziness, fainting, palpita-tions or short-ness of breath); ",., ~;-.and questions ~ "-".about family ~4:.,~.:r:..-T;.. .health history.

The pdmaryhealthcare pro-vider needs toknow if anyfamily memberdied suddenly during phys.ical activity orduring a seizure. They also need to knowif anyone in the family under the age of50 had an unexplained sudden deathsuch as drowning or car accidents. Thisinformation must be provided annually for

each exam because it is so essential toidentify those at risk for sudden cardiacdeath.The required physical exam includesmeasurement of blood pressure and acareful listening ex-amination of theheart, especially formurmurs and rhythmabnormalities. Ifthere are no warningsigns reported onthe health historyand no abnormalitiesdiscovered on exam,no further evaluationor testing is recom-mended.When should a student athlete seea hear~ specialist?If the primary healthcare provider orschoo.i physician has concems, a referralto a child heart specialist, a pediatric car-diologist, is recommended. This special-ist will perform a more thorough evalua-tion, including an electrocardiogram(ECG), which is a graph of the e.lectdcalactivity of the heart. An echocardiogram,which is an ultrasound test to allow fordirect visualization of the heart structure,will likely also be done. The specialist ¯may also order a treadmill exercise testand a monitor to enable a longer re-cording of the heart rhythm. None of thetesting is invasive or uncomfortable.

Can sudden cardiac death be preventedjust through proper screening?A proper evaluation should find most, butnot all, conditions that would cause suddendeath in the athlete. This is because somediseases are difficult to uncover and mayonly develop later in lif~. Others can de-velop following a normal screening evalua-tion, such as an infection of the heart mus-cle from a virus.This is why screening evaluations and areview of the family health history need tobe performed on a yeady basis by the ath-lete’s primary healthcare provider. Withproper screening and evaluation, mostcases can be identified and prevented.Why have an AED on site duringsporting events?The only effective treatment for v.entricularfibrillation is immediate use of an auto-mated extemal defibrillator (AED). An AEDcan restore the heart back into a normalrhythm. An AED is also life-saving for ven-tricular fibrillation caused by a blow to thechest over the heart (commotio cordis).The American Academy of PediatricslNewJersey Chapter recommends that schools:

Have an AED available at every sportsevent (three minutes total time to reachand return with the AED)

o Have personnel available who aretrained in AED use present at practicesand games.

. Have coaches and athletic trainerstrained in basic life support techniques(CPR)

° Call 911 immediately while someone isretrieving the AED.

New Providence Board of Education

Concussion, Sudden Cardiac Death and Steroid TestingAcknowledgment Form

.

Please read the attached information sheets on Sports-Related Concussions andHead Injury, Sudden Cardiac Death in Young Athletes, and NJSlAA Steroid

testing. Please, print, sign and date the bottom of the page that you have readand understand the information provided, and return with the physical form. Ifyou have .any questions or concerns, please contact the School Nurse CarolMcCabe at (908) 464-4700 X642 or the Athletic Trainer Karen Magliacano at

(908) 464-4700 X361.

I have read the attached information on Sudden Cardiac Death. in Young Athletes. Iunderstand its contents. I have been given an opportunity to ask questions and allquestions have been answered to my satisfaction.

I have read the attached information on Sports-Related Concussions and Head InjuryFact Sheet. I understand its contents. I have been given an opportunity to ask questionsand all questions have been answered to my satisfaction.

I have read the attached information on NJSIAA Steroid testing policy. I understand itscontents. I have been given an opportunity to ask questions and all questions have beenanswered to my satisfaction. By signing below, we consent to random testing inaccordance with the NJSIAA steroid testing policy. We understand that, if the student orthe student’s team qualifies for a state championship tournament or statechampionship competition, the student may be subject to testing for bannedsubstances.

Parent/Guardian Name (print) Parent/Guardian Name (Signature),,,/ /

(date)

Student Name (print)/ /

Student (Signature) (date)

NEW PROVIDENCE HIGH $OHOOLNew Providence, NJ

September 2013To All Pioneer Families,

The NPH8 Athletic Booster Club’s mission is to support all of our High School sports programs offeredeach season. To help us accomplish this goal we would encourage every family to become a memberof the Athletic Booster Club by making a donation.

Here is a list of just some of the benefits we provide fdr our student athletes:Fall Kick Off Barbeque (for All Athletes, Cheerleaders, Marching Band)Fall, Winter & Spring Awards (All Trophies, Plaques, Varsity Letters, Pins,Certificates)Fall, Winter & Spring Programs with Team PhotographScholarships for four Senior AthletesSenior Banquet to honor all Senior AthletesFur~ds towards Team Championship recognition (Rings, Jackets, etc.)NEW! Coaches Wish List Program (to grant items not covered in the schoolbudget.)

Our funds are raised in the following manner:¯ Membership Drive¯ Fall, Winter & Spring Shack¯ Clothing Drives & Fall Plant Salee Spirit Wear

Various "Night Out" events (Pioneer Potluck Pigout, Bingo, etc.)

We have made great strides but we are in need of your assistance to continue these benefits to ourathletes. Please make an annual contribution to the NPHS Athletic Booster Club and help us to bettersupport your children.

Thank you,Laud~ Barbt~a.President

PS. Would you like to volunteer? Please consider joining the NPH8 ABO Executive Committee to volunteersome of your time and expertise to benefit our athletes! Indicate below and we will contact you. We are presentlyin need of help with graphics, volunteers for events, Shack help and grillem for the ,£hack!

Please send your contribution to: NPH8 Athletic Booster Club., 35 Pioneer Drive, New Providence, NJ07974 Attn: Treasurer

$280 & above-MVP CLUB; $tO0-PRESIDENT8 CLUB; $50-PIONEER CLUB; $2~-SPORTSMAN CLUB

Name;

Student Name(s)/Grade;Sport/Sports;

Donation/Le.vei:

__.Yes, In addition to my donation, ! would like to join the NPH8 ABC Executive Committee to ¯