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Medical School

Boston, Massachusetts, United States
October 15, 2016

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May 28, 2015

Welcome to Boston Public Schools Athletics! Thank you for your interest and commitment to participating in the athletics program. Athletic participation is based on satisfying all MIAA, Boston Public Schools and specific school rules, policies and procedures around athletics.

Fall Sports: Cheerleading, Cross Country, Football, Boys’/Girls’ Soccer, Girls’ Volleyball Winter Sports: Boys’/Girls’ Basketball, Boys’/Girls’ Hockey, Indoor Track, Swimming, Wrestling Spring Sports: Baseball, Outdoor Track, Softball, Boys’/Girls’ Tennis, Boys’ Volleyball First Practice First Game

Fall Season 8/24/15(FB), 8/27/15 9/8/15, 9/11/15(FB), Winter Season 11/30/15 12/10/15

Spring Season 3/21/16 3/30/16

The following attachment contains all pertinent forms required for participation in Boston Public Schools Athletics. All forms must be signed and accurately completed to the best of your knowledge prior to the start of practice. Forms to be Completed and Returned:

1. Sports Physical Form

2. Medical Questionnaire

3. Parental Consent Form

4. Massachusetts Concussion Reporting Form

a. Concussion Information Form (is information for parents/guardians) BPS Requirements for Athletic Participation:

1.67 GPA or Higher (the GPA requirement may be higher at some schools)

School attendance of 93% or higher

Updated physical in the last 13 months

Completed physical, parental consent and concussion forms

MIAA Age Requirement- A student who is 19 years of age prior to September 1 is not eligible for high school athletic participation. (Student-athletes can appeal this rule to the MIAA) If you have any questions, or need any additional information, please contact your Athletic Coordinator or the BPS Athletics Department.


Avery Esdaile

Boston Public Schools- Director of Athletics

■ ■■ P reparticipation Physical Evaluation



1. Consider additional questions on more sensitive issues

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

• Do you ever feel sad, hopeless, depressed, or anxious?

• Do you feel safe at your home or residence?

• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?

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

• Do you drink alcohol or use any other drugs?

• Have you ever taken anabolic steroids or used any other performance supplement?

• Have you ever taken any supplements to help you gain or lose weight or improve your performance?

• Do you wear a seat belt, use a helmet, and use condoms? 2. Consider reviewing questions on cardiovascular symptoms (questions 5–14). EXAMINATION

Height Weight Male Female

BP / Pulse Vision R 20/ L 20/ Corrected Y N MEDICAL NORMAL ABNORMAL FINDINGS


• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat

• Pupils equal

• Hearing

Lymph nodes

Heart a

• Murmurs (auscultation standing, supine, +/- Valsalva)

• Location of point of maximal impulse (PMI)


• Simultaneous femoral and radial pulses



Genitourinary (males only)b


• HSV, lesions suggestive of MRSA, tinea corporis

Neurologic c












• Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. bConsider GU exam if in private setting. Having third party present is recommended. cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for

Not cleared

Pending further evaluation

For any sports

For certain sports Reason Recommendations I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If condi- tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type) Date Address Phone Signature of physician, MD or DO

©2010 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. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503 9-2681/0410

1 Have you had a medical illness or injury since your last check up or sports physical?

19 Have you ever been knocked out, become

unconscious, or lost your memory?

2 Have you ever been hospitalized overnight? 20 Have you ever has a seizure? 3 Have you ever had surgery? 21 Do you have frequent or sever headaches? 4 Are you currently taking any prescription or non- prescription (over-the-counter) medications or pills or using an inhaler?

22 Have you ever had numbness or tingling in

your arms, hands, legs, or feet?

5 Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance? 23 Have you ever had a stinger, burner, or

pinched nerve?

6 Do you have any allergies (for example, to pollen, medicine, food, or stinging insects)?

24 Have you ever become ill from exercising in


7 Have you ever had a rash or hives develop during or after exercise?

25 Do you cough, wheeze, or have trouble

breathing during or after exercising?

8 Have you ever passed out during or after exercise? 26 Do you have Asthma? 9 Have you ever been dizzy during or after exercise? 27 Do you have seasonal allergies that require medical treatment?

10 Have you ever had chest pain during or after exercise? 28 Do you use any special protective or corrective equipment or devices that aren't

usually used for your sport or position (for

example, knee brace, special neck roll, foot

orthotics, retainer on your teeth, hearing aid?

11 Do you get tired more quickly than your friends do during exercise?

29 Have you had any problems with your eyes or


12 Have you ever had racing of your heart or skipped heartbeat?

30 Do you wear glasses, contacts, or protective


13 Have you had high blood pressure or high cholesterol? 31 Have you ever had a sprain, strain, or swelling after injury?

14 Have you ever been told you have a heart murmur? If yes, please explain.

32 Have you broken or fractured any bones or

dislocated any joints?

15 Has any family member or relative died of heart problems or of sudden death before age 50?

33 Have you had any other problems with pain

or swelling in muscles, tendons. Bones, or

joints? If yes, circle and explain on back side

of this questionnaire: Head, Elbow,

Forearm, Wrist, Hand, Upper Arm, Hip, Thigh,

Knee, Shin/Calf, Foot,

Head, Neck, Back, or Chest?

16 Has a physician ever denied or restricted your

participation in sports for any heart problems?

34 Do you want to weigh more or less than you

do now?

17 Do you have any current skin problems (for example) itching, rashes, acne, warts, fungus, or blisters)? 36 Do you lose weight regularly to meet weight

requirements for your sport?

18 Have you ever had a head injury or concussion? How many? . What was the longest duration of

symptoms? days, weeks, months, years

Explanations of "yes: responses: (attach any

documentation necessary.

Parent Signature: Date: The following information is for review by the school nurse, for the purpose of optimizing safe sports participation. Please indicate Y

(yes), N (no), DK (don't know).

Sex: D.O.B.: Gr.

Boston Public Schools


This form must be completed by parents and returned to the coach along with the physical examination form completed by a physician, or medical equivalent.

School: Coach:

Student Name:

BPS MS + K8 OFFERINGS Others (Please record)



Cross Country




SPORTS PARTICIPATION: Please select each sport in which you intend to participate. Phone Contacts: (Cell) (Home) (Work)

Relationship to Student:

Winter Spring Baseball

Indoor Track Softball

Boston Public Schools


School: School Year:

Last Name: First Name: Student #



Parent/ Guardian # 1: Parent Guardian 2:

Home Phone: Home Phone:

Cell Phone: Cell Phone:


Emergency Contact Information

City/Town: State: Zip:

Outdoor Track

Double Dutch

Basketball Baseball Basketball

I acknowledge that there are many inherent RISKS of INJURY involved in participating in athletic events. In acknowledging these RISKS (including, but not limited to injuries to vital joints, ligaments, tendons, organs, muscles, bones, as well as head injuries, neck and spinal injuries, partial paralysis, brain damage, and even death) and in consideration of the opportunity for my child to participate in the above checked sport(s), I agree to hold Boston Public Schools collectivelly and individually, its employees, agents, representatives, medical personnel, coaches, and volunteers, including managers and athletic trainers, harmless from any and all liability, actions, causes of actions, debts, claims, or demands of any kind and nature whatsoever (including attorney fees) which may arise by or in connection with my childs' participation. The terms hereof shall serve as a release and assumnption of risk for my heirs, estate, executor, administrators, assignees, and for all members of my family. If needed, I hereby authorize dispensation of medication by non-nursing personnel as provided by my child's medical provider. MEDICAL QUESTIONNAIRE and PHYSICAL EXAMINATIONS



Track + Field

Both the student and parent/guardian must read carefully and sign below Volleyball




I hereby state to the best of my knowledge, my answers to the sports medical questionnaire are complete and correct and submitted to my child's school nurse along with a current (13 months) physical examination document. I give permission for my child to participate in Boston Public Schools athletic programs. Boston Public Schools and its athletic trainers and associated medical personnel have permission to seek necessary emergency medical treatment for my child during his/her participation in conditioning, practices, play, and play competitions in any and all above-checked athletics teams, activities, and programs. Tennis


I understand that Massachusetts State Laws requires parents, guardians, volunteers and parent volunteers of participating student athletes in any Boston Public school athletic activity, team, program, or event, to participate in SPORT/HEAD INJURIES and CONCUSSION AWARENESS ( online or through written materials) training. By my signature I attest I have completed the training. Signature (Parent/Guardian): Date:

Signature (Student): Date:

Student’s Name

Sex Date of Birth Grade

School Sport(s)

Home Address


Has student ever experienced a traumatic head injury (a blow to the head)? Yes No If yes, when? Dates (month/year): Has student ever received medical attention for a head injury? Yes No If yes, when? Dates (month/year): If yes, please describe the circumstances:

Was student diagnosed with a concussion? Yes No If yes, when? Dates (month/year): Duration of Symptoms (such as headache, difficulty concentrating, fatigue) for most recent concussion: Parent/Guardian:

Name: Signature/Date

(Please print)

Student Athlete:

Signature/Date The Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

250 Washington Street, Boston, MA 02108-4619












This form should be completed by the student’s parent(s) or legal guardian(s). It must submitted to the Athletic Director, or official designated by the school, prior to the start of each season a student’ plans to participate in an extracurricular athletic activity. Parent/Athlete Concussion

Information Sheet

A concussion is a type of traumatic brain injury

that changes the way the brain normally works. A

concussion is caused by bump, blow, or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.



Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of

concussion listed below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.

Did You Know?

• Most concussions occur without loss

of consciousness.

• Athletes who have, at any point in their

lives, had a concussion have an increased

risk for another concussion.

• Young children and teens are more likely to

get a concussion and take longer to recover

than adults.

SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES Appears dazed or stunned Headache or “pressure” in head Is confused about assignment or position Nausea or vomiting Forgets an instruction Balance problems or dizziness Is unsure of game, score, or opponent Double or blurry vision Moves clumsily Sensitivity to light

Answers questions slowly Sensitivity to noise

Loses consciousness (even briefly) Feeling sluggish, hazy, foggy, or groggy Shows mood, behavior, or personality changes Concentration or memory problems Can’t recall events prior to hit or fall Confusion Can’t recall events after hit or fall Just not “feeling right” or “feeling down” CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on

the brain in a person with a concussion and crowd

the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

• One pupil larger than the other

• Is drowsy or cannot be awakened

• A headache that not only does not diminish,

but gets worse

• Weakness, numbness, or decreased coordination

• Repeated vomiting or nausea

• Slurred speech

• Convulsions or seizures

• Cannot recognize people or places

• Becomes increasingly confused, restless, or agitated

• Has unusual behavior

• Loses consciousness (even a brief loss of

consciousness should be taken seriously)



If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.




If you suspect that an athlete has a concussion,

remove the athlete from play and seek medical

attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.

Rest is key to helping an athlete recover from a

concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause

concussion symptoms to reappear or get worse.

After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.


Concussions affect people differently. While

most athletes with a concussion recover

quickly and fully, some will have symptoms

that last for days, or even weeks. A more seri-

ous concussion can last for months or longer.

It’s better to miss one game than the whole season. For more information on concussions, visit:

Student-Athlete Name Printed Student-Athlete Signature Date Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date

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