DELAWARE INTERSCHOLASTIC ATHLETIC ASSOCIATION

Parents/Guardian: There are 7 pages in the DIAA pre-participation physical evaluation (PPE) and consents form. Pages one, two and four require your signature while pages five, six and seven are references for you to keep. The physician must sign page 3 on or after April 1; the physical examination must have been conducted within 12 months of the physician’s signature; and the PPE is valid through June 30 of the following school year.

Athlete:                    ____			Phone:  		School:  		

Age:_ 		
Gender:  		
Date of Birth:  		
Grade:  		

Parent/Guardian Name:  (Please Print:  		

PARENT/GUARDIAN/STUDENT CONSENTS

 	Has my permission to participate in all interscholastic sports NOT checked below?
            (Name of Athlete)

NOTE- If you check any sport below the athlete will NOT be permitted to participate in that sport. spsportsport.	
	Baseball		Basketball		Cheerleading		Cross Country		Crew	
	Field Hockey		Football		Golf		Ice Hockey		Lacrosse (B)	
	Lacrosse (G)		Soccer		Softball		Squash		Swimming	
	Tennis		Track		Volleyball		Wrestling			

1.		My permission extends to all interscholastic activities whether conducted on or off school premises.   I have read and discussed the Parent/Player Concussion Information Form; Symptoms and Risk Factor for Sudden Cardiac Arrest form; and the list of items that protect against the loss of athletic eligibility, with said participant and I will retain those pages for my reference.  I have also discussed
with him/her and we understand that physical injury, including paralysis, coma or death can occur as a result of participation in interscholastic athletics.  I waive any claim for injury or damage incurred by said participant while participating in the activities NOT checked above.

Parent Signature:  		Date:  	 Student Signature:  		Date:  	  
2.		To enable DIAA and its full and associate member schools to determine whether herein named student is eligible to participate in interscholastic athletics, I hereby consent to the release of any and all portions of school record files, beginning with the sixth grade, of the herein named student, including but not limited to, birth and age records, name and residence of student’s parent(s), guardian(s) or
Relative Care Giver, residence of student, health records, academic work completed, grades received and attendance records.

Parent Signature:   	   Date:  	

3.		I further consent to DIAA’s and its full and associate member schools use of the herein named student’s name, likeness, and athletically related information in reports of interscholastic practices, scrimmages or contests, promotional literature of the association, and other materials and releases related to interscholastic athletics.

Parent Signature:  	   Date:  	

4.	By this signature, I hereby consent to allow the physician(s) and other health care provider(s) selected by myself or the schools to perform a pre-participation examination on my child and to provide treatment for any injury received while participating in or training for athletics for his/her school.  I further consent to allow said physician(s) or health care provider(s) to share appropriate information concerning my child that is relevant to participation, with coaches, medical staff, Delaware Interscholastic Athletic Association, and other school personnel as deemed necessary.  Such information may be used for injury surveillance purposes.

Parent Signature:   	  Date:  	

5.     By this signature, I agree to notify the physician and school of any health changes during the school year that could impact participation in interscholastic athletics.

Parent Signature:   	  Date:  		

HISTORY FORM
(Note: This form is to be filled out by the patient and parent prior to seeing the physician.)

Date of Exam   		 Name    	Date of birth   	
Sex   	Age    	Grade   	School   	Sport(s)   	

Medicines and Allergies: Please list all of the prescription  and over-the-counter  medicines and supplements  (herbal and nutritional)  that you are currently taking

Do you have any allergies?	¨ Yes     ¨  No    If yes, please identify specific allergy below.		
¨  Medicines	¨  Pollens	¨  Food	¨  Stinging Insects	
Explain “Yes” answers  below. Circle questions you don’t know the answers to.

MEDICAL  QUESTIONS	Yes	No	
26. Do you cough, wheeze, or have difficulty breathing during or after exercise?			
27. Have you ever used an inhaler or taken asthma medicine?			
28. Is there anyone in your family who has asthma?			
29. Were you born without or are you missing a kidney, an eye, a testicle
(males), your spleen, or any other organ?			
30. Do you have groin pain or a painful bulge or hernia in the groin area?			
31. Have you had infectious  mononucleosis  (mono) within the last month?			
32. Do you have any rashes, pressure sores, or other skin problems?			
33. Have you had a herpes  or MRSA skin infection?			
34. Have you ever had a head injury  or concussion?			
35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?			
36. Do you have a history of seizure disorder?			
37. Do you have headaches with exercise?			
38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?			
39. Have you ever been unable to move your arms or legs after being hit or falling?			
40. Have you ever become ill while exercising in the heat?			
41. Do you get frequent muscle cramps when exercising?			
42. Do you or someone in your family have sickle cell trait or disease?			
43. Have you had any problems with your eyes or vision?			
44. Have you had any eye injuries?			
45. Do you wear glasses or contact lenses?			
46. Do you wear protective eyewear, such as goggles or a face shield?			
47. Do you worry about your weight?			
48. Are you trying to or has anyone recommended that you gain or lose weight?			
49. Are you on a special diet or do you avoid certain types of foods?			
50. Have you ever had an eating disorder?			
51. Do you have any concerns that you would like to discuss with a doctor?			
FEMALES ONLY			
52. Have you ever had a menstrual period?			
53. How old were you when you had your first menstrual period?		
54. How many periods have you had in the last 12 months?		

GENERAL QUESTIONS	Yes	No	
1. Has a doctor ever denied or restricted your participation in sports for any reason?			
2. Do you have any ongoing medical conditions? If so, please identify below: ¨  Asthma    ¨  Anemia    ¨  Diabetes     ¨  Infections
Other:   				
3. Have you ever spent the night in the hospital?			
4. Have you ever had surgery?			
HEART HEALTH  QUESTIONS  ABOUT  YOU	Yes	No	
5. Have you  ever  passed  out or nearly  passed  out  DURING or
AFTER exercise?			
6. Have you ever had discomfort,  pain, tightness, or pressure in your chest during exercise?			
7. Does your heart ever race or skip beats (irregular beats) during exercise?			
8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
¨  High blood pressure 	¨  A heart murmur
¨  High cholesterol 	¨  A heart infection
¨  Kawasaki disease	Other:   				
9. Has a doctor ever ordered  a test for your heart? (For example, ECG/EKG, echocardiogram)			
10. Do you get lightheaded or feel more short of breath than expected during exercise?			
11. Have you ever had an unexplained seizure?			
12. Do you get more tired or short of breath more quickly than your friends during exercise?			
HEART HEALTH  QUESTIONS  ABOUT  YOUR FAMILY	Yes	No	
13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?			
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic  right ventricular cardiomyopathy, long QT syndrome,  short  QT syndrome,  Brugada syndrome,  or catecholaminergic polymorphic ventricular tachycardia?			
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?			
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?			
BONE AND JOINT  QUESTIONS	Yes	No	
17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?			
18. Have you ever had any broken or fractured bones or dislocated joints?			
19. Have you ever had an injury  that required  x-rays,  MRI, CT scan, injections, therapy, a brace, a cast, or crutches?			
20. Have you ever had a stress fracture?			
21. Have you ever been told that you have or have you had an x-ray for neck instability  or atlantoaxial instability? (Down syndrome or dwarfism)			
22. Do you regularly use a brace, orthotics, or other assistive device?			
23. Do you have a bone, muscle, or joint injury that bothers you?			
24. Do any of your joints become painful, swollen, feel warm, or look red?			
25. Do you have any history of juvenile arthritis  or connective tissue disease?			

Explain “yes” answers here

 	

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  	

PHYSICAL EXAMINATION FORM

Name    	Date of birth   	
PHYSICIAN REMINDERS
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 if you do not practice abstinence are you using protection?
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	
Appearance
•  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)			
Pulses
•  Simultaneous femoral and radial pulses			
Lungs			
Abdomen			
Genitourinary (males only)b			
Skin
•  HSV, lesions   suggestive    of MRSA, tinea corporis			
Neurologic c			
MUSCULOSKELETAL			
Neck			
Back			
Shoulder/arm			
Elbow/forearm			
W rist/hand/fingers			
Hip/thigh			
Knee			
Leg/ankle			
Foot/toes			
Functional
•  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.

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

o   Not cleared
o    Pending further evaluation
o   For any sports
o   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 Health Care Provider (Print/type)   	Date  	

Address

Phone

Signature of Health Care Provider   	, MD, DO, PA, or NP

SCHOOL ATHLETE MEDICAL CARD
(Parent/Guardian: please print and complete Sections 1, 2 & 3)

Section 1: CONTACT/PERSONAL INFORMATION

NAME:                                                                                         SPORT(S):                                                               
AGE:       GRADE:        BIRTH DATE:                       GUARDIAN NAME:                                                                      ADDRESS:                                                                                                                                                                             PHONE: (H)                                              (W)                                      (C)                                  (P)                                    

Other authorized person to contact in case of emergency:
NAME:                                                                                   PHONE(s):                                                                              NAME:                                                                                    PHONE(s):                                                                             

Preference of Physician (and permission to contact if needed):
NAME: 			PHONE: 	  HOSPITAL PREFERENCE: 	INSURANCE: 		
POLICY #: 	_   GROUP: 	PHONE: 	

Section 2: MEDICAL INFORMATION
MEDICAL ILLNESSES: 	
LAST TETANUS (mo/yr): 	ALLERGIES: 		 MEDICATIONS: 		 (any medications that may be taken during competition require a physician’s note)

PREVIOUS HEAD/NECK/BACK INJURY: 	 HEAT DISORDER, OR SICKLE CELL TRAIT: 	 
PREVIOUS SIGNIFICANT INJURIES:  	
ANY OTHER IMPORTANT MEDICAL INFORMATION: 	

Section 3:  Consent for Athletic Conditioning, Training and Health Care Procedures
I hereby give consent for my child to participate in the school’s athletic conditioning and training program, and to receive
any necessary healthcare treatment including first aid, diagnostic procedures, and medical treatment, that may be provided by the treating physicians, nurses, athletic trainers, or other healthcare providers employed directly or through a contract by
the school, or the opposing team’s school. The healthcare providers have my permission to release my child’s medical information to other healthcare practitioners and school officials. In the event I cannot be reached in an emergency I give
permission for my child to be transported to receive necessary treatment. I understand that Delaware Interscholastic Athletic Association or its associates may request information regarding the athlete’s health status, and I hereby give my permission for the release of this information as long as the information does not personally identify my child. Parent/Guardian Signature:  	Date: 	
Athlete’s Signature:  		Date: 	

Cleared without restrictions

Section 4:  Clearance for Participation
Cleared with the following restrictions:

Health Care Provider’s Signature:  	MD/DO, PA,NP   Date:  	

For office use only:	This card is valid from April 1, 20  	 through	June 30, 20 	
Note: If any changes occur, a new card should be completed by the parent/guardian. The original card should be
kept on file in the school athletic director’s or athletic trainer’s office. A copy should be kept in the sports’ athletic kits. This card contains personal medical information and should be treated as confidential by the school, its employees, agents, and contractors.
Name of School:  		Name of ATC:   	

PROTECT YOUR ATHLETIC ELIGIBILITY

YOU ARE NOT ELIGIBLE:
1.	If you attend a high school and become 19 years of age before June 15 immediately preceding that school year.  (Reg. 1009.2.1.1)
2.    If you attend a junior high/middle school that terminates in the 8th grade and become 15 years of age before June 15 immediately preceding that school year.  (Reg. 1008.2.1.1.1)
*3.   If you are not legally enrolled at the school which you represent.  (Reg. 1008.2.3.1 and Reg. 1009.2.3.1)
4.    If you are not residing with your custodial parent(s), court appointed legal guardian(s), Relative Caregiver, or are a student 18 years of age or older and living in the attendance zone of the school you attend unless you are participating in the Delaware School Choice Program, attend a private school or are a boarding school student. IF YOUR CUSTODIAL PARENT(S), LEGAL GUARDIAN(S) OR RELATIVE CAREGIVER(S) RELOCATES TO A DIFFERENT ATTENDANCE ZONE, YOU MUST NOTIFY YOUR ATHLETIC DIRECTOR IMMEDIATELY.  (Reg. 1008.2.2.1 and Reg. 1009.2.2.1)
*5.  If you were absent unexcused or absent due to illness or injury; have been suspended (in-school or out-of-school); or have been assigned to homebound instruction or an alternative school for disciplinary reasons.  (Reg. 1008.2.3.4 and 1008.2.3.5 Reg. 1009.2.3.5 and 1009.2.3.6)
6.  If you failed to complete the preceding semester for reasons other than personal illness or injury.  (Reg. 1008.2.3.6;  Reg. 1009.2.3.7)
*7.  If you do not pursue a regular course of study and pass at least five credits per marking period (equivalent of four credits in junior high/middle school), two credits of which must be in the areas of Mathematics, Science, English, or Social Studies.  IF YOU ARE A SENIOR, YOU  MUST  PASS  ALL  COURSES WHICH  SATISFY  AN  UNMET GRADUATION REQUIREMENT. (Reg. 1008.2.6.; Reg. 1009.2.6.1)
8.   A student who has previously participated in interscholastic athletics that transfers more than one time during their first year of eligibility shall be ineligible in any sport for a period of ninety (90) school days commencing with the first day of official attendance in the receiving school. The period of ineligibility shall continue to the next grade/school year until 90 school days have passed.
9.    If you transfer after the first day of school of your second year of high school, you are ineligible to participate in any sport you previously participated in for a period of one school year  ( Reg. 1009.2.4)
10.  If you participated in the Delaware School Choice Program during the previous academic year and transferred to your “home school” for the current academic year without completing your two-year commitment or receiving a release from the sending school.  (Reg. 1008.2.3.3;  Reg.
1009.2.3.4)
11.  If you participated in the Delaware School Choice Program during the previous academic year and transferred to another “choice school” for the current academic year unless you are playing a sport not sponsored by the sending school.  (Reg. 1008.2.4.6.1; Reg. 1009.2.4.7.1)
12    If you reached the age of majority (18), occupied a residence in a different attendance zone than your custodial parent(s) or court appointed legal guardian(s), and have not been in regular attendance at your receiving school for at least 90 school days unless you are participating in the Delaware School Choice Program and your application was properly submitted prior to your change of residence.  (Reg. 1009.2.2.1.7)
13.  If you attend a high school and more than four years has elapsed since you first entered 9th grade, or more than five years has elapsed since you just entered 8th grade in schools with 8th grade eligibility for high school sports.  (Reg. 1009.2.7.1 and 2.7.2.1)
14.  If you attend a junior high/middle school in which only grades 7-8 are permitted to participate in interscholastic athletics and more than two years has elapsed since you first entered 7th grade.  (Reg. 1008.2.7.1)
15.  If you attend a junior high/middle school in which grades 6-8 are permitted to participate in interscholastic athletics and more than three years has elapsed since you first entered 6th grade.  (Reg. 1008.2.7.2)
16.  If you have played on or against a professional team or have accepted cash or a cash equivalent (savings bond, certificate of deposit, etc.); a merchandise item(s) with an aggregate retail value of more than $150; a merchandise discount; a reduction or waiver of fees; a gift certificate or other valuable consideration for athletic participation.  (Reg. 1009.2.5.1.4 and 2.5.1.5)
17.  If  you  have  used  your  athletic  status  to  promote  a  commercial  product  or  service  in  an  advertisement  or  personal  appearance.	(Reg.
1009.2.5.1.7)
18.  If you have not received a physical examination from a licensed physician (M.D. or D.O.), a certified nurse practitioner or a certified physician’s assistant  on  or  after  April  1  and  written  consent  from  your  custodial  parent(s)  or  court  appointed  legal  guardian(s)  to  participate  in interscholastic athletics is not on file in the school office.  (Reg. 1009.3.1.1.1 and Reg. 1008.3.1.1)
19.  If you participate in an all-star game not approved by DIAA before you graduate from high school.  (Reg. 1009.5.4)
20.  If  you  are  a  foreign  exchange  student  not  participating  in  a  two-semester  program  listed  by the  Council  on  Standards  for  International
Educational Travel (CSIET).  (Reg. 1009.2.8.1.2)
21.   If  you  are  an  international  student  not  in  compliance  with  all  DIAA regulations  including  Reg.  1009.2.2  residency requirements.  (Reg.
1009.2.8.2)

*IF YOU ARE NOT IN COMPLIANCE WITH THESE REQUIREMENTS, YOU MAY NOT TRY-OUT,PRACTICE, SCRIMMAGE OR PLAY IN A GAME.
NOTE:	Consult with your coach, athletic director, or principal for information concerning additional eligibility requirements.

Delaware Interscholastic Athletic Association
Parent/ Player Concussion Information Form

A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly.  In other words, even a “ding” or a bump on the head can be serious.   You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:	Teammates, parents and coaches may notice these:
Headaches           Pressure in head              Nausea or vomiting           Appears dazed                       Vacant facial expression
Neck pain            Balance problems            Dizziness                           Confused about assignment  Forgets plays
Disturbed vision  Light/noise sensitivity    Sluggish                            Unsure of game/score, etc.     Clumsy
Feeling foggy	Drowsiness	Changes in sleep	Responds slowly	Personality changes Amnesia	“Don’t feel right”	Low energy	Seizures	Behavior changes Sadness	Nervousness	Irritability	Loss of consciousness	Uncoordinated Confusion	Repeating questions	Poor Concentration	Can’t recall events before or after hit

What can happen if my child keeps on playing with a concussion or returns to soon?
Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one (second impact syndrome).  This can lead to prolonged recovery, or even to severe brain swelling with devastating and even fatal consequences.  It is well known that adolescent or teenage athletes will often under report symptoms of injuries, and concussions are no different. As a result, education of administrators, coaches, parents and students is the key for the student-athlete’s safety.

If you think your child has suffered a concussion
Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. The injury may also require the student to be withheld from school until cleared by the physician. Close observation of the athlete should continue for several hours. You should also inform your child’s coach if you think that your child may have a concussion Remember it is better to miss one game than miss the whole season. And when in doubt, the athlete sits out.
For current and up-to-date information from the CDC on concussions you can go to:
http://www.cdc.gov/concussion/HeadsUp/youth.html
For a current update of DIAA policies and procedures on concussions you can go to:
http://www.doe.k12.de.us/diaa
For a free online training video on concussions you can go to:
http://nfhslearn.com/

All parents and players must sign the signature portion of the PPE indicating they have read and understand the above.

Adapted from the KHSAA, CDC and 3rd International Conference on Concussion in Sport, 4/2011

SUDDEN CARDIAC ARREST AWARENESS FORM

Revised August 2013

What is Sudden Cardiac Arrest?
Ø   Occurs suddenly and often without warning.
Ø   An electrical malfunction (short-circuit) causes the bottom chambers of the heart (ventricles) to beat dangerously fast (ventricular tachycardia or fibrillation) and disrupts the pumping ability of the heart.
Ø   The heart cannot pump blood to the brain, lungs and other organs of the body.
Ø   The person loses consciousness (passes out) and has no pulse.
Ø   Death occurs within minutes if not treated immediately.

What causes Sudden Cardiac Arrest?
Ø   Conditions present at birth (inherited and non-inherited heart abnormalities)
Ø   A blow to the chest (Commotio Cordis)
Ø   An infection/inflammation of the heart, usually caused by a virus.  (Myocarditis )
Ø   Recreational/Performance-Enhancing drug use.
Ø   Other cardiac & medical conditions/Unknown causes.  (Obesity/Idiopathic)

What are the symptoms/warning signs of Sudden Cardiac Arrest?
Ø   Fainting/blackouts (especially during exercise)
Ø   Dizziness
Ø   Unusual fatigue/weakness
Ø   Chest pain
Ø   Shortness of breath
Ø   Nausea/vomiting
Ø   Palpitations (heart is beating unusually fast or skipping beats)
Ø   Family history of sudden cardiac arrest at age < 50
ANY of these symptoms/warning signs may necessitate further evaluation from your physician before returning to practice or a game.

What are ways to screen for Sudden Cardiac Arrest?

Ø   The American Heart Association recommends a pre-participation history and physical including 12 important cardiac elements.
Ø   The DIAA Pre-Participation Physical Evaluation – Medical History form includes ALL 12 of these important cardiac elements and is mandatory annually. Please answer the heart history questions on the student health history section of the DIAA PPE carefully.
Ø  Additional screening using an electrocardiogram and/or an echocardiogram is readily available to all athletes, but is not mandatory.

Where can one find additional information?

Ø   Contact your primary care physician
Ø   American Heart Association ( www.heart.org )
Ø   August Heart (  www.augustheart.org )
Ø   Championship Hearts Foundation ( www.champhearts.org )
Ø   Cypress ECG Project (  www.cypressecgproject.org )
Ø	Parent Heart Watch (  www.parentheartwatch.com )