Shrine Bowl Medical Participation Form

Shrine Bowl of the Carolinas
    377 Rubin Center
    Suite 106
    Ft. Mill, SC 29708
    803-547-0300
    803-547-9545 Fax
    1-800-648-2695

Sponsoring Shrine Centers
OMAR, Charleston, SC
SUDAN, New Bern, NC
HEJAZ, Mauldin, SC
JAMIL, Columbia, SC
AMRAN, Raleigh, NC

Shrine Bowl of the Carolinas

2010 Medical Participation Form

Please Print in Ink or Type:

______________________________ _______________________________________ ___________

(Participant’s Last Name) (First Name) (Middle Initial)

Date of Birth: _____________________________ Social Security Number. ________________________

(Month / Day / Year)

Home Address: _______________________________________________________________________________

_________________________________________________________ City: ___________________________

State: _________Zip Code: ______________ Home Phone Number: (_______)___________________

Area Code

Father’s / Guardian’s Name: ___________________________________________________________________

Daytime Phone: (_______)____________________ Page or Cell _______)____________________

Area Code Area Code

Mother’s / Guardian’s Name: __________________________________________________________________

Daytime Phone: (_______)____________________ Page or Cell (_______)___________________

Area Code Area Code

Alternate Emergency Contact Person:___________________________________________________________

Daytime Phone: (_______)____________________ Page or Cell (_______)___________________

Area Code Area Code

Nighttime Phone: (_______)____________________ Page or Cell (_______)___________________

Area Code Area Cod

Head Football Coach’s Name: __________________________________________________________________

Home Phone: (_______)____________________ Page or Cell (_______)___________________

Area Code Area Code

Family / Team Physician’s Name: _______________________________________________________________

Office Phone: (_______)____________________

Area Code

Medical Insurance Company Name:_____________________________________________________________

Policy Number/s: ____________________________________________________________________

____________________________________________________________________

**RETURN IN THE GREEN ENVELOPE PRIOR TO NOVEMBER 23. Please include a copy of your CURRENT PHYSICAL EXAM and MEDICAL INSURANCE CARD when you return this packet**

MEDICAL HISTORY

The following questions are intended to provide the Shrine Bowl Medical / Athletic Training Staff background regarding your medical history. Your responses Will Not affect your affect your acceptance to play—that is determined entirely by the pre-game health screening.
Please be as honest and frank as possible with your responses.

Circle the appropriate answer

ALLERGIES

1. YES NO Are you allergic to any type of Medications? If YES please list:

__________________________________________________________________________________

2. YES NO Are you allergic to anything else, (Bee’s, Food, etc.)? If YES please list:

__________________________________________________________________________________

Circle the appropriate answer

GENERAL HISTORY

1. YES NO Are you currently taking any medication(s)? If YES, please list the name and dosage

__________________________________________________________________________________

2. YES NO Do you have a history of Asthma? If YES, List prescribed medication ______________

3. YES NO Have you ever been knocked out or experienced a concussion? If YES, how many

(TIMES)__________________ (DATE OF LAST INCIDENT) ___________________

4. YES NO Have you ever been told you have a heart murmur or heart disease?

5. YES NO Are you missing any of your paired organs (eyes, kidneys, testicles, etc.)

6. YES NO Is there a known history of mental disorder, convulsions, or seizures?

Circle the appropriate answer

BONE & JOINT

1. YES NO Do you have any permanent deformity or disability? If YES describe ________________

_________________________________________________________________________________

2. YES NO Have you had a shoulder dislocation or separation since entering high school?

3. YES NO Have you ever had a "BURNER" or "STINGER"? How many THIS YEAR? ________

4. YES NO Have you ever been advised to have surgery for a bone or joint condition?

5. YES NO Have you ever had an injury to your back or neck?

6. YES NO Have you had a knee injury since entering high school? If YES, describe _____________

___________________________________________________________________________

7. YES NO Do you have a pin, plate, or screw somewhere in your body? If YES, what and where?

__________________________________________________________________________

8. YES NO Have you had a fracture during the past TWO YEARS? If YES, what was fractured?

__________________________________________________________________________________

MEDICAL HISTORY CONTINUED

Circle the appropriate answer

EYES & DENTAL

1. YES NO Do you wear (glasses) or (contact lenses) when practicing and playing? If YES, circle

which.

2. YES NO Do you wear a dental appliance? If YES, describe __________________________________

_________________________________________________________________________________

3. YES NO Do you have dead teeth? If YES, give the approximate location.

___________________________________________________________________________________

Circle the appropriate answer

ADDITIONAL

1. YES NO Have you missed ANY practices or games because of an injury sustained this year?

If YES, How many practices and / or games did you miss? ________________________

Describe the Injury or Injuries________________________________________________

__________________________________________________________________________

In the space below give any medical information you feel is essential to your well-being and our ability to provide quality

health care for you during your week with the Shrine Bowl.

________________________________________________________________________________________________________

CONSENT TO PARTICIPATE

As legal guardian of (Participant’s printed name)________________________________________________________,
I hereby give my consent to his practice and play in the Shrine Bowl of the Carolinas.

MEDICAL AUTHORIZATION

I also grant my permission for treatment deemed necessary for a condition arising during participation in these activities, including medical or surgical treatment recommended by a medical doctor. I understand that every effort will be made to contact me prior to treatment, and I fully understand the Shrine Bowl will not accept liability for PRE-EXISTING INJURIES. I also agree to allow Shrine Bowl physicians to obtain any complete medical information from anyone involved prior to treatment(s).

I agree to the need for a screening medical examination and certify the medical history included is accurate to the best of my knowledge. Failure to give an accurate and complete medical history could result in rejection of your son by the medical staff even if he’s in excellent health.

RISK AWARENESS

I / We hereby acknowledge an awareness that participation in the Shrine Bowl Game of the Carolinas involves a risk of injury which may include severe injuries involving paralysis, permanent mental disability or death; and that these injuries may occur in some instances as a result of unavoidable accidents. I / We accept these risks in giving consent to participate in the Shrine Bowl of the Carolinas during the current session by the undersigned athlete.

Parent/Guardian ______________________________ __________________________________ Date __________

(Signature) (Printed Name of Parent/Guardian)

Student Athlete: ____________________________ _____________________________________ Date __________

(Signature) (Printed Name of Student Athlete)

SHRINE BOWL PRE-GAME HEALTH SCREENING FORM

TO BE COMPLETED BY SHRINE BOWL PHYSICIANS ONLY

GENERAL INFORMATION

Athlete’s Name:____________________________________ School:________________________________

Stated Height:__________ Stated Weight:____________ Blood Pressure:___________ / ____________

Read by ____________________________

GENERAL EXAMINATION

Eyes:___________________________ Abdomen:_____________________________

ENT:___________________________ Genetalia:_____________________________

Heart:__________________________ Neurological:__________________________

All Findings Normal:_____________ ______________________________________

Examining Physician

Abnormalities:_________________________________________________________________________________________________

______________________________________________________________________________________________________________

________________________________________________________________________________

MUSCULOSKELETAL EXAMINATION

All Findings Normal:_____________ ______________________________________

Examining Physician

Abnormalities:_________________________________________________________________________________________________

______________________________________________________________________________________________________________

________________________________________________________________________________

Sent to X-ray to verify a pre-existing injury: Yes:______________

DENTAL EXAMINATION

(Please identify missing teeth with an “X”. Identify fracture teeth with an “F”.)

Abnormalities: (Describe)___________________________

_________________________________________________

_______________________________________________

Examining Dentist

The above player has received a limited pre-participation health screening and although every possible problem cannot be detected in an examination of this type, no obvious disqualifying factors were observed. We therefore grant permission for his participation in the Shrine Bowl Game.

PHYSICIAN’S APPROVAL FOR PARTICIPATION: __________________________________________________