Passaic Athletic Registration

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PASSAIC ATHLETIC REGISTRATION

Each page must be read and completed by the prospective student-athlete's parent/guardian.
ATHLETIC CLEARANCE PROCESS:

1. Read, complete, and submit this "Passaic Athletic Registration Form."

2. Complete and submit a Pre-Participation Physical Form. Once this Registration Form has been submitted, please Check Your Physical Date /Clearance Status.

Once in the document please follow these steps:

a) To check your status please hit CTRL F and type in your School ID #

b) You will need a new physical form if your physical was done on, or prior to 11/21/2021

Pre-Participation Physical Evaluation Form (PPE)-English

Pre-Participation Physical Evaluation Form (PPE)-Spanish

c) You simply need a Health Update Form if your physical form on file was completed after 11/22/2021.

Health Update Form- English

Health Update Form-Spanish

3. Complete Concussion Education and Impact Testing with the Athletic Training staff. Please bring your fully-charged Chromebook when you submit your paperwork. Collection and testing dates/times will be posted on the sport Google Classroom.

4. Receive academic eligibility clearance from the Athletics Department.

Please read the Student-Athlete Code of Conduct document below.

Student-Athlete Code of Conduct

Please note that your child will not be cleared for participation until these steps are completed.
Student ID Number*
Student Name*

First NameLast Name
Grade*
Student Date of Birth*

MonthDayYear
Date
School*
Sport*
Student Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Parent/Guardian Name *

First NameLast Name
Parent/Guardian Cell Phone Number*
Do you consent to receiving text notifications if we cannot reach you by phone?*

YesNo
Parent/Guardian Email Address*
example@example.com
Emergency Contact Name*

First NameLast Name
Relationship *
Emergency Contact Phone Number*
Secondary Emergency Contact*

First NameLast Name
Secondary Emergency Contact Phone Number*
Preferred Hospital, in case of emergency*

Insurance Company (if no insurance, please write "none")*
Insurance Company Phone Number (if no insurance, please write "none")*
Policy Number (if no insurance, please write "none")*
Group Number (if no insurance, please write "none")*
Passaic Sports Medicine

I am aware that trying out, practicing, or playing in any sport can be a dangerous activity involving many risks or injuries. I acknowledge the fact that, to the best of my knowledge, my child has no physical condition that would prevent them from athletic participation. I understand that the dangers and risks include, but are not limited to, death, serious head, neck, and spinal injuries, paralysis, injuries or impairment to the musculoskeletal system, or other aspects of the body, general health, and well-being.

Due to associated risks of participating in sports, I will discuss with our child the importance of following the instructions of the athletic department personnel regarding playing techniques, training, and rules of equipment use. Additionally, I will discuss with our child that all injuries/illnesses that occur during official athletic participation (including all regularly scheduled practices and competitions) must be reported to the athletic trainer or coach immediately.

I hereby grant permission, in the case of an emergency, for my child to be transported, examined and/or treated at the local medical center or hospital by a certified physician. Passaic Athletics Staff will notify myself or another emergency contact in case of such circumstance.

Additionally, I hereby authorize the Passaic School District Athletic Trainer, who is under the direction and guidance of the Passaic Board of Education Team Physician, to render to our child any preventive measures for injuries, first aid, treatment, rehabilitation, emergency treatment, and/or telehealth/telemedicine that they deem reasonable and necessary to the health and well-being of our child.

Please note that the Passaic Team Physian will determine the playing status of any injured player.

It is with my consent and approval that my child will be allowed to
participate in Passaic BOE Athletics, including team travel for the school year.

By signing below, I understand the contents of the statement above and attest the information given by us is accurate.
Parent/Guardian Signature- Sports Medicine Acknowledgement *

Clear
Date*

MonthDayYear
Date

ImPACT Concussion Management Testing Permission Form

Participation in competitive sports may place student-athletes at risk of suffering a concussion. The safety and well-being of every student-athlete is our top priority. For this reason, the Passaic Board of Education’s Athletic Department will be utilizing ImPACT, a computerized pre-season baseline and concussion management program for our athletes. We are one of over 200 secondary schools in New Jersey that will be using this software.

Many professional sport organizations and teams, including the NFL, NCAA, NBA, MLB and MLS, are currently using the lmPACT pre-season baseline testing software. Baseline testing takes the guesswork out of concussion management and return-to-play decisions. The protocol involves a 20-minute test covering: Verbal Memory Composite, Processing/Visual Motor Speed Composite. Visual Memory Composite, Reaction Time Composite and Impulse Control. Upon completion of the test, your child's scores will be stored for 7 years. This web-based program is completely confidential and password protected. In the unfortunate event of a concussion, a post-test will be conducted. The results of both the pre- and post-tests will be given to you to review with your physician, which your child will have to see if a concussion has occurred. This data will permit your physician to make a more objective decision concerning return-to- play protocols.

By signing below, I understand the purpose of the lmPACT Concussion Management Program and give consent to have my child participate in the testing.
Parent/Guardian Signature- ImPact Testing Acknowledgement *

Clear
Date*

MonthDayYear
Date

Please read: Sports-Related Concussion and Head Injury Fact Sheet

By signing below, I have read and understand the "Sports-Related Concussion and Head Injury Fact Sheet" as per the New Jersey Department of Education, the New Jersey Interscholastic Athletic Association and the Passaic Board of Education.
Parent/Guardian Signature- Concussion/Head Injury Acknowledgement *

Clear
Date*

MonthDayYear
Date

Please read: Sudden Cardiac Death in Young Athletes Educational Fact Sheet

By signing below, I have read and understand the "Sudden Cardiac Death in Young Athletes Educational Fact Sheet" as per the New Jersey Department of Education, the New Jersey Interscholastic Athletic Association and the Passaic Board of Education.
Parent/Guardian Signature- Sudden Cardiac Death Acknowledgement *

Clear
Date*

MonthDayYear
Date

Please read: Opioid Use and Misuse Educational Fact Sheet, Keeping Student-Athletes Safe

By signing below, I have read and understand the "Opioid Use and Misuse Educational Fact Sheet, Keeping Student-Athletes Safe" as per the New Jersey Department of Education, the New Jersey Interscholastic Athletic Association and the Passaic Board of Education.
Parent/Guardian Signature- Opioid Use/Misuse Acknowledgement *

Clear
Date*

MonthDayYear
Date

Please read: Sports-Related Eye Injuries: An Educational Fact Sheet for Parents

By signing below, I have read and understand the "Sports-Related Eye Injuries: An Educational Fact Sheet for Parents" as per the New Jersey Department of Education, the New Jersey Interscholastic Athletic Association and the Passaic Board of Education.
Parent/Guardian Signature- Sports-Related Eye Injury Acknowledgement *

Clear
Date*

MonthDayYear
Date

NJSIAA STEROID TESTING POLICY CONSENT TO RANDOM TESTING

In Executive Order 72, issued December 20, 2005, Governor Richard Codey
directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying 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 attached page, without written prescription by a fully licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA’s sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition.

Student-athletes may submit supplements and medicines to Drug Free Sports
AXIS to receive information regarding banned substances or safety issues. Athletes or parents/guardians may login to the NJSIAA account at www.dfsaxis.com using the password “njsports.”

2021-22 NJSIAA Banned Substances

The NJSIAA will test certain randomly selected individuals and teams that
qualify for a state championship tournament or state championship competition for banned substances. The results of all drug tests are confidential and will only disclosed to the student, their parent/guardian and the school district. No student-athlete may participate in NJSIAA competition unless the student-athlete and their parent/guardian consent to random testing.

By signing below, we consent to random testing in accordance with the NJSIAA
steroid testing policy. We understand that, if the student or the student’s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances.
Parent/Guardian Signature- Steroid Testing Policy Acknowledgement *

Clear
Date*

MonthDayYear
Date
Opioid Education Video

To address the increased risk of opioid abuse among high school athletes, the Office of the New Jersey Coordinator for Addiction Responses and Enforcement Strategies (NJCARES) and the New Jersey State Interscholastic Athletic Association (NJSIAA) announced on February 19, 2019, a new partnership to educate student athletes and their parents/guardians on addiction risks associated with sports injuries and opioid use.

This educational initiative, spearheaded by Attorney General Gurbir Grewal and approved by the Executive Committee of the NJSIAA, is a collaborative effort to use video programming to raise awareness among high school athletes that they face a higher risk of becoming addicted to prescription pain medication than their fellow students who do not play sports.

We are making available to all student athletes and their parents/guardians, an educational video about the risks of opioid use as it relates to student athletes. The video will be available on NJSIAA website under “Athlete Wellness” which is located under the “Health & Safety tab. We are strongly encouraging student athletes and parents/guardians to watch the video as soon as it becomes available. Below you will find an acknowledgement that students and their parents/guardians have watched the video.

All member schools are asked to add to their current athletic consent forms the sign-off listed below. The sign-off acknowledgment is an NJSIAA mandate; student athletes are required to view the video only once per school year prior to the first official practice of the season in their respective sport, but the signed acknowledgment is required for each sport a student participates in. Athletes that are 18 years or older do not need the parents/guardians to watch the video. Opioid Video is located at: https://youtu.be/3Rz6rkwpAx8

By signing below, my child and I have viewed the NJ CARES educational video on the risks of opioid use for high school athletes. We understand the NJSIAA policy that requires students, and their parents(s)/guardian(s) if a student is under the age of 18, to view this video and sign this acknowledgment.
Date*

MonthDayYear
Date
Parent/Guardian Signature- Opioid Education Acknowledgement *

Clear

ATHLETIC CLEARANCE PROCESS:

1. Read, complete, and submit this "Passaic Athletic Registration Form."

2. Complete a Pre-Participation Physical. Once this form has been submitted, please Check Your Physical Date /Clearance Status.

Once in the document please follow these steps:

a) To check your status please hit CTRL F and type in your School ID #

b) You will need a new physical if your physical was done on, or prior to 11/21/2021

Pre-Participation Physical Evaluation Form (PPE)-English

Pre-Participation Physical Evaluation Form (PPE)-Spanish

c) You will need a Health Update Form if your physical was completed after 11/22/2021.

Health Update Form- English

Health Update Form-Spanish

3. Complete Concussion Education and Impact Testing with the Athletic Training staff. Please bring your fully-charged Chromebook when you submit your Physical Forms.

4. Receive academic eligibility clearance from the Athletics Department. Please read the following document.

Student-Athlete Code of Conduct

By submitting this Athletic Registration Form, you acknowledge that your child will not be cleared for participation until all the steps above are completed and you understand the eligibility requirements set forth by the NJSIAA.
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PASSAIC ATHLETIC REGISTRATION