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PRE-PARTICIPATION PHYSICAL EVALUATION HISTORY FORM

THIS FORM NEEDS TO BE COMPLETED BEFORE PARTICIPATING

Birthday
Year
Month
Day
Do you have an epi pen?
Yes
No
Do you have any allergies?
Yes
No

GENERAL QUESTIONS

Has a doctor ever denied or restricted your participation in sports for any reason?
Yes
No
Have you ever spent the night in the hospital?
Yes
No
Have you ever had surgery?
Yes
No
Do you have any ongoing medical conditions?
Have you ever had an unexplained seizure?
Yes
No

HEART HEALTH QUESTIONS ABOUT YOU

Have you ever had discomfort, pain, tightness or pressure in your chest doing exercise?
Yes
No
Does your heart ever race skip beats (irregular beats) during exercise?
Yes
No
Do you get lightheaded or feel more short of breath than expected during exercise?
Yes
No
Do you get more tired or short of breath more quickly than your friends during exercise?
Yes
No
Have you passed out or nearly passed out DURING or AFTER exercise?
Yes
No
Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram)
Yes
No
Has a doctor ever told you that you have any heart problems? If so, check all that apply:

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

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)?
Yes
No
Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
Yes
No
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?
Yes
No
Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
Yes
No

BONE AND JOINT QUESTIONS

Have you ever had a stress fracture?
Yes
No
Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
Yes
No
Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
Yes
No
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)
Yes
No
Do you have a bone, muscle, or joint injury that bothers you?
Yes
No
Have you ever had any broken or fractured bones or dislocated joints?
Yes
No
Do you regularly use a brace, orthotics, or other assistive device?
Yes
No
Do any of your joints become painful, swollen, feel warm, or look red?
Yes
No
Do you have any history of juvenile arthritis or connective tissue disease?
Yes
No

MEDICAL QUESTIONS

Do you cough, wheeze, or have difficulty breathing during or after exercise?
Yes
No
Is there anyone in your family who has asthma?
Yes
No
Do you have groin pain or a painful bulge or hernia in the groin area?
Yes
No
Were you born with any missing organs?
Yes
No
Do you have a history of seizure disorder?
Yes
No
Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
Yes
No
Have you ever become ill while exercising in the heat?
Yes
No

MEDICAL QUESTIONS

Have you had any eye injuries?
Yes
No
Do you or someone in your family have sickle cell trait or disease?
Yes
No
Do you wear protective eye wear, such as goggles or a face shield?
Yes
No
Have you ever had an eating disorder?
Yes
No
Have you ever used an inhaler or taken asthma medicine?
Yes
No
Have you had infectious mononucleosis (mono) within the last month?
Yes
No
Do you have any rashes, pressure sores, or other skin problems?
Yes
No
Have you had a head injury or concussion?
Yes
No
Have you ever had a hit or blow to the head that caused confusion, prolonged headaches, or memory problems?
Yes
No
Do you have headaches with exercise?
Yes
No
Have you ever been unable to move your arms or legs after being hit or falling?
Yes
No
Do you get frequent muscle cramps when exercising?
Yes
No
Have you had any problems with your eyes or vision?
Yes
No
Do you wear glasses or contact lenses?
Yes
No
Are you on a special diet or do you avoid certain types of foods?
Yes
No

EMERGENCY CONTACT INFORMATION

All personal information will not be shared with any 3rd party without first getting consent from the guardians or participants

Performance Analytics Institute Waiver and Release Form

Birthday
Year
Month
Day

Acknowledgment of Risk and Release of Liability

I, the undersigned, hereby acknowledge and agree to the following: 

Assumption of Risk 

I understand that participation in Performance Analytics Institute involves physical activity that may result in injury or accidents. I voluntarily assume all risks related to my participation, including but not limited to falls, contact with other participants, or any other injury that may occur during the camp. I understand that it is my responsibility to ensure that I am physically fit to participate in the camp activities. 


Medical Treatment Authorization 

I grant permission to Performance Analytics Institute organizers and their staff to administer first aid and seek emergency medical treatment if necessary. In the event of an emergency, I authorize Performance Analytics Institute staff to arrange for medical treatment and transportation to the nearest hospital if needed. 


Release of Liability 

In consideration of my participation in Performance Analytics Institute, I hereby release and hold harmless the camp organizers, staff, volunteers, and all other associated individuals or entities from any liability, claims, demands, and causes of action that may arise as a result of my participation in Performance Analytics Institute. This release includes, but is not limited to, any injury, loss, or damage that may occur as a result of negligence or otherwise. 


Photo/Video Release 

I grant permission to the Performance Analytics Institute organizers to take and use photographs or videos of me during the camp for promotional purposes, social media, and marketing materials. I waive any rights to compensation for such use.


Indemnification 

I agree to indemnify and hold harmless the Performance Analytics Institute organizers, their affiliates, employees, and agents from any and all liabilities, damages, or costs (including legal fees) arising from my actions or omissions during the program. 

Participant's Agreement:  

By signing this waiver, I confirm that I have read, understood, and agree to the terms of this waiver. I acknowledge that I am voluntarily participating in Performance Analytics Institute and take full responsibility for my actions and well-being during the program. 

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Date
Year
Month
Day

If the participant is under 18 years of age, a parent or legal guardian must sign below: 

Parent/Guardian Consent: 

I, the undersigned, am the parent or legal guardian of the above-named participant. I consent to the participant’s involvement in Performance Analytics Institute and agree to the terms of this waiver on their behalf. 

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