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Brandon Valley High School
April Newsletter
Brandon Valley High School 301 South Splitrock Blvd. Brandon, SD 57005
www.brandonvalley.k12.sd.us
605-582-3211
Principal Dr. Gregg Talcott
Website: Brandonvalley.k12.sd.us
Link: Principal
Associate Principal Mark Schlekeway
Associate Principal Randy Marso
Counselor (A-G) Kara Likness
Counselor (H-N) Michelle Stemwedel
Counselor (O-Z) Katie Murdy
April 2017
April brings State-mandated testing, the Prom, the final chorus concert, spring sports in
full swing, the Turkey Supper, National Honor Society Induction Ceremony, a home
track and field invite, Region Music Contests, Senior Athletic Banquet, the High School
Press Convention, the State FFA Convention…
The state-mandated testing requires that all juniors take the Smarter Balanced English
Language Arts and Math tests and a Science test. All of these tests will be taken on
computer on April 11 and 12. Their annual Senior Retreat with staff from Youth Fron-
tiers out of the Twin Cities will be on April 11. The seniors will have a special schedule
with a variety of transition activities on April 12. Thanks go to the Senior Parent Organi-
zation for paying for the retreat and to the Brandon Assembly of God Church for
providing a place for the retreat. The sophomores and freshmen will be having one
special event each day but will have all of their classes both days in a shortened form.
The BVHS Prom is a sure sign that Spring is here. The Prom will be held at the Shrine
Mosque in Sioux Falls on Saturday, April 8. The doors are open to the students and
public at 8:00 to see the students all dressed up and to take pictures. Large group pho-
tos will be taken from 8:45-9:15. The event will be closed to the students and their
guest from 9:15-11:45. The Senior Parent Organization is providing a free breakfast for
all prom participants at the Brandon Fire Hall following the dance.
Yearbook [email protected]
From the Principal [email protected]
Have you ordered your 2016-2017 Lynxonian yearbook yet?
April is the last month to order and pay for a yearbook from
Jostens. Pay online by going to the BVHS homepage and click-
ing the "Buy a Yearbook" icon.
No extra yearbooks will be ordered for purchase in the fall. If you are uncertain if you
have already paid for a yearbook, you can check online or by contacting Jostens direct-
ly. Questions? Contact Miss Maggie Bryant at [email protected]
2
PROM! [email protected]
The El Riad Shrine Mosque will once again be the site for the BVHS prom. This year’s prom will be held on Saturday, April 8th. The theme for the evening event will be “Paris by Moonlight." Cobblestone pathways through ivy lighted arches lead the prom attendees toward the ballroom floor. The ballroom will be transformed into a night at the city of romance with a twinkling Eiffel Tower and a cafe with bistro lighting. Streetlights, park benches, candlelight lanterns, and roses accent the Parisian theme. As a new feature this year, Pinnacle Productions provides music and lighting for the dance event. The company will also have a photo booth available for the prom attendees.
Students are expected to pick up his or her prom ticket from March 29-April 6th in the High School office. Students are allowed to bring non-BVHS guests provided that they met the criteria outlined in the form that was due March 24th. Students may not bring guests who have had a drug or alcohol violation in the last year. All guests will be re-quired to bring photo identification and documentation that demonstrates their cur-rent age. The behavior of all guests is the responsibility of the student that brings them to the dance. Any inappropriate behavior will result in removal and the conse-quences will transfer to their sponsoring student. BVHS students will be required to present their student identification cards to collect their tickets and will not need their identification cards the night of the dance.
The dance is free to all juniors and seniors that worked at one of the concession stands during their junior or senior years. The out-of-school guest is also free if a stu-dent had worked at a concession stand. Students that have not worked a concession stand will be charged $25. This amount will cover them individually and will also cover their guest. At the dance, hors d'oeuvures will be served to the students courtesy of the Advanced Foods class from Brandon Valley High School. One bottle of water per student is available for free to each prom attendee and the Mosque will also have pop available for purchase. The dance is over at midnight.
The doors will open at 8:00 pm. Parents and guests are welcome to the Mosque to take pictures, but will be asked to leave by 9:00 pm before the dance begins. Doors will be locked at 9:30 pm. After that time, students will not be allowed entrance. Par-ents of students that have tickets for prom that do not show will be called just to noti-fy the parents of their absence. Parents of students that wish to leave prom prior to 11:00 will also be called to notify them of their child’s early departure.
The Child Nutrition Services Department is excited to announce a new resource available for your use. We have a program named “Brandon Valley Nutrislice”. Nutrislice comes in an app or computer version for your convenience. It gives you the opportunity to see the menu daily, monthly, or by school year for each school location. In addition to the menu items, an-other useful tool Nutrislice provides is the nutritional content and/or known allergens for our student meals based on our most current information. If there is a menu change due to weather or delivery related issues, we are able to change it im-mediately so you can always see up-to-date menu information. As we continue implementation of this program, you will see actual photos of the food items we offer. We feel this is a great opportunity for you as parents to see what your children are eating. As we continue to enhance the program, we welcome your feedback as always. On each school website, you can utilize Brandon Valley Nutrislice. You may select any of the school entities and view the Breakfast, Second Chance Breakfast (Elementary and Intermediate only), or Lunch Menu for the day or entire School Year. Download the free phone app today to use as a quick reference. Just search for “Nutrislice”.Your child’s school nutrition is just a click away!
Nutrislice [email protected]
3 www.brandonvalley.k12.sd.us
Choir News [email protected]
Nineteen members from BVHS participated in this year's Region 2 Vocal Solo/Ensemble Contest at Augustana College March 14. The students had been preparing solo and ensemble pieces since January. Each singer performed for an adjudicator, and received written comments, numerical scoring, and brief one-on-one verbal comments.
Twelve singers received a Superior Rating for their solos: Alexa Hokenstad, Marshall Elkin, Issy DeWitt, Sierra Coyle, Emma Eichelberg, Jimmy Hoffmann, Johnny Hoffmann, Emili Widrig, Erika Christopherson, Andrea Poole, Hayley Vogel, and Abby Waldner. Receiving Excellent Ratings were Briana Plastow, Kendra Christopherson, Lauryn Van Regenmorter, Danielle Spen-cer, and Colton Bultje. Two ensembles received Superiors-- Girls Duet: Taylor Brummels and Morgan McKellep, Girls Trio: Shiela Coyle, Issy DeWitt, Emma Eichelberg.
The BVHS Concert Choir, Lynx Choir, and Chamber Choir will participate in the Region 2 Large Group Contest Wednesday, April 19 in the BVHS PAC. Typically held at two sites here in Brandon, this year's contest will feature an abbreviated list of participating schools, due to a calendar conflict with the Sioux Falls Schools. Bands will perform on the morning of the 19th, with choirs in the afternoon. The public is welcome to attend the Region 2 Contest at any time during the day; admission is free. Here is the schedule for the BV choirs: 1:15- Chamber Choir, 2:00- Concert Choir, 2:55- Lynx Choir. Reminder to choir parents: ALL CHOIR MEMBERS will need their concert black shoes (and boys need black dress pants/socks) in school Wednes-day, April 19.
Four Concert Choir members will audition April 22 for this summer's South Dakota High School Honor Choir. SD Honor Choir is a week-long music camp featuring 150 of the finest 10th and 11th grade singers in the state, rehearsing with a guest con-ductor, and performing in concert. The audition consists of a solo, sight-singing, and a written test. Good luck to Issy DeWitt, Emma Eichelberg, Marshall Elkin, and Jonas Kulzer.
The BV Choirs will perform their Spring Concert Thursday, April 27 in the Performing Arts Center. The concert will feature the Concert Choir, Lynx Choir, and Chamber Choir, a tribute to graduating choir seniors, and recognition of the Outstanding Sen-ior Awards and the Landon Wulf Scholarship recipient. Admission is free; concert time is 7:30 pm.
April and May are very busy, exciting months in the BV band room! Here is a look at some up-coming events. We cordially in-vite you to all of them!
Monday, April 3rd– Brandon Valley Activities Center held a gathering of all band students in the district. This 5-12 concert fea-tured each band and also a mass band piece for a finale!
Wednesday, April 19th – All three Brandon Valley High School bands, along with bands from Sioux Falls and Brookings will be performing at the Region II Large Group Contest in the Brandon Valley PAC. A panel of judges will provide comments and ratings for the bands. The performances are open to the public. Performance times are not published yet.
Saturday, April 22rd – The Annual Turkey Supper and Pops Concert will be held at the High School starting at 4:15pm. Groups from the middle school and high school will be performing continuously throughout the evening.
Monday, May 1st- The Band Awards Banquet takes place in the HS commons at 6:30pm. We will be honoring all of the great accomplishments of the band students from this year.
Sunday, May 7th - The Loyalty Day Parade Event in Brandon! This parade begins at 2pm! The members of The Marching Lynx will bring music through the streets of Brandon.
Monday, May 15th – Spring Concert. This will feature all of our concert bands. It is a special evening as we also recognize our seniors. The concert is free and will begin at 7:30pm in our Performing Arts Center. It will be an unforgettable evening!
Thank you for your continued support of the Brandon Valley Band Program and we look forward to seeing you at all of these events!
Band News [email protected]
Summer Opportunity [email protected]
Looking for something for your child to do this summer? A list of summer opportu-nities can be found on the BVHS counselor’s webpage and click on the document called “Summer Opportunities.” Opportunities include SD School of Mines & Tech-nology’s Chem/Bio Engineering Camp, University of South Dakota’s Beacom School of Business Accounting Institute, South Dakota State’s Health Professions Career Camp, and SD Highway Patrol’s Trooper Academy. Dates, application dead-lines, and links for more information can also be found on the page. For questions, contact Katie Murdy.
Fall Dual Credit options are
available on SDMyLife. Class of
2018 and 2019 are able to take
advantage of dual credit courses
through SD Board of Regents for
a reduced rate, as long as they
meet eligibility requirements.
For more information visit
www.sdmylife.com and click on
Dual Credit. Questions? Contact
your school counselor!
A job-postings page has been added to the Counselors Web site. To get to the page, select the Counselors Link under Student Resources. Then scroll down the page to the “Job Postings” button under “Upcoming Opportunities & Summer Camps.” Click here to go directly to the job-postings page. Postings are added as they are received, so it’s a good idea to check back periodically.
4
Dual Credit Options [email protected]
Job Opportunities this Summer [email protected]
New Sports Physical Form Effective April 1, 2017, through March 31, 2018
All students who plan to participate in Brandon Valley athletics and/or marching band during the 2017-18 school year must have a new physical on or after April 1, 2017, using Brandon Valley’s two-page physical form. This form is available on the BVHS Website, in both of the Brandon medical clinics, and in the middle school and high school offices. It is also at the end of this newsletter.
When you complete, sign and submit BOTH pages of the 2017-18 physical form, you are agreeing to the SDHSAA Annual Consent and Medication Information, the Concussion Fact Sheet, and the HIPPA Consent for Release of Medical Information. These informational forms are accessible through the “Sports Physicals” link on the BVHS Website.
When you complete the new form, you are ALSO stating that you have completed all Family Access emergency and per-mission updates for the 2017-18 year, including permission to print student information used for team travel, printed rosters, and standard media coverage. Please note that this may require that you go back into Family Access when you receive the annual update request from the Central Office. (The Family Access update process must be completed each year.)
If you have questions concerning physicals, please contact the high school office at 582-3211.
AGAIN, PLEASE NOTE THAT ANY PHYSICAL DATED PRIOR TO APRIL 1, 2017, WILL NOT BE CONSIDERED VALID FOR THE 2017-18 SCHOOL YEAR
The Brandon Valley High School Golf Team will be making some changes to their golf program beginning Fall of 2017. As spring meetings are held and summer approaches ahead of the 2017 golf season, it is important that parents and athletes know of these changes. The team will consist of no more than 20 golfers ranging from 7-12 grades. Of these 20 golfers, at least 6 will be made up of 7th and 8th grade student athletes. All high school and middle school athletes will tryout the week of August 7 through August 11. Practices will be held at Brandon Municipal Golf Course and Hidden Valley.
BV Golf News Randy. [email protected]
www.BrandonValley.k12.sd.us 5
April Calendar
Sat., April 1, 2017 "Damn Yankees" 7:00 p.m. FR/SO BA vs SFL @ Aspen 1:00 & 3:00 TR ESD Indoor Inv @ Brookings 1:00
Sunday, April 2, 2017 "Damn Yankees" 1:00
Monday, April 3, 2017 All District Band Concert (5-12) @ HS 7:00 BA vs SFR @ Valley 5:00(V)/7:00(JV
Tuesday, April 4, 2017 FR/SO BA vs SFO @ Aspen 5:00 & 7:00 BT vs SFR/Yankton @ Yankton 1:00/3:15 TR @ Harrisburg Inv 3:45
Wednesday, April 5, 2017 JV BA vs SFW @ Valley 5:00 & 7:00
Thursday, April 6, 2017 SDSU Jazz Festival 7:00 p.m. Sub-V BT @ SFW 4:00 BT vs Harrisburg @ BV 4:00 JV TR Metro @ SFR 4:00
Friday, April 7, 2017 BA vs W. Fargo @ Harmodon 5:00 & 7:00 FR/SO BA vs SFW @ Aspen 5:00 & 7:00 BT vs Brookings/O+G @ BV 12:00/5:30
Saturday, April 8, 2017 Prom FR/SO BA vs Bkings @ Aspen 12:00/ 2:00 TR - Lynx Inv 10:30 Monday, April 10, 2017 BT vs Central/Roncalli @ BV 11:00/1:30
Tuesday, April 11, 2017 SALSA Meeting 7:00 a.m. JV BA vs SFL @ Harmodon 5:00 & 7:00 FR/SO BA vs SFR @ Harmodon 5:00 & 7:00 BT @ Vermillion 4:00 V/JV TR vs Yank/Mitchell @ Yankton 4:00
Thursday, April 13, 2017 NO SCHOOL (if snow days unused) BA vs SFL @ Valley Springs 5:00 & 7:00 GG @ Harrisburg Inv (Spring Creek) 10:00
Friday, April 14, 2017 NO SCHOOL - Spring Break BA @ RCS (McKeague Field) 2:00 & 4:00 BT vs RCS/Watertown @ BV 10:00/3:00
Saturday, April 15, 2017 FR/SO BA vs West Central @ Aspen TBD BA @ RCS(McKeague Field) 2:00 & 4:00
Monday, April 17, 2017 NO SCHOOL - Spring Break Sub-V BT vs SFW @ BV 4:00 BT vs SFW/Pierre @ SFW 1:30/4:00
Tuesday, April 18, 2017 BA @ Yankton (Riverside) 5:00 & 7:00 JV BA vs SFO @ Valley Springs 5:00 & 7:00 FR/SO BA vs Hburg @ Aspen 5:00 & 7:00 GG VS Yankton/Brookings @ BV 2:00 V/JV TR vs SFO/SFW/Yank @ Yankton 4:00
Wednesday, April 19, 2017 Blood Drive Region 2 Large Group Band/Chorus Contest Thursday, April 20, 2017 Blood Drive BA vs SFW @ Valley 5:00(V)/7:00(JV) JV GG Metro @ Kuehn 4:00 GG @ Sioux Falls (O+G) 4:00 Sub-V BT vs SFL @ BV 4:00 BT vs SFL/Millbank @ SFL 2:00 JV TR @ Lennox Inv 4:00
Friday, April 21, 2017 FR/SO BA @ Sturgis Fields 5:00 & 7:00 SD-ACDA HS Honor Choir Auditions @ SFW TR @ Pierre Legion 1:00
Saturday, April 22, 2017 Band Boosters Turkey Supper BA vs Fargo Davies @ Valley 12:00 & 2:00 JV BA @ Mitchell (Cadwell) 12:00 & 2:00 FR/SO BA vs RCC @ McKeague 12:00 & 2:00 SD-ACDA HS Honor Choir Auditions @ SFW
Monday, April 24, 2017 GG vs Brookings/SFL/SFW @ BV 2:00 BT vs SFR @ BV 4:00 Sub-V BT @ SFR 4:00
Tuesday, April 25, 2017 Senior Athletic Banquet 6:30 FR/SO BA vs SFL @ Harmodon 5:00 & 7:00 JV BA vs Harrburg @ Valley 5:00 & 7:00 BA @ Harrisburg 5:00 & 7:00 JV GG Metro @ Elmwood 4:00 BT vs Watertown/SFC @ W-Town 10:00/2:30 JV TR @ Dakota Valley Inv 4:00
Thursday, April 27, 2017 BA vs SFR @ SF Harmodon 5:00 & 7:00 HS Chorus Concert GG vs SFW @ BV 4:00
Friday, April 28, 2017 JV BA @ Yankton (Riverside) 5:00 & 7:00 FR/SO BA vs SFO @ Aspen 5:00 & 7:00 BT vs RCC/RC Inv 10:00/2:00 TR Metro @ HWF 3:00 Saturday, April 29, 2017 FR/SO BA vs SFO @ Harmodon 12:00 & 2:00 BA vs Aberdeen @ Valley 2:00 & 4:00 BT @ RC Inv 8:00
April
Brandon Valley Summer School
Brandon Valley High School will be offering summer school for students who have failed a course and
need to recover credit. Our summer school program is not an option for students looking to work
ahead in credits. Summer courses are offered online through our Edgenuity program. Edgenuity’s
self-paced learning and pretesting allow students to spend more time on what they need and less
time on content they’ve already mastered. Courses run June 5th-29th (Monday-Thursday) and cost
$175 per 0.5 credit. Session times are available in the morning 7:30am-11:30am and afternoon
11:30am-3:30pm. Please see the attached registration form to register for courses. For questions
contact Kara Likness. [email protected] or 605-582-3211
Sioux Falls Summer School Programs
Sioux Falls Public School and Sioux Falls Christian School also offer options for summer school
programs. These programs are available to students who are needing to recover credit or are looking
to work ahead in credits. Cost and dates vary by programs. Please see below for more information.
Sioux Falls Public School: Course options & registration: http://www.sf.k12.sd.us/schools/summer-school-high-school Registration due by: May 19th Cost for out of district students: $220 per 0.5 credit Please contact Kara Likness for out-of-district registration paperwork.
Sioux Falls Christian: Course options can be found at https://goo.gl/laJEuk The registration form can be found at http://goo.gl/forms/ekZWLRRWy7 Registration due by: April 14th
Contact Information: Pam Tiefenthaler Chief Education Officer Sioux Falls Christian Schools [email protected]
Brandon Valley High School 301 S. Splitrock Blvd.
Brandon, SD 57005 605-582-3211
2017 Summer School – Edgenuity Teachwell Academy will be offering courses through Edgenuity at Brandon Valley High School as a summer school option for students. Edgenuity courses are completely on-line and students work independently at their own pace. Courses will be offered for credit recovery only. This means a student has to already have taken a course and failed it in order to retake through Edgenuity. Students must attend daily, maximum 3 absences allowed, including tardies.
Please choose one:
SESSION A: JUNE 5-29th (Maximum 18 per session) Monday – Thursday, 7:30 AM- 11:30 AM
SESSION B: June 5-29th (Maximum 18 per session) Monday - Thursday, 11:30 AM – 3:30 PM
SESSION C: July To be determined after sessions A & B are filled.
Please complete all information and include payment or your spot will not be reserved.
Student Name:
Student Cell:
Parent(s) Name:
Parent Phone:
Address:
City/State/Zip
Parent Email:
Payment Information
Check: Make payable to Teachwell Academy.
Cash :
Courses Available: English 9-10-11-12 Government Algebra 1 American History Geometry World History Biology Economics Physical Science Geography
Course requested: ____________________________________ Semester: ________
COST: $175 per .5 credit (semester)
Brandon Valley Band Parents Present:
53rd Annual Band Supper & Pops Concert
Saturday, April 22, 2017
4:00-8:00 p.m. in the BVHS Commons
The tradition continues! Great food, great music, and a great tradition come to-gether as the Brandon Valley Band Parents present the 53rd Annual Band Supper & Pops Concert, better known as the Turkey Supper. All proceeds from this annu-al fundraiser benefit the Brandon Valley band program. For your listening pleas-ure, the following bands will perform in the BVHS Performing Arts Center at the times indicated.
Tony’s Catering will handle the details of food preparation; as always, we can be sure that a great meal will be provided. As in past years, Turkey and Pork will be the main entrees, with potatoes and vegetables on the side.
Adults: $11.00 ($12.00 at the door)
Children Ages 3 to 10: $7.00 ($8.00 at the door)
Children Ages 2 and Under: Free (no ticket needed)
Tickets available from any band member before March 31. Tickets may also be purchased at the door.
4:10 – 4:25 p.m. Percussion Ensemble
4:30 – 4:50 p.m. Middle School Jazz Band
4:55 – 5:15 p.m. High School Jazz 2
5:20 – 5:40 p.m. Middle School 7th Grade Band
5:45 – 6:05 p.m. Concert Band
6:10 – 6:30 p.m. High School Jazz 1
6:35 – 6:55 p.m. Middle School 8th Grade Band
7:00 – 7:20 p.m. Symphonic Band
7:25 – 7:45 p.m. Wind Ensemble
April Newsletter
Brandon Community Library www.siouxlandlib.org / 605-582-2390
Paracord Bracelets Tween/Teen Tuesday, April 18 at 3:30 – 4:30 pm
Learn to make paracord bracelets and make your own to take
home. 5th -12th grades are invited to attend. Please register online
at www.siouxlandlib.org/teens or call 582-2390.
Easter Bunny Visit and Storytime Saturday, April 8 at 10:15 am
Join us at the Brandon Community Library for a family storytime
and a visit from the Easter Bunny. Parents, bring your cameras
for a photo-op with the Easter Bunny!
Early Literary Classes
Lapsit Mondays at 10:15 am
Delight and stimulate your baby with songs, stories and playtime.
This program is for babies 6 months to 24 months to attend with a
parent or caregiver. Preschool Storytime Tuesdays at 10:15 am
Encourage a love of reading while developing your
preschooler's early literacy skills with stories, rhymes, songs, and
movement activities. For children 3-5 and their caregivers.
Toddler Time Wednesdays at 10:15 am
Keep your busy toddler moving while nurturing their love of
books through music, movement, and story activities. For two-
year-olds to attend with a caregiver. Family Storytime Thursdays at 7:00 pm
Stimulate early learning with books, rhymes, music, and
movement at this drop-in program for the whole family.
Check Out Our
Digital Collection
BRANDON VALLEY
PHYSICAL FORM
STEP 1 COMPLETE THE BOTTOM OF
PAGE 1. (PARENT/GUARDIAN
AND STUDENT SIGNATURES
ARE REQUIRED.)
STEP 2 COMPLETE PAGE 2.
STEP 3 GIVE THE FORM TO THE
DOCTOR TO COMPLETE THE
TOP OF PAGE 1.
STEP 4 SUBMIT COMPLETED PAGES 1
AND 2 TO THE HIGH SCHOOL
OR MIDDLE SCHOOL OFFICE.
SPORTS PARTICIPATION RECOMMENDED FOR: All Sports: Collision, Contact/Endurance and Other __________Contact/Endurance and Other ____Other Sports Only Cleared for ALL, but with recommendations for further evaluation or treatment for ____________________________________ Above clearance to be granted only after _____________________________________________________________ Clearance cannot be given at this time because ____________________________________________________________
Sport Definitions: Collision = Football, Wrestling. Contact/Endurance = Baseball, Basketball, Cheer, Cross Country, Dance, Powerlifting, Soccer, Softball, Tennis, Track and Volleyball. Other Activities = Bowling, Golf, Marching Band
PRINTED NAME OF EXAMINER:______________________________________________ DATE_________________ 20______ SIGNATURE OF EXAMINER__________________________________________________________________________________
NOTE: The following licensed medical personnel are qualified to perform the examination and certify the health of the student athlete: Doctor of Medicine, Doctor of Osteopathy, Doctor of Chiropractic, licensed Physicians Assistant and licensed Nurse Practitioner.
PHYSICAL EXAMINATION FORM
(2017-2018)
______________________________________ ________________ ____________________________________ __________________
PARENT (or GUARDIAN) Signature DATE STUDENT Signature DATE
2. Height ___________
3. Weight ____________
4. Vision 20/_______(L) 20/_______(R)
5. Head
6. Mouth (dentures, braces?)
7. Eyes (contacts?)
8. Chest/lung
9. Heart
a. Heart sounds
b. Murmurs
c. pulse discrepancy (rad. vs fem.)
d. abnormal rhythm
10. Abdomen
a. liver or spleen enlargement
b. masses
11. Genitalia (males only)
a. hernias
b. testes
12. Orthopedic
a. cervical spine
b. shoulder shrug
c. deltoid
d. arms/elbow
e. hands
f. hips
g. knees
h. ankles
i. Scoliosis
Normal
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Abnormal
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Comments
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NAME ____________________________________________________________________________________ GRADE ______ (Fall of 2017)
DATE OF BIRTH_______________________ PLACE OF BIRTH ______________________ MALE ______ FEMALE ______
1. Blood pressure (sitting) _____/_______ Repeat in 5 minutes, if elevated _____/_______
Page/Side 1
PARENT/GUARDIAN AND STUDENT:
REVIEW, SIGN, AND DATE BELOW — AND SUBMIT COMPLETED PAGES 1 AND 2.
We have read and agree to ALL statements in the Concussion Facts, Medical Info and SDHSAA Annual Parent/Student Consent form (on Web site). We have ALSO read and agree to all statements in the online HIPPA form. We have ALSO completed the Family Access (FA) update process for THE 2017-18 YEAR, including emergency info AND permission to print student information used for team travel, printed rosters, and standard media coverage.
SUBMIT COMPLETED
PAGES 1 AND 2.
PRE-PARTICIPATION PHYSICAL EVALUATION
(Note: This form is to be filled out by the patient and parent/guardian prior to seeing the physician. The physician should keep a copy of this form in the chart.)
Explain “Yes” to the answers below. Circle questions you don’t know answers to:
Date of Exam: ____________________________________________ Student Name: __________________________________________________________________
Parent Name: _____________________________________________ Student Date of Birth: _____________ Student Place of Birth: ___________________________
Gender: ______ Age: _______ Grade (2017-18 school year): _______School: ____________________________________ Sport (s): ___________________________
Medications and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking: _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________
Do you have allergies? □ Yes □ No If yes, please identify allergy below:
□ Medicines □ Pollens □ Food □ Stinging Insects
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?
By signing page 1 of this form, we — the parent/guardian and student — state that, to the best of our knowledge, our answers to the above questions are complete and accurate.
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 Yes No
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?
Explain “yes” answers in this space. Also List all precautions (allergies, diseases, medi-cations, etc.) that should be considered in treating the above named student:
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Page/Side 2
SUBMIT COMPLETED VERSION OF THIS PAGE
AND PAGE 1 TO THE SCHOOL OFFICE.
