Creighton Prep Athlete/Parent Contract and Permission Form

Creighton Prep Athlete/Parent Contract and Physical Form
IMPORTANT: This form must be filed with the ATHLETIC OFFICE before a student can practice or
compete with any Creighton Prep athletic team. This one form covers all athletic competition by the
student during this school year.
(Please Print)
STUDENT NAME Grade_______
As a parent of a Creighton Prep athlete, I/we understand the existence of potential dangers associated with
athletic participation, including injuries ranging from minor muscle strains and sprains to more serious
injuries to ligaments, bones and tendons to catastrophic injuries to the head, neck and spinal cord. We also
understand it is our responsibility to carry adequate insurance coverage and that Creighton Prep and the
NSAA are not responsible for the cost of medical care associated with such injuries.
As a parent of a Creighton Prep athlete, I/we understand that it is the responsibility of the student athlete
named above to return all equipment and uniforms in the condition they were received or pay the cost of
replacement.
As an athlete at Creighton Prep, I understand there is no guarantee of any amount of playing time. I agree
to support the coaches’ decisions and show good sportsmanship to all opponents, officials, coaches and
fans of both schools.
As a parent of a Creighton Prep athlete, I agree to support the coaches’ decisions. I will show good
sportsmanship to all players, coaches, fans and officials of both schools.
As an athlete at Creighton Prep, I agree to abide by all school policies as stated in the Student-Parent
Handbook. Athletes at Creighton Prep are expected to demonstrate exemplary conduct on and off the
field/court, in the classroom, at home, and in any public place.
Signing below indicates you understand the policies of the school and the athletic department and
agree to support them. The parent signature will also serve as your permission for the student
named above to participate on Creighton Prep athletic teams.
Your signature acknowledges your awareness of the ever present risk of athletic injury to your son
while participating in athletics and authorizes that the health information of the student be
disclosed to and used by Creighton Prep for the purposes of record retention and injury evaluation
with respect to participation in athletics and activities sponsored by the school.
In case of emergency please contact us at the following numbers:
Mother Home Work
Father Home Work
Insurance Company
Parent/Guardian Signature Date
Student Signature Date
Cell
Cell
(PLEASE NOTE...PHYSICAL FORM ON OTHER SIDE)

CREIGHTON PREP PHYSICAL EXAM AND HISTORY
Name_________________________________________ Age_________ Date of Birth_____________ Date________________
Grade____________ Personal Physician___________________________________ Phone#_______________________________
HISTORY (explain Yes answers below **)
Y N Have you been hospitalized
Y N Have you had any surgery
Y N Are you now on any medication
Y N Do you have any allergies
Y N Have you ever passed out
Y N Have you ever been dizzy during activities
Y N Have you ever had chest pain during exercise
Y N Do you tire more quickly than your friends
Y N Have you ever had high blood pressure
Y N Have you ever been told you have a heart murmur
Y N Have you ever had a racing heart or skipped beats
Y N Has any one in your family had heart problems
Y N Do you have any skin problems
Y N Have you ever had a head injury
Y N Have you ever been knocked out
Y N Have you ever had a seizure
Y N Have you ever had a stinger, or pinched nerve
Y N Have you ever had heat or muscle cramps
Y N Have you ever been dizzy or passed out in heat
Y N Do you have trouble breathing
Y N Do you use any special equipment
Y N Have you had any problem with eyes or vision
Y N Do you wear glasses or contacts
Y N Have you ever sprained ,dislocated, broken any bones
__Head __ shoulder __ thigh__ neck__ elbow__knee
__ Chest__ forearm__ back__ wrist __ ankle__ hip
__ hand __ foot
Y N Have you had any other medical problems
Y N Have you had any problem since your last exam
When was your last tetanus shot____________
When was your last measles immunization ________
**Explain YES answers______________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
I hearby state that to the best of my knowledge, my answers are correct
Date_______________
Signature of athlete_________________________________________
Signature of parent/guardian __________________________________
PHYSICAL EXAM (To be filled out by Physician)
Height_________Weight_________ BP______/______ Pulse_______
Vision R 20/_____ L 20/______ corrected Y N Pupils_______
Cardiopulminary
Pulses
Heart
Lungs
Tanner Stage
Skin
Abdominal
Genitalia
Musculoskeletal
A. Cleared
Normal
1 2
Abnormal findings
3 4 5
B. Cleared after completing evaluation for: ______________________
______________________________________________________
C. Not cleared for: Collision______
Contact ______
Noncontact_______
Due to _________________________________________
Recommendation__________________________________________
________________________________________________________
________________________________________________________
Name of Physician ________________________________________
Signature of Physician____________________________________

CREIGHTON PREPARATORY SCHOOL
PERFORMANCE ENHANCING DRUG POLICY AND CONSENT FORM
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 to treat a medical condition,
violates the Creighton Preparatory School sportsmanship rule, and is subject to the following penalties and
procedures:
1. A student who is found to have used a substance on the list of banned drugs, either through
random testing or according to the rules of apprehension stated in the Student-Parent Handbook,
shall be declared ineligible to participate in Creighton Preparatory School athletics (both NSAA
sanctioned sports and club sports), for one calendar year (365 days) after the date of the positive
drug test. In order to be reinstated after one calendar year, the student must submit to random
testing for the duration of the suspension. A student who fails a drug test during the suspension
shall be declared permanently ineligible.
2. After reinstatement, any student who tests positive a second time for a substance on the list of
banned drugs shall be declared permanently ineligible to participate in Creighton Preparatory
School athletics (both NSAA sanctioned sports and club sports).
3. A student who tests positive for any banned substance is also subject to the general school policy
on substance abuse as delineated in the Student-Parent handbook.
4. A student who tests positive may challenge the finding by following the protocol described in the
Student-Parent handbook. The original specimen, which will be retained by the lab, will then
undergo a second analysis. If the second analysis is negative, the student will be immediately
reinstated. If the second analysis is also positive, the student will remain suspended and the
student or his family will be responsible for the cost of the second analysis.
CONSENT TO RANDOM TESTING
Creighton Preparatory School has contracted with the National Center for Drug Free Sport (or an agency
approved by the school) to test certain randomly selected individuals and teams year-round for banned
substances. The results of all tests shall be considered confidential and shall only be disclosed to the student,
his or her parents and Creighton Preparatory School. No student may participate in athletics unless the student
and the student’s parent/guardian consent to random testing.
By signing below, we consent to random testing in accordance with the Creighton Preparatory School
performance enhancing drug policy. We understand that the student may be randomly selected for testing for
banned substances at any point after he begins participation in athletics. If selected, the student will provide a
urine sample to a certified specimen collector as assigned by the National Center for Drug Free Sport (or an
agency approved by the school). We also understand that the penalty for missing a scheduled drug test or
refusing to submit to a test is the same as the penalty for testing positive. This consent is valid for the duration
of the student’s career at Creighton Preparatory School.
A complete description of the Performance Enhancing Drug Policy protocol can be found in the Student-
Parent Handbook.
___________________________________________________________
Name of student-athlete (Print)
______________________________ __________________________
Signature of student-athlete Date
______________________________ __________________________
Signature of parent/guardian Date

2011-12 Banned Drugs
Creighton Prep follows the NCAA Drug Testing Program and bans the following classes of drugs:
a. Stimulants
b. Anabolic Agents
c. Alcohol and Beta Blockers (banned for rifle only)
d. Diuretics and Other Masking Agents
e. Street Drugs
f. Peptide Hormones and Analogues
g. Anti-estrogens
h. Beta-2 Agonists
Note: Any substance chemically related to these classes is also banned.
The student-athlete shall be held accountable for all drugs within the banned drug class regardless of
whether they have been specifically identified.
Drugs and Procedures Subject to Restrictions:
a. Blood Doping.
b. Local Anesthetics (under some conditions).
c. Manipulation of Urine Samples.
d. Beta-2 Agonists permitted only by prescription and inhalation.
e. Caffeine if concentrations in urine exceed 15 micrograms/ml.
Some Examples of Banned Substances in Each Drug Class
NOTE: There is no complete list of banned drug examples
Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen);
methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange);
methylhexaneamine, etc. Exceptions: phenylephrine and pseudoephedrine are not banned.
Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione):
boldenone; clenbuterol; DHEA (7-Keto); nandrolone; stanozolol; testosterone; methasterone;
androstenedione; norandrostenedione; methandienone; etiocholanolone; trenbolone; etc.
Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol;
propranolol; timolol; etc.
Diuretics (water pills) and Other Masking Agents: bumetanide; chlorothiazide; furosemide;
hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc.
Street Drugs: heroin; marijuana; tetrahydrocannabinol (THC); synthetic cannabinoids (eg. spice, K2, JWH-
018, JWH-073)
Peptide Hormones and Analogues: growth hormone(hGH); human chorionic gonadotropin (hCG);
erythropoietin (EPO); etc.
Anti-Estrogens: anastrozole; tamoxifen; formestane; 3,17-dioxo-etiochol-1,4,6-triene(ATD), etc.
Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; etc.
Any substance that is chemically related to the class of banned drugs is also banned! (unless otherwise
noted)