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Joining the Cross Country Team

Cross Country Season is August to December

To begin the registration process, please complete the forms below and email them to lasvegaseliterunners@gmail.com.

If you have any questions, please feel free to fill out the contact form below, and we’ll get back to you as soon as possible.

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Email these completed forms to lasvegaseliterunners@gmail.com

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Sports Physical Clearance

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LAS VEGAS ELITE RUNNERS (LVER)
Pre-Participation Physical Evaluation

SPORTS PHYSICAL CLEARANCE FORM

Track and Field

(Use this form instead of providing LVER with completed Medical History and Physical Exam forms when HIPAA concerns apply. The forms must still be completed as instructed and kept by the athlete’s physician. )
Athlete cannot practice or compete if not cleared by your physician.

Athlete Name:

Date of Birth:

Age

Sex:
M
F

EMERGENCY INFORMATION:

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CLEARED without restriction for all track and field events, including running, sprinting, jumping, and throwing.

NOT CLEARED for all track and field events

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Reason (If NOT CLEARED):

NOT CLEARED for specific track and field events.
List Event(s) and Reason

EMERGENCY INFORMATION:

Allergies:
List Known Allergies

Special or prescription medications or pertinent information:
List Medications/Pertinent Information

List restrictions or medical conditions that may affect training or competing:
List Restrictions/Conditions

Patient/Athlete has a medical alert bracelet or necklace:
Yes
No
Non-Applicable

Type of Medical Alert”

Physician: I certify that I have examined the above-named athlete and completed the Pre-Participation Physical Evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical examination and medical history is on record in my office and can be made available to the LVER staff at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete and parents/guardians. I also certify that I am a licensed medical physician, physician's assistant, or nurse practitioner.

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My office has a copy of the physical examination and medical history, which is available to LVER staff at the parents’ request.

Name of physician:

Date:

Address
Street Address City State / Province / Region ZIP / Postal Code

Phone

Email

Signature of Physician:
Your Name
Your Name
Your Name

Signature of Athletes:
Your Name
Your Name
Your Name

Signature of Parent:
Your Name
Your Name
Your Name

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LAS VEGAS ELITE RUNNERS
Pre-Participation Physical Evaluation
MEDICAL HISTORY FORM

Track and Field

Cross Country
Athlete Name:
Sex:

M

F
Date of Birth:
Do you have any allergies?

M

F
Check all that apply:

Medicines

Pollens

Food

Stinging Insects
Do you have a medical alert bracelet or necklace?
Yes
No
Non-Applicable
GENERAL QUESTIONS
1. Has a doctor ever denied or restricted your participation in sports for any reason?
Yes
No
2. Do you have any medical conditions: If so, please identify
Asthma
Anemia
Diabetes
Infections
Other
3. Have you ever spent the night in the hospital?
Yes
No
4. Have you ever had surgery?
Yes
No
HEART HEALTH QUESTIONS ABOUT YOU
5. Have you ever passed out or nearly passed out DURING exercise?
Yes
No
6. Have you ever passed out or nearly passed out AFTER exercise?
Yes
No
7. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Yes
No
8. Does your heart race or skip beats (irregular beats) during exercise?
Yes
No
9. Has your doctor ever told you that you have any heart problems? If so, check all that apply
High blood pressure
Heart murmur
Kawasaki Disease
High cholesterol
Heart infection
Other
10. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram)
Yes
No
11. Do you get lightheaded or feel more shortness of breath than expected during exercise?
Yes
No
12. Have you ever had an unexplained seizure?
Yes
No
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50?
Yes
No
14. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
Yes
No
15. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
Yes
No
16. 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
BONE AND JOINT QUESTIONS
17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss practices, meets, or games? Ex. Sprain, muscle or ligament tear, tendonitis
Yes
No
18. Have you ever had any broken or fractured bones or dislocated joints?
Yes
No
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
Yes
No
20. Have you ever had a stress fracture?
Yes
No
21. Have you ever been told that you have or have you had an x-ray for neck instability or Atlantoaxial instability?
Yes
No
22. Do you regularly use a brace, orthotic, or other assistive device?
Yes
No
23. Do you have a bone, muscle, or joint injury that bothers you?
Yes
No
24. Do any of your joints become painful, swollen, feel warm, or look red?
Yes
No
25. Do you have any history of juvenile arthritis or connective tissue disease?
Yes
No
MEDICAL QUESTIONS
26. Do you cough, wheeze, or have difficulty breathing during or after exercise?
Yes
No
27. Have you ever had an inhaler or taken asthma medicine?
Yes
No
28. Is there anyone in your family who has asthma?
Yes
No
29. Where you born without or are you missing a kidney, an eye, a testicle, your spleen, or any other organ?
Yes
No
30. Do you have groin pain or a painful bulge or hernia in the groin area?
Yes
No
31. Have you had infectious mononucleosis(mono) within the last month?
Yes
No
32. Do you have any rashes, pressure sores, or other skin problems?
Yes
No
33. Have you had a Herpes or MRSA skin infection?
Yes
No
34. Have you ever had a head injury or concussion?
Yes
No
35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
Yes
No
36. Do you have a history of a seizure disorder?
Yes
No
37. Do you have headaches with exercise?
Yes
No
38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
Yes
No
39. Have you ever been unable to move your arms or legs after being hit or falling?
Yes
No
40. Have you ever become ill while exercising in the heat?
Yes
No
41. Do you get frequent muscle cramps when exercising?
Yes
No
42. Do you or anyone in your family have sickle cell trait or disease?
Yes
No
43.Have you had problems with your eyes or vision?
Yes
No
44. Have you had any eye injuries?
Yes
No
45. Do you wear eyeglasses or contact lenses?
Yes
No
46. Do you wear protective eyewear such as goggles or a face shield?
Yes
No
47. Are you on a special diet or do you avoid certain types of food?
Yes
No
48. Are you trying to or has anyone recommended that you gain or lose weight?
Yes
No
49. Do you have any concerns that you would like to discuss with a doctor?
Yes
No
FEMALES ONLY
50. Have you ever had a menstrual period?
Yes
No
51. How old were you when you had your first menstrual period?
Yes
No
52. How many periods have you had in the last 12 months?
Yes
No
Signature of Athlete:
Your Name
Your Name
Your Name
Signature of Parent/Guardian:
Your Name
Your Name
Your Name
Date:

LAS VEGAS ELITE RUNNERS
Pre-Participation Physical Evaluation
PHYSICAL EXAMINATION FORM - TO BE COMPLETED BY THE PHYSICIAN
Date of Exam:
Athlete Name:
Sex:
M
F
Age:
Date of Birth:

Height:
Weight:
Pulse:
BP:
Vision: R 20/
L 20/
Corrected:
Yes
No
EMERGENCY INFORMATION:
Drug Allergies:
Other Information:
MEDICAL
Appearance
Marfan stigmata (kyphoscoliosis, high arched palate, peclus excavatum, arachnodactyly, arm span>height, hyperlaxity, myopia, arotic insufficiency)
Eyes/Nose/Throat Pupils equal Hearing
Lymph Nodes
Heart Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI)
Consider ECG, echocardiogram and referral to cardiology for abnormal heart history or exam.
Pulses Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary / Hernia (males only)
If exam is in a private setting, a third party present is recommended.
Skin HSV, lesions suggestive of MRSA, tinea corporis
Neurologic
Consider cognitive evaluation or baseline neuropsychiatric testing if history of significant concussion is present.
MUSCULOSKELETAL: ROM, Strength
Neck
Back/Spine
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
Functional Duck-walk, Single leg hop right Single leg hop left
Cleared for all sports without restriction
Cleared for all sports without restriction with recommendations for further evaluation or treatment for
Not cleared
Pending further evaluation
For any sports
For Track Events
For Field Events
For Cross Country
Reason
Recommendations
Physician: I certify that I have examined the above-named athlete and completed the Pre-Participation Physical Evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical examination and medical history is on record in my office and can be made available to the LVER staff at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete and parents/guardians. I also certify that I am a licensed medical physician, physician's assistant, or nurse practitioner.
Name of physician: (print/type/stamp)
Date:

Address:
Phone:
Signature of Physician:
Your Name
Your Name
Your Name
Signature of Athletes:
Your Name
Your Name
Your Name
Signature of Parents:
Your Name
Your Name
Your Name

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Birthday

Color
Career Goal
College, University, Trade School
Memorable Moment
Animation/Cartoon Character
Person
Video Game
Snack(s)
Food(s)
Dessert
Cake and icing
Restaurant - fast food
Restaurant - sit down
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Book
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Holiday
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Clothing Line - sporting
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Run Longer, Run Smarter

Joining the Cross Country Team

Cross Country Season is August to December

Parent Downloads

Cross Country Registration

Track and Field Registration

Sports Physical Clearance

Athlete Downloads

Athlete Get to Know Me

Please Fill Out the Form Below