This form is approved by the north carolina high school athletic association sports medicine advisory committee and the nchsa a board of directors. Ihave examined the abovenamed student and completed the preparticipation physical evaluation. Kansas state high school activities association 601 sw commerce place po box 495 topeka, ks 66601 7852735329. Birmingham public schools preparticipation physical evaluation i hereby give my consent for the disclosure to the mhsaa of information otherwise protected by ferpa and hipaa for the purpose of determining eligibility for interscholastic athletics. Preparticipation physical form ogden community schools. It must be completed if there are yes answers to specific questions on the students medical history for on the reverse side. The student must turn in only the last page medical eligibility formpage 5 to the school. Preparticipation physical evaluation medical history revised 12414 this medical history form must be completed annually by parent or guardian and student in order for the student to participate in athletic activities. Athletic participation form parental and student consent and. Mshsaa preparticipation physical form 201920 physical and consent form 201920. Supplement to piaa application for school membership involving piaa member private sr high schools. Kansas state high school activities association pre. Health examination and consent form it is required all students complete a history and physical examination prior to hisher first 9th and 11th grade practice in the interscholastic 912 athletic program in the state of idaho.
Entire completed form is to be returned to school administration. Schools may download either the 4page or 2page form below. Khsaa form ge04 high school parental permission and consent rev. Ihsa steroid testing policy consent to random testing this section for high school students only 202014 school term. It must be completed if there are yes answers to specific questions on the students medical history form on. I have examined the student named on this form and completed the sports qualifying physical exam as required by the minnesota state high school. Eligibility brochure pdf physical evaluation form pdf ihsaa rule 310 requires that between april 1 and students first practice in preparation for interschool athletic participation, the student shall have a physical examination by, or shall provide.
I have examined the student named on this form and completed the sports qualifying physical exam as required by the minnesota state high school league. Please note that for the 201920 season no physicals will be excepted date prior to 6119. The athlete does not present apparent clinical contraindications to practice and participate in the sports as outlined above. This form is valid for 365 calendar days from the date of the evaluation as written on page 2. The physician should keep a copy of this form in the chart. Khsaa forms kentucky high school athletic association. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. The aaa recommends the following forms from the american academy of family physicians to be used for athletic physicals. The most frequently requested and downloaded form is the studentathlete physical exam medical history form. If, in the judgment of any representative of the school, the above student should. General administrative forms physical,transfer,contract ge01application for membership pdf ge02new member school information pdf ge04combined parent permission and athletic physical forms english, high school ge04combined parent permission and athletic physical forms spanish, high school ge04ppepre participation physical exam. Health examination and consent form idaho high school.
Vhslrevised february 2017physical form is required for all studentathletes that plan to try out for sports teams. Separate signed form is required for each school year. El9 home education student academic progress report. History form pages 1 and 2, physical examination form page 3, athletes with disabilities form. Preparticipation physical evaluation florida high school athletic. Participation examination suggested exam protocol for medical provider revised may 2017 oregon school activities association forms physical examination. Schools are encouraged not to change this form from its published format. Supplement to contract for contests involving nonmember schools. Preparticipation examination form utah high school. Ghsa membership dues invoice 20192020 sanctioned tournaments. I have examined the abovenamed student and completed the preparticipation physical evaluation.
The athlete does not have apparent clinical contraindications to practice and participate in the sports as outlined on this form. Click on the link s of the form s you need and print the page to your local printer. This completed form must be kept on file by the school. Athletic participationparental consentphysical examination form. Athletic participation form parental and student consent.
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. A preparticipation physical evaluation form along with the. The state board of education adopts by reference the form entitled school sports pre. This form has been developed with the assistance of the committee on sports medicine of the iowa medical society and has been approved for use by the iowa department of education, iowa high school athletic association, and iowa girls high school athletic union. As a minimum requirement, this physical examination form must be completed prior to junior high athletic participation and again prior to first and third years of high school athletic participation. Families will complete all other pages, and pages 3 and 4 must be completed before the doctors appointment. History form should be filled out by the student and parentguardian prior to the physical examination ppe. Kansas state high school activities association preparticipation physical evaluation ppe is required annually and shall not be taken earlier than may 1 preceding the school year for which it is applicable. A currentyear physical is one given on or after april 15 of the previous school year. The form must be turned in to the activities office. We would like to show you a description here but the site wont allow us. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event. Florida high school athletic association preparticipation physical evaluation page 3 of 3 this completed form must be kept on file by the school.
There are other places you can get a ppe, but we recommend athletes get a ppe during their well visit at their doctors office or school based health center. Ahsaa physical form alabama high school athletic association. Please note that the 201920 piaa physical form is the only form that will be accepted. Preparticipation physical evaluation seaholm high school. June 30 may 1 athletic participationparental consent. Blood test required if resides in chicago or high risk zip code. Supplement to the athlete history page 4, and the medical eligibility form page 5. The preparticipation physical evaluation consists of four parts. A health examination must be performed annually and the preparticipation physical evaluation form must be completed before any student may participate in athletic activities sponsored by this. By signing this form, all parties agree that they have accurately completed all sections of the form and have read and agree to the terms of this form as detailed. The exam is at the expense of the student and may not be taken prior to may 1 of the 8th and 10th grade years. This certificate of physical examination is valid for the purposes of this rule for one 1.
Preparticipation physical evaluation page 1 of 3 this completed form must be kept on file by the school. Preparticipation physical evaluation history form note. Association approved sports physical packet must be used for all preparticipation examinations and all forms must be submitted to your school prior to participation. Physical forms recommended by aaa arkansas high school. Ohio high school athletic association 4080 roselea place, columbus oh 43214 fax. Idaho high school activities association idaho health. Participation examination dated may, 2017 that must be used to document the physical examination and sets out the protocol for conducting the physical examination. Students fill out this activity log to meet physical education waiver requirements. As a minimum requirement, this physical examination form must be completed prior to junior high participation and again prior to first and third years of high school participation.
Marfan stigmata kyphoscoliosis, higharched palate, pectus excavatum, arachnodactyly, arm span height, hyperlaxity, myopia, mvp, aortic insufficiency neck. Eligibility brochure pdf physical evaluation form pdf ihsaa guidance on 202021 physical forms. The michigan high school athletic association, inc. This ensures exams cover everything important about your overall health and wellbeing. This form is to be completed by the physical education department chair and school administrator. State of illinois certificate of child health examination. Member school renewal form, 202021 pdf request to play up in classification form, 201920 pdf request for coaches to provide instruction and coaching after week no. Athletics forms in pdf san mateo union high school. It must be completed if there are yes answers to specific questions on the students medical history form on the reverse side. Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school andor kindergarten. Currentyear physical given on or after april 15 of the previous school year medical normal abnormal musculoskeletal normal abnormal appearance. Click on the links of the form s you need and print the page to your local printer. It is the responsibility of the parentguardian to notify the school if there are any unique individual problems that are not listed on the preparticipation physical evaluation form.