Mark Keppel High School

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MKHS believes in providing the 3 O's: Overall student well-being, Opportunity, Options            
Athletics » Physical Clearance and Forms

Physical Clearance and Forms

INCOMING 9TH GRADERS MUST HAVE THERE MEDICAL FORMS TURNED INTO THE NURSE NOT THE COACH  TO PARTICIPATE IN ANY PRACTICES/TRYOUTS. ANY FORMS TURNED IN AFTER JUNE 25TH WILL NOT BE ABLE TO PARTICIPATE TILL THEY ARE CLEARED THE FIRST WEEK OF SCHOOL.
 
*ALL RETURNING ATHLETES - REMEMBER TO CHECK WHEN YOU PHYSICAL EXPIRES YOU MUST HAVE A NEW PHYSICAL EACH YEAR AND COMPLETE THE 2018/2019 FORMS TO PARTICIPATE*
 
2018-2019 SCHOOL YEAR
Sports Physical Clearance Checklist
Please read and sign all forms

___ P 1. Checklist page.
____P 2.  Physical Evaluation Form -- must only be done by MD, DO, PNP ( No Chiropractors).

 BE SURE to mark clearance or not.
 EXAMINATION date needs to be within a year.
 REQUIRED Doctor’s office stamp.

____P 3. Health History form-- complete and MAKE SURE it’s signed by parent/guardian & athlete.
____P 4/5  Complete #1 Emergency and insurance information form & student insurance
verification letter (For Athletic Director).
**** Please attach one copy of current insurance card ***
____P 6/7. Complete #2 Emergency and insurance information form & student insurance
verification letter (For coach).

**** Please attach one copy of current insurance card ***
____ P 8. Athlete code of Ethics-- Read and sign by athlete and parent/guardian.
____ P 9. Parent/Guardian Code of Ethics -- Read and signed by parent/guardian.
____ P 10. Waiver of liability and release -- read and signed by parent/guardian and athlete.
____P 11. Sudden Cardiac Arrest information Sheet—read and signed by parent/guardian and athlete.
____ P 12/13. Concussion Information Sheet-- read and signed by parent/guardian and athlete.

PLEASE RETURN ALL COMPLETED FORMS TO THE HEALTH OFFICE
The student will NOT be cleared to participate in sports without Health Office clearance.

Student Name________________________________________________Student ID #__________________________Grade level ________

For MKHS Health Office Use Only:
Received completed sports physical form on _________________________________________________
Date/Health Office Stamp/Signature
Student is clear to play sports till ___________________________                                                           updated 6/13/18