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 BY JUNE 25TH, ANY TURNED IN LATER WILL NOT BE ABLE TO PARTICIPATE TILL THEY ARE CLEARED THE FIRST WEEK OF SCHOOL.
 
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 sign by parent/guardian.
____ P 10. Waiver of liability and release -- read and sign by parent/guardian and athlete.
____P 11. Sudden Cardiac Arrest information Sheet—read and sign by parent/guardian and athlete.
____ P 12/13. Concussion Information Sheet-- read and sign by parent/guardian and athlete.

PLEASE RETURN ALL COMPLETED FORMS TO THE HEALTH OFFICE
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 3/5/18