Sports Physical Clearance Checklist

P1.        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.
 
P4/5      Complete copy #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 copy #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.


 

Student will NOT be cleared to participate in sports without Health Office clearance.


                            SEE    ATTACHED    FOR   ALL    FORMS
 
                                 Hard copies are also available in the Health Office


                   


                    PLEASE RETURN ALL COMPLETED FORMS TO THE HEALTH OFFICE