Preparticipation physical evaluation page 1 of 3 this completed form must be kept on file by the school. Preparticipation physical evaluation history form aafp. Ndhsaa preparticipation physical evaluation form starting with the 201011 school year, student athletes participating in ndhsaa sanctioned sports programs will be required to file a preparticipation health history screening and physical examination clearance form page 4 with their school office prior to their participation on a yearly basis. 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. American college of sports medicine acsm, american academy of family physicians. Upon entering the first and third years of high school, a physical examination signed by a. Piaa comprehensive initial preparticipation physical.
Pages one, two and four require your signature while pages five, six and seven are references for you to keep. The athlete does not present apparent clinical contraindications to practice and participate in the sports as outlined above. Annual health and medical record the scouting adventure, camping trips, highadventure excursions, and having fun are important to everyone in scoutingand so is your safety and wellbeing. Every year each student grades 712 shall present to the students superintendent a certificate signed by a licensed physician and surgeon, osteopathic physician and surgeon, osteopath. Piaa comprehensive initial preparticipation physical evaluation new. Preparticipation examination to be completed by athlete or parent prior to examination. This is a screening examination for participation in sports. The ppe provides guidance on the proper timing, setting, and structure of the evaluation to improve the health and well being of athletes and is available on shopaap. It must be completed if there are yes answers to specific questions on the students medical history form on the reverse side. Page three requires the exam date and physicians signature. Athletic eligibility 1 preparticipation physical examination. Students enrolled in grades 912 must have an annual preparticipation physical evaluation in order to participate in montgomery county public schools. Name school year last first middle address citystate phone no.
Youngstown state university does not discriminate on the basis of race, color, national origin, sex, sexual orientation, gender indentity andor expression, disability, age, religion or veternmilitary status in its programs and activtities. Complete and sign this form with your parents if younger than 18. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and. Mshsaa preparticipation documentation annual requirements interim medical history note. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
I have examined the abovenamed student and completed the preparticipation physical evaluation. Prior to any student participating in practices, interschool practices, scrimmages, andor contests, at any piaa member school in any school year, the student is required to 1 complete a comprehensive initial pre participation physical evaluation cippe. It is the responsibility of the parentguardian to notify the school if there are any unique individual problems that are not listed. The preparticipation sports evaluation american family. We are excited to have you participating in intercollegiate athletics at. By the execution of this consent, the student athlete named above and hisher parentguardians do hereby consent to screening, examination, and testing of the student athlete during the course of the preparticipation examination by those performing the evaluation, and to the taking of. Upon written request, i may receive a copy of this document for my personal health care provider. History form should be filled out by the student and.
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. In the event of an emergency or when the parents or guardian is unable to directly supervise health care services needed by the student for injuries or. Pre participation physical evaluation history this page to be completed by student and parentguardian. Preparticipation physical evaluation history form author. Finally, if available and desired by the student, parent or member school, a new pre participation physical and consent form on the most current ihsaa. This completed form must be kept on file by the school.
By the execution of this consent, the student athlete named above and hisher parentguardians do hereby consent to screening, examination, and testing of the student athlete during the course of the pre participation examination by those performing the evaluation, and to the taking of. 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. Preparticipation physical exam form revised 2019 pdf. Ndhsaa preparticipation physical evaluation form starting with the 201011 school year, student athletes participating in ndhsaa sanctioned sports programs will be required to file a pre participation health history screening and physical examination clearance form page 4 with their school office prior to their participation on a yearly basis. It is the responsibility of the parentguardian to notify the school if there are any unique individual problems that are not listed on the pre participation physical evaluation form. Kansas state high school activities association 601 sw commerce place po box 495 topeka, ks 66601 7852735329. I have examined the abovenamed student and completed the pre participation physical evaluation.
Piaa comprehensive initial pre participation physical evaluation new. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in uil practices, games or matches yes yes nosi no 1. Preparticipation physical evaluation kansas state high school activities association 601 sw commerce place po box 495 topeka, ks 66601 7852735329 history form should be filled out by the student and parentguardian prior to the physical examination ppe name sex age date of birth gradesports school. Preparticipation physical evaluation form pdf preparticipation physical examination ppe form to embed this safety tip in your site use the following code. This form is used by a physician to examine children before they are allowed to participate in sports. Preparticipation physical exam form word template revised 2019. For title iisection 504 cordinator information, visit. Preparticipation physical evaluation page 1 of 3 fhsaa. The major change involves new state law requirements related to informing parents of the ability to receive cardiac screening. Preparticipation physical evaluation form pdf safe kids. William penn university sports medicine department pre.
Welcome to william penn university and statesmen athletics. The uil posted an updated medical history pre participation physical examination ppe form on the uil website for the 20202021 school year. Preparticipation physical evaluation for athletics montgomery. This does not substitute for a comprehensive examination with your childs regular physician where important preventive health information can be covered. The uil posted an updated medical history preparticipation physical examination ppe form on the uil website for the 20202021 school year. The preparticipation physical evaluation ppe monograph, 5th edition serves as a resource for medical providers to keep athletes safe and healthy while participating in sports. The form is designed to identify risk factors prior to athletic participation by way of a thorough medical history and physical examination. Preparticipation physical evaluation page 1 of 2 part 1. Completing the annual health and medical record is the first step in making sure you have a. Pre participation physical evaluation page 1 of 2 part 1. Preparticipation examination physical examination form name last first middle examination.
Iowa athletic preparticipation physical examination. Kansas state high school activities association pre. Pre participation physical forms sports medicine department 201 trueblood avenue, oskaloosa, ia page 1 of 10. William penn university sports medicine department dear studentathlete and parentsguardians.
Preparticipation physical evaluation form pdf safe. Athletic and marching band preparticipation physical. Preparticipation physical this part must be completed by certified and licensed physicians md, do, nurse practitioners, or physician assistants. If condi tions 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. Preparticipation physical and consent form completed prior to eligibility and competition. Preparticipation physical forms sports medicine department 201 trueblood avenue, oskaloosa, ia page 1 of 10. The preparticipation physical evaluation is a commonly requested medical visit for. 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. William penn university sports medicine department. Prior to any student participating in practices, interschool practices, scrimmages, andor contests, at any piaa member school in any school year, the student is required to 1 complete a comprehensive initial pre. Click on the link s of the form s you need and print the page to your local printer. On the basis of the examination on this day, i approve this childs participation in interscholastic sports for 395 days from this date. Preparticipation history and physical examination this form is not required as long as the conditions of 18. This includes any studentathlete coming from an out of state school to an ihsaa member school or any student who did not particip ate in sports during the 20192020 school year.
Pre participation physical evaluation history form author. The ihsaa preparticipation physical evaluation ppe is the. Annual health and medical record boy scouts of america. Have you had a medical illness or injury since your last check up or sports physical. If condi tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and. 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. Preparticipation physical this part must be completed by certi. Informed consent, release agreement, and authorization.
Athletic eligibility 1 pre participation physical examination. For title iisection 504 cordinator information, visit the ada compliance page on ysu. Preparticipation physical exam texas tech university. Student information the parent or guardian should fill out this form with assistance from the student. Nfhs sports medicine advisory committee smac as we head into the fall preseason, i want to give everyone a gentle, but forceful reminder to be mindful of the heat, and of the risks. Completing the annual health and medical record is the first step in making sure you have a great scouting experience. Name sex age date of birth grade address phone in case of emergency, contact. The california interscholastic federation requires an annual preparticipation physical examination ppe by a health practitioner for all studentathletes before the student engages in a tryout, practice, or actual competition cif bylaw 308. This medical history form must be completed annually by parent or. Pre participation physical this part must be completed by certified and licensed physicians md, do, nurse practitioners, or physician assistants.
Delaware interscholastic athletic association preparticipation physical evaluation the diaa preparticipation physical evaluation and consents form consist of seven pages. I hereby authorize the release the information contained in this document to the wpu sports medicine staff. This certificate of physical examination is valid for one 1 calendar year. Prior to any student participating in practices, interschool practices, scrimmages, andor contests, at any piaa member school in any school year, the student is required to. I do not know of any existing physical condition or additional health reason that would preclude my participation in sports. El9 home education student academic progress report. Sep 01, 2015 the preparticipation physical evaluation is a commonly requested medical visit for amateur and professional athletes of all ages. Name sex age date of birth gradeschoolsports home address phone. The preparticipation physical evaluation ppe monograph, 5th edition serves as a resource for medical providers to keep athletes safe and healthy while. This form is valid for 365 calendar days from the date. The overarching goal is to maximize the health of athletes and.