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PHYSICAL/PARENTAL CONSENT FORMS
8/28/2009

 

 

KENTUCKY HIGH SCHOOL ATHLETIC ASSOCIATION

2280 Executive Drive, Lexington, Kentucky 40505
Athletic Participation/Physical Examination Form/Consent and Release

PART I - ATHLETE INFORMATION

(This part must be completed by the student)

 

Name (Last, First, Initial)

 

School Year

 

 

Home Address (Street, City, State, Zip):

 

 

 

Gender

 

Grade

 

 

School

 

Date of Birth:

 

Birth Place (County, State):

 

 

Attendance History

 

Grade

School Name

School Year

Varsity Play - (Yes/No)?

 

9

 

 

 

 

10

 

 

 

 

11

 

 

 

 

12

 

 

 

 

                     

 

I am planning to participate in the following (circle all you might try to play):

Baseball          Basketball          Cross Country         Football          Golf          Soccer          Fast Pitch Softball

Swimming         Tennis          Track and Field          Volleyball                   Wrestling         Cheerleading          Other

  

PART II - MEDICAL HISTORY

This part must be completed by parent and student and presented to the authorized health care provider before the physical.

CHECK THE APPROPRIATE RESPONSE TO EACH ITEM:........................................................................................................................................ YES       NO

1.     Have you ever been hospitalized? ................................................................................................................................................................ r         r

2.     Have you ever had surgery of any kind (e.g., tonsillectomy).......................................................................................................................... r         r

3.     Are you presently taking any medications or pills?....................................................................................................................................... r         r

4.     Do you have any allergies (medicine, bees, or other insects)?...................................................................................................................... r         r

5.     Have you ever passed out during exercise?.................................................................................................................................................. r         r

6.     Have you ever been dizzy during or after exercise?....................................................................................................................................... r         r

7.     Have you ever had chest pain during or after exercise?................................................................................................................................ r         r

8.     Have you ever had high blood pressure?...................................................................................................................................................... r         r

9.     Have you ever been told you have a heart murmur?..................................................................................................................................... r         r

10. Have you ever had racing of your heart?....................................................................................................................................................... r         r

11. Has anyone in your family died of heart problems before 50?...................................................................................................................... r         r

12. Do you have any skin problems? (itching, rashes, acne)............................................................................................................................... r         r

13. Have you ever had a head injury? ................................................................................................................................................................. r         r

14. Have you ever been knocked out or unconscious? ....................................................................................................................................... r         r

15. Have you ever had a seizure or suffer from epilepsy? ................................................................................................................................... r         r

16. Have you ever had a stinger, burner or pinched nerve?................................................................................................................................ r         r

17. Have you ever had heat related problems? .................................................................................................................................................. r         r

18. Have you ever been dizzy or passed out in the heat?..................................................................................................................................... r         r

19. Do you cough heavily, or breath heavily during activity? .............................................................................................................................. r         r

20. Do you use any special equipment (e.g., knee brace)?.................................................................................................................................. r         r

21. Have you had any problems with your eyes or vision?................................................................................................................................... r         r

22. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any bones? ......................... r         r

23. Are you missing one of any paired organs (e.g., eyes)................................................................................................................................... r         r

24. Have you ever been diagnosed with any form of asthma? ............................................................................................................................ r         r

25. Are you using an inhaler for asthma?............................................................................................................................................................ r         r

26. Are you diabetic? ......................................................................................................................................................................................... r         r

27. Do you administer insulin to yourself?.......................................................................................................................................................... r         r

28. Are you presently using tobacco in any form?............................................................................................................................................... r         r

29. Do you have a history of sickle-cell anemia in your family?........................................................................................................................... r         r

30. Have you had any other medical problems?................................................................................................................................................. r         r

31. Have you had a medical problem or injury within the last year?.................................................................................................................... r         r

32. Can you swim?.............................................................................................................................................................................................. r         r

33. When was your last tetanus shot? ___________________________________________________________________________

Please explain any YES answers from questions 1-31 on page 1.__________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

  

PART III - PHYSICAL EXAMINATION

This part must be completed by the authorized health care provider named in Bylaw 2.

PATIENT NAME: ____________________________________________

HEIGHT: ______ WEIGHT ______ BP _____ / ______ PULSE ______

VISION: R- 20/ ____ L- 20/ ____ BOTH- 20/ ____ CORRECTED? Y N

 

Normal

Abnormal

Comment

HEART

 

 

 

 Rhythm (Regular/Irregular)

 

 

 

 Murmur (supine)

 

 

 

 Murmur (standing)

 

 

 

ENT

 

 

 

Lungs

 

 

 

Skin

 

 

 

Abdominal

 

 

 

Genitalia

 

 

 

Musculoskeletal

 

 

 

 Neck

 

 

 

 Shoulder

 

 

 

 Elbow

 

 

 

 Wrist

 

 

 

 Hand

 

 

 

 Back

 

 

 

 Knee

 

 

 

 Ankle

 

 

 

 Foot

 

 

 

Dental

 

 

 

Other

 

 

 

After having reviewed the data above and the student's medical history, I make the following recommendations on participation in athletics:

1. Cleared ______________________________________________________________________________________________

2. Cleared after additional evaluation for __________________________________________________________________________

3. Restricted from participating in the sports of ______________________________________________________________________

4. Cleared only to participate in the sports of _______________________________________________________________________

Recommendations/Restriction (attach additional if necessary)___________________________________________________________

______________________________________________________________________________________________________

In accordance with KHSAA Bylaws, I have examined the physical condition of the student and find the said student to be physically fit to practice for and participate in interscholastic athletic contests.

 

 

 

Provider's Name (please print)

 

Authorized Signature

 

Address:

 

 

 

City/State/Zip

 

Date:

 

Phone

 

This Physical Examination is valid for one year from date administered.

PART IV - EMERGENCY PERMISSION FORM

(This part must be completed by student and custodial parent / guardian)

STUDENT NAME__________________________________________________________________________________________

SOCIAL SECURITY NUMBER__________________________________________________________________________________

ADDRESS______________________________________________________________________________________________

CITY/STATE/ZIP__________________________________________________________________________________________

SCHOOL_______________________________________________________________________________________________

BIRTH DATE_____________________________________________________________________________________________

PHONE________________________________________________________________________________________________

PERSON TO CONTACT IN CASE OF MEDICAL EMERGENCY:

NAME_________________________________________________________________________________________________

RELATION______________________________________________________________________________________________

ADDRESS______________________________________________________________________________________________

CITY/STATE/ZIP__________________________________________________________________________________________

DAYTIME PHONE__________________________________________________________________________________________

EVENING PHONE__________________________________________________________________________________________

 

Please list any health problems/concerns your child may have, including allergies (medications / others) and any medications presently being used:           

 

Students desiring to participate in Wrestling must also complete KHSAA Form WR101 and required attachments between October 15 and the first contest.

 

This form must be reproduced in order for a copy to travel with respective athlete.

 

PART V - CONSENT TO PARTICIPATE, ACKNOWLEDGMENT OF RISK, ACKNOWLEDGEMENT OF ELIGIBILITY RULES, LIABILITY WAIVER AND CONSENT AND RELEASE

The student and parents/guardian must read this statement carefully. This form must be completed before the student participates (hereinafter including try out for, practice and/or compete) in interscholastic athletics.

As parent/legal guardian, I agree to allow my child to participate in interscholastic athletics.

The student and parent/legal guardian recognize that participation in interscholastic athletics involves some inherent risks for potentially severe injuries, including but not limited to death, serious neck, head and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system, and serious injury or impairment to other aspects of the body, or effects to the general health and well being of the child. Because of these inherent risks, the student and parent/legal guardian recognize the importance of the student obeying the coaches' instructions regarding playing techniques, training and other team rules. By signing this form, the student and parent/legal guardian acknowledge that the student's participation is wholly voluntary and to having read and understood this provision.

The student and parent/legal guardian individually and on behalf of the student, hereby irrevocably, and unconditionally release, acquit, and forever discharge the KHSAA and its officers, agents, attorneys, representatives and employees (collectively, the "Releasees") from any and all losses, claims, demands, actions and causes of action, obligations, damages, and costs or expenses of any nature (including attorney's fees) that the student and/or parent/legal guardian incur or sustain to person, property or both, which arise out of, result from, occur during or are otherwise connected with the student's participation in interscholastic athletics if due to the ordinary negligence of the Releasees.

The student and parent/legal guardian acknowledge that they have read and understood the KHSAA Bylaws 1 through 33 by distribution through the member school or by review at http://www.khsaa.org/handbook/. Please be aware that a student is subject to the one year period of ineligibility in Bylaw 6, otherwise known as the "Transfer Rule," upon participation in any varsity contest regardless of the amount of participation or lack thereof.

The student and parent/legal guardian agree to abide by the KHSAA Bylaws and Due Process Procedure as now enacted or later amended. The student and parent/legal guardian further acknowledge that they agree to abide by the rulings of the Commissioner, Assistant Commissioner, Hearing Officer and Board of Control.

The student and parent/legal guardian acknowledge that the student must have insurance coverage up to a limit of $25,000 in order to be eligible to participate in interscholastic athletics.

PART V - CONSENT TO PARTICIPATE, ACKNOWLEDGMENT OF RISK, ACKNOWLEDGEMENT OF ELIGIBILITY RULES, LIABILITY WAIVER AND CONSENT AND RELEASE (continued)

The student and parents/guardian must read this statement carefully. This form must be completed before the student participates (hereinafter including try out for, practice and/or compete) in interscholastic athletics.

The student and parent/legal guardian consent to this student receiving a physical examination as required by the KHSAA.

The student and parent/legal guardian, individually and on behalf of this student, give the high school, the KHSAA and their representatives permission to release this student's demographic information (including motion picture and still photography) and participation statistics (including height, weight and year in school, participation history) and other information as may be requested, and agree that the student may be photographed or otherwise digitally or electronically captured during school-based competition and such image or other report may be used without permission or compensation.

The student and parent/legal guardian, individually and on behalf of this student, consent to the high school and the KHSAA and their representatives to use and disclose the necessary personally identifiable information from the student's education records including academic, financial and health care information, to third parties including school representatives, coaches, athletic trainers, medical facilities, medical staffs, KHSAA legal counsel and the media, for the purpose of receiving proper/necessary medical care and complying with the KHSAA bylaws, including making determinations regarding eligibility to participate in interscholastic athletics and any administrative or legal proceedings resulting from participation or attempted participation in interscholastic athletics, without such disclosure constituting a violation of my rights under the Family Educational Rights and Privacy Act. I further release the high school, the KHSAA and their representatives from any and all claims arising out of the use and disclosure of said necessary personally identifiable information. I also agree to release to the high school, the KHSAA, and their representatives, upon request, the detailed and completed application for financial aid.

The student and parent/legal guardian, individual and on behalf of the student, hereby consent to allow the student to receive medical treatment that may be deemed advisable by the high school, the KHSAA, and their representatives in the event of injury, accident or illness while participating in interscholastic athletics, including, but not limited to, transportation of the student to a medical facility.

 

 

 

 

Students' Name (please print)

 

School

 

Student and Parent/Guardian Address

 

 

 

Signature of Student

 

Date

 

 

 

Name of Parent(s)/Guardian(s) who has/have custody of this student (please print)

 

Emergency Phone Number

 

 

 

Signature of Parent(s)/Guardian(s) who has/have custody of this student

 

Date

 

 

 

Insurance Carrier

 

Policy Number