IRevlsed March 20111 Routing I Page I of 4-

~ VIRGINIA HIGH SCHOOL LEAGUE, INC. ;~~ 1642 State Farm Blvd., Charlottesville, Va. 2291I 3

Athletic Participation/Parental Consent/Physical Examination FormSennrnle signed form is required fOl' filCh school yell I' May 1 of tile current year through Jnne 30 oCtile succeeding YClll",

For School Year

PRINT CLEARLY

PART I - ATHLETIC PARTICIPATION(To be filled in and signed by the student)

Male----Female _

Name StudentI.D #

(Last) (First) (Middle Initial)

Home Address. _

City/Zip Code _

Home Address of Parents _

City/Zip Code _

Date ofBnth .Place ofBnth

This is my semester in, .High School, and my semester since first entering the ninth grade. Last', ..

semesterIattended .Schooland passed credit subjects, and I am taking credit subjects

this semester. I have read the condensed individual eligibility rules of the Virginia High School League that appear below and believe I am eligible to

represent my present high school in athletics.

INDIVIDUAL ELIGIBILITY RULESTo be eligible to represent yonr school in any VHSL interscholastic athletic contest, you-. -• must be a regular bona fide student in good standing of the school you represent• must be enrolled in the last four years of high school. (Eighth-grade students may be eligible for junior varsity.)• must have enrolled not later than the fifteenth day of the current semester.• for the first semester must be currently enrolled in not fewer than five subjects, or their equivalent, offered for credit and which may

be used for graduation and have passed five subjects, or their equivalen~ offered for credit and which may be used for graduation theimmediately preceding year or the immediately preceding semester for schools that certify credits on a semester basis. (Check withyour principal for equivalent requirements). May not repeat courses for eligibility purposes for which credit has beenpreviously awarded.

• for the second semester must be currently emolled in not fewer than five subjects, or their equivalen~ offered for credit and whichmay be used for graduation and have passed five subjects, or their equivalent, offered for credit and which may be used forgraduation the immediately preceding semester. (Check with your principal for equivalent requirements.)

• must sit out all VHSL competition for 365 consecutive calendar days following a school transfer unless the transfer correspondedwith a family move. (Check with your principal for exceptions.)

• must not have reached your nineteenth birthday on or before the first day of August ofthe cunent school year.must not, after enternlg the ninth grade for the first time, have been emolled in or been eligible for emollment in high school morethan eight consecutive semesters.

• must have submitted to your principal hefore any kind of participation, including tryouts or practice as a member of any schoolatllletic or cheedeading team, an AtWetic ParticipationlParental Consent/Physical Examination FOlm, completely filled in andpropedy signed attesting that you have been examined during this school year and found to be physically fit for athletic competitionand that your parents consent to your participation.

• must not be in violation ofVHSL Amateur, Awards, All Star or College Team Rules. (Check with your principal for clarification inregard to cheedeading.)

Eligibility to participate in interscholastic atWetics is a privilege you earn by meeting not only the above-listed minimum standards, butalso all other standards set by your League, district and school. If you have any question regarding your eligibility or are in doubt aboutthe effect an activity might have on your eligibility, check with your principal for interpretations and exceptions provided underLeague rules. Meeting the intent and spirit of League standards will prevent you, your team, school and community from beingpenalized. Additionally, I give my consent and approval for my picture and name to be printed in any high school or VHSL athleticprogram, publication or video.LOCAL SCHOOL DIVISIONS AND VHSL DISTRICTS MAY REQUIRE ADDITIONAL STANDARDS TO THOSE LISTED ABOVE.

Student Signature: Date: _

Providing false information will result in ineligibility for one year.

••I Page2of4MEDICAL HISTORY.IIp

!Revised March 20111

••• ••• '"'"••••••••• A'"

• Explain ••Yes" answers DelUW I I

This form must be completed and signed, prior to the physical examination, for review by examining practitioner •Exnlain "Yes" answers below with number of the auestion. Circle nuestions vou don't know the answers to.

GENERAL MEDICAL HISTORY Yes No MEDICAL OUESTIONS (cont) Yes No

1. Has a doctor ever denied or restricted your participation in 0 029. Do you have groin pain or a painful bulge or hemia in 0 0

snorts for anv reason?the eroin area?

2. Do you currently have an ongoing medical condition? Ifso,Please identify: 0 Asthma o Anemia o Diabetes 0 0 30. Have you had mononucleosis (mono) within the last 0 0

o Infections 0 Other:month?

3. Have you ever spent the night in the hospital? 0 031. Do you have any rashes, pressure sores, or other skin 0 0nroblems?

4. Have vou ever had surnerv?, 0 32. Have vou ever had a heroes or MRSA skin infection? 0 0

HEART HEALTH QUESTIONS ABOUT YOU Yes No 33. Are you currently taking any medication on daily basis? 0* 0

5. Have you ever passed out or nearly passed out DURING or 0 034. Have you ever had a head injury or concussion? Ifso, 0 0

AFTER exercise?date of last iniurv:

6. Have you ever had discomfort, pain, or pressure in your chest 0 035. Have you ever had numbness, tingling, or weakness in 0 0

durin~ exercise?vour arms or leQ:safter being hit or fallinQ:?

7. Does vour heart race or skin beats dunnQ: exercise? 0 II 36. Do YOU 11aveheadaches with exercise? 0 0

8. Has a doctor ever told you that you have (check all that apply):DHigh Blood Pressure DA heart mUnTlllr 0 0

37. Have you ever been unable to move your arms or legs 0 0DHigh cholesterol DA heart infection

after being hit or falling?

DKawasaki disease OOthc•.9. Has a doctor ever ordered a test for your heart? 0 0

38. When exercising in heat, do you have severe muscle 0 0(For ex: ECG/EKG, echocardiolrra~\

cramos or become ill?

10. Do you get lightheaded or feel more short of breath than39. Has a doctor told you that you or someone in your family 0 0

expected during exercise? 0 0 has sickle cell trait or sickle cell disease?

II. Have you ever had an unexplained seizure? 0 0 40. Have you had any other blood disorders? 0 0

HEARTHEALTHoUESTIONSABOUTYOURFAMILY Yes No 41. Have vou had anv 'Problems with vaur eves or vision? 0 0

12. Has any family member or relative died of heart problems or0 0 0

had an unexpected sudden death before age SO (ill~~~ingdrowning, 0 42. Do you wear glasses or contact lenses?

unex:nlailledcar accident or sudden infant death s""drome ?13. Does anyone in your family have a heart problem? 0 0 43. Do you wear protective eyewear, such as goggles or a 0 0

face shield?

14. Does anyone in your family have a pacemaker or implanted 0 0 44. Do you worry about your weight? 0 0defibrillator?15. Does anyone in you: ~~ilY have Marfan syndrome, 0 to 45. ~ ~u trying to or has any professional recommended 0 0cardiomvnnathv, or Lolli?: -1'7

that vnu to gain or lose weight?

16. Has anyone in your family had unexplained fainting, 0 0 46. Do you limit or carefully control what you eat? 0 0unexnlained seizures, or near drowninl!?BONE AND JOINT QUESTIONS Yes No 47. Do you have any concerns that you would like to discuss 0 0

with a doctor'?

17. Have you ever had an injury, like a sprain, muscle or ligament 0 048. What is the date OfyOUTlast Tetanus immunization?

tear, or tendonitis that caused vau to miss a nractice Of Q:ame?Date:

18. Have you had any broken or fractured bones or dislocated 0 049.00 you have an allergy to medicine, food or stinging

joints?insects? 0 0

19. Have you had a bone or joint injury that required x-rays, MRl, FEMALESONLYCT, surgery, injections, rehabilitation, physical therapy, a 0 0 49. Have you ever had a menstrual period? 0 0

brace, a cast, or crutches?20. Have you ever had an x-ray of your neck for atlanta-axial

instability? OR Have you ever been told that you have that 0 0 . 51. Age when you had your first menstrual period? ___

disorder or anv neck/snine nroblem?

21. Have you ever had a stress fracture ofa bone? 0 0 52. How many periods have you had in the last 12 months?

22. Do u TelIularlv use a brace or assistive device?r- 0 EXPLAIN "YES" ANSWERS BELOW:

23. Do you currently have a bone, muscle, or joint injury thatbothers ~ou?

0 024. Do any of your joints become painful, swollen, feel warm, or

#- »

look red?0 0

#- ))

25. Do you have a history of juvenile arthritis or connective tissue 0 0disease? #- ))

MEDICAL OUESTIONS Yes No26. Do you cough, wheeze, or have difficulty breathing during or

#- ))

after exercise?0 0

#-- ))

27. Do ~u have asthma or use asthma medicine (inhaler, 0 0 *Llst medications and nutritional supplements you are currently tnkfng here:nebulizer28. Were you born without or are you missing a kidney, an eye, a

testicle, spleen or any other organ? 0 0

v~~Parent/Guardian Signature: _ Date: Athlete's Signature:

~. I Page-3 0-[4 IPART 111-PHYSICAL EXAMINATION

(Physical examination is required each school year after May 1 of the preceding school year and is good through June 30lh

of the current school year)"

!Revised March 20111

NAME Date of Birth School

EXAMINATIONHeight Weight o Male o Female

BP / Resting Pulse Vision R 20/ L20/ Corrected 0 Yes ONo

MEDICAL NORMAL ABNORMAL FINDINGSAppearanceEyes/ ears/nose/throatLymph nodesHeartPulsesLungsAbdomenGenitourinary (males only)Skin

Neurologic.:: ,c

MUSCULOSKELETAL NORMAL ABNORMAL FINDINGSNeckBackShoulder/armElbow/forearmWristlhandlfingersHip/thighKneeLeg/ankleFoot/toesFunctionalMedical Practitioner to School Staff (please indicate any instructions or recommendations here)Emergency medications required on-site I o Inhaler 0 Enineohrine 0 Glucal!on 0Other:Comments:

I have reviewed the data above, reviewed his/her medical history form and make the following reconunendations for hislher participation in athletics.o CLEARED WITHOUT RESTRICTIONSo CLEARED WITH FOLLOWING NOTATION: -------------------------o Cleared AFTER documented further evaluation or treatment for:

o Cleared for Limited participation (check and explain "reason" for all that apply): "Limited Until Date" when appropriate

o Not cleared for (specific sports) Until Date: _

Reason(s): _

o NOT CLEARED FOR PARTICIPATION Reason --------------------J hnve cxRminetilhe above-nometl slutlenlantl completed the prepnrticipnlioll physical evaluation.

PhysicianSignature: ('MD, DD,LNP,PAl. DateCircle one

Examiner's Name and degree (print): .Phone Number _

Address: City State Zip _

+ Only signatures of Doctor of Medicine, Doctor of Osteopathic Medicine, Nurse Practitioner or Physician's Assistant licensed topractice in the United States will be accepted

IRevlsed March 20111

~PART IV •• ACKNOWLEDGEMENT OF RISK AND INSURANCE STATEMENT

(To be completed and signed by parent/guardian)I give permission for (name of child/ward) to participate in any of the following sports that

are not crossed out: baseball, basketball, cheerleading, cross country, field hockey, football, golf, gymnastics, lacrosse, soccer, softball,swimming/diving, tennis, track, volleyball, wrestling, other (identify sports). _

I have reviewed the individual eligibility rules and I am aware that with the pallicipation in sports comes the risk of injury to mychild/ward. I understand that the degree of danger and the seriousness of the risk varies significantly from one SPOll to another withcontact sports carrying the higher risk. I have had an opportunity to understand the risk inherent in sports through meetings, writtenhandouts, or some other means. He/she has student medical/accident insurance available through the school (yes_ no-J; has athleticparticipation insurance coverage through the school (yes_ no_); is insured by our family policy with:

Name of Medical Insurance Company: _

Policy Number: Name of Policy Holder: ----------------

I am aware that participating in sports will involve travel with the team I ackoowledge and accept the risks inherent in the sportand with the travel involved and with this koowledge in mind, grant permission for my child/ward to participate in the sport and travel

with the team.By this signature, I hereby consent to allow the physician(s) and other health care provider(s) selected by myself or the school to

perform a pre-participation examination on my child and to provide treatment for any injury Or.condition resulting from participating inathletics/activities for hisfber school during the school year covered by this form. I further consent to allow said physician(s) or heathcare provider(s) to share appropriate information concerning my child that is relevant to participation in athletics and activities withcoaches and other school personnel as deemed necessary.

Additionally I give my consent and approval for the above named student's picture and name to be printed in any high school or

VHSL athletic program, puhlication or video.

PART V - EMERGENCY PERMISSION FORM(fa be completedand signed by parent/guardian)

STIJDENT'S NAME. GRADE AGE----

IDGH SCHOOL CITY _Please list any significant health problems that might be significant to a physician evaluating your child in case of an emergency

Please list any allergies to medications, etc. _

Is the student currently prescribed an inhaler or Epi-Pen? List the emergency medication: ---------Is student presently taking any other medication? If so, what type?Does student wear contact lenses? Date oflast tetanus shot _

EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give permission to physiciansselected by the coaches and staff of .High School to hospitalize, secure proper treatmentfor and to order injection and/or anesthesia and/or surgery for the person named above.

Daytime phone number (where to reach you in emergency)

Evening time phone number (where to reach you in emergency)

Cell phone _

p.~~Signature of parent or guardian Date _

Relationship to student. _'Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency treatment if needed.

I certify all the above information is correct _p.~~ Parent/Guardian Signature