CHECKLIST FOR SPORTS CLEARANCE
ALL of the following MUST be handed in to the Nurse
BEFORE participating in a sports tryout or practice.
ALL of the following MUST be handed in to the Nurse
BEFORE participating in a sports tryout or practice.
Medical Physical Form
Required every year
Required every year
Physical Form
Valid for one year from the date of the exam. Required every year
This form is required for participation in all school sponsored sports. The parent/guardian completes Part A (the first three pages), and the physician completes Part B. A physical exam is good for one year. This form must be into the nurse's office by the first day of try outs. Even if your child is not trying out for a sport, it is advisable to have this form completed and returned to your school nurse whenever you bring your child for a physical examination. This way we can keep your child's health records up to date.
Valid for one year from the date of the exam. Required every year
This form is required for participation in all school sponsored sports. The parent/guardian completes Part A (the first three pages), and the physician completes Part B. A physical exam is good for one year. This form must be into the nurse's office by the first day of try outs. Even if your child is not trying out for a sport, it is advisable to have this form completed and returned to your school nurse whenever you bring your child for a physical examination. This way we can keep your child's health records up to date.
Head Injury Fact Sheet
Required every year.
Required every year.
Head Injury Fact Sheet - Must be read and signed by student and parent.
This form must be signed by the parent/guardian and the student and returned to the nurse before the student is eligible to try out for any sport.
This form must be signed by the parent/guardian and the student and returned to the nurse before the student is eligible to try out for any sport.
Sudden Cardiac Death Fact Sheet and Sign Off Sheet
Required every year.
Required every year.
Sudden Cardiac Death Information Pamphlet
This can be read online, then print out form below and fill out to acknowledge it has been read
This can be read online, then print out form below and fill out to acknowledge it has been read
Sudden Cardiac Sign Off Sheet
Print this out and sign to indicate you read the information pamphlet
Print this out and sign to indicate you read the information pamphlet
Opioid Use and Misuse Educational Fact Sheet and Sign Off Sheet
New for 2018 And Every Year Thereafter
New for 2018 And Every Year Thereafter
SECOND AND THIRD SPORT
Please complete the form below if your child's physical exam was done more than 90 days before the first tryout date.This form is also used if your child is trying out for a second or third sport during the school year. For example, if your child tried out for or participated in a fall sport and she/he is trying out for a winter sport, please complete this form and return to Mrs. Pape at Black River Middle School.