Khsaa Middle School Physical Form 2019 Details

You might find it beneficial to know how much time you'll need to fill out this kentucky high school sports form and just how lengthy the document is.

QuestionAnswer
Form NameKentucky High School Sports Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameskhsaa physical form high school, khsaa sports physical form, khsaa sports physical form 2020, khsaa middle school physical form 2019

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MEDICAL INFORMATION AND PHYSICAL EXAMINATION FORM

FOR INCOMING STUDENTS 2021-2022

ALL INCOMING STUDENTS MUST SUBMIT A PHYSICAL EXAMINATION FORM—

PHYSICALS COMPLETED PRIOR TO APRIL 2021 WILL NOT BE ACCEPTED.

In compliance with KRS 158.035, KRS 214.0, and KAR 2:060

the original certificate of immunization against diphtheria, tetanus, poliomyelitis, measles, rubella, hepatitis A, and meningitis

must be submitted by every student and kept on file by the school.

Student's final admission status is not complete until the physical examination form and the required

certificate of immunization status have been submitted.

Important Information for Incoming Students Planning to Participate in Athletics

In accordance with KHSAA regulations, the student’s medical history and physical must be reported on the KHSAA form which follows.

Students trying out for CHEERLEADING AND DANCE: physical examination must be completed and health forms turned in prior to tryouts in mid-April. If the physical was conducted between April 2020 and March 2021, it will satisfy the KHSAA requirement, but a current physical examination, conducted April-July 2021, is required by July 29, 2021, to meet the school requirement.

PART 1 - STUDENT INFORMATION

Student's Full Legal Name: _____________________________________________________________________________________

LastFirstMiddle2021-2022 Grade

Student’s Home Address: ______________________________________________________________________________________

Number & Street

City

State

Zip Code

Student’s Date of Birth: ______________________________

Student's Social Security #: ________________________________

Primary Physician _________________________________

Office Phone # ___________________________

Family Dentist ____________________________________

Office Phone # ___________________________

PART 2 – PARENTAL PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATION/ PARENTAL CONSENT/PERMISSION TO TREAT AUTHORIZATION – 2021-2022

Parent/guardian signatures are required in order for your daughter

to receive any necessary medical treatment or medication (including Tylenol, Advil, etc.).

In the event of an injury or illness during the school day or at a school event or, if applicable, an athletic event or practice session, I give

permission for my daughter,, to receive proper/necessary care from the school nurse, staff member, certified athletic trainer, or coach. In addition, I authorize treating physicians and/or their representatives to release medical information to representatives of the Assumption Administration, Athletic Department, and coaching staff, as applicable.

In the event of an emergency during the school day or at a school event or, if applicable, an athletic event or practice session, I give

permission for my daughter,, to be transported to an appropriate medical facility for treatment. Furthermore, I give permission for the staff at the medical facility to render any and all treatment that is necessary for the well-being of my daughter. In addition, I authorize treating physicians and/or their representatives to release medical information to representatives of the Assumption Administration, Athletic Department, and coaching staff, as applicable.

Signature: _____________________________________________________ Date: __________________________________

New Kentucky Immunization Laws

The following is a summary of the recent changes, effective June 21, 2017, to 902 KAR 2:060:

Immunizations schedules for attending child day care centers, certified family child care homes, other licensed facilities which are for children, preschool programs, and public and private primary and secondary schools, https://www.lrc.ky.gov/kar/902/002/060.htm . This amended Kentucky Administrative Regulation requires all children to have a current immunization certificate on file, contains the required immunizations schedule for attending, and has a process to obtain a religious exemption from the required immunizations.

One new age-specific immunization requirement and one booster dose requirement effective for the school year beginning on or after July 1, 2018:

2-Dose Series of Hep A ( Age: 12 months through 18 years, to be compliant for the series the second Hep A is given six months after the first inject.)

Quadrivalent meningococcal vaccine (MenACWY) booster dose (Age: 16 years)

Homeschooled children are required to submit to current immunization certificate to participate in any public or private school activities (classroom, extra curriculum activity, or sports).

All vaccines administered are printed on the Commonwealth of Kentucky Certificate of Immunization Status now including immunizations not required for school entry.

Out of state immunization certificates may be accepted if they meet the same age – specific requirements as outlined in this regulation.

A Commonwealth Certificate of Immunization Status printed from the Kentucky Immunization Registry (KYIR) does not require a signature

Routine certificate reviews are to occur at enrollment in a day care center, kindergarten, new enrollment at any grade; upon legal name change; and at a school required examination pursuant to 702 KAR 1:160.

A child whose certificate has exceeded the date for the certificate to be valid shall be recommended to visit the child’s medical provider or local health department to receive immunizations required by this administrative regulation. An updated and current certificate shall be provided to the:

Day care center, certified family child care home, or other licensed facility that cares for the children by a parent or guardian within thirty (30) days from when the certificate was found to be invalid.

School by a parent or guardian within fourteen (14) days from when the certificate was found to be invalid.

Physical Education/Athletic Participation Form

Parental and Student Consent and Release For High School Level (grades 9 - 12) participation

KHSAA Form GE04

High School Parental Permission and Consent

Rev.7/20, page 1 of 2

© KHSAA, 20 20

The student and parents/guardian must read this statement carefully and sign where required. By signing this form, all parties agree that they have accurately completed all sections of the form and have read and agree to the terms of this form as detailed. This form must be completed before the student participates (hereinafter including try out for, practice and/or compete) in interscholastic athletics/physical education. This form should be kept in a secure location until the student has exhausted eligibility, graduated from high school and reached the age of 19.

STUDENT/ATHLETE INFORMATION (This part must be completed by the student and family.)

Name (Last, First, Initial)

 

 

 

 

 

 

 

 

School Year

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

Gender

 

 

 

Grade

 

 

 

School

 

 

 

 

 

Date of Birth:

 

 

 

 

Birth Place (County, State):

 

 

 

 

 

School Attendance History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varsity Play –

 

Grade

School Name

 

 

 

 

 

School Year

 

 

(Yes/No)?

 

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am planning to participate in the following

 

NONE

 

Basketball

 

 

Soccer

 

Softball

 

 

Wrestling

 

Archery

 

 

Esports

 

Other __________

 

EMERGENCY CONTACT INFORMATION

(check

all you might try to play):

Cross Country

 

 

Football

Swimming

 

 

Tennis

Bass Fishing

 

 

Bowling

Golf

Track and Field

Competitive Cheer

Lacrosse

Volleyball

Dance

 

 

Name (please print)

 

 

 

 

 

Relation to Student

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact Address, including City, State and Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone

 

 

 

 

 

Cell Phone

 

 

 

 

FOR ATHLETES: REQUIRED INSURANCE INFORMATION (KHSAA Bylaw 12)

 

Prior to participation in practice or contests (including trying for a place on a team)

in any sport or sport activity during the limitation of seasons

 

as defined in Bylaw 23 , all students are required to have medical insurance with coverage limits of at least $25,000. If this coverage is

 

provided through the school, contact the Principal or Athletic Director regarding any potential claim.

Individual schools and districts may

 

impose additional requirements for insurance or coverage during additional periods for activities outside of Bylaw 23.

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Carrier

 

Policy Number / ID Number

 

Group Number

 

 

 

Plan

 

 

 

 

FOR ATHLETES: EMERGENCY TREATMENT INFORMATION

 

The following information is

recorded solely for potential hospitalization and emergency care needs and is not required to be recorded on this

form. However, those failing to provide this information should be aware that this might be required by emergency treatment facilities prior to rendering service, and failure to provide could result in lack of appropriate care.

Social Security Number

 

Birth Date

FOR ATHLETES: CONSENT INFORMATION TO PARTICIPATE, ACKNOWLEDGMENT OF RISK, ACKNOWLEDGEMENT OF ELIGIBILITY RULES, LIABILITY WAIVER AND CONSENT AND RELEASE

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 internal organs, serious injury to 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 eects 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 stude nt’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 ocers, 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 a ttorney’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 ne gligence of the Releasees.

The student and parent/legal guardian acknowledge that they have read and understood the KHSAA Bylaws by distribution under the handbook links at http://khsaa.org/. Please be aware that a student is subject to the one-year period of ineligibility the bylaw commonly referred to 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 Ocer and Board of Control.

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

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 photographic images) and participation statistics (including height, weight and year in school, participation history and other performance based statistics) and other informa tion as may be requested, and agree that the student may be photographed or otherwise digitally or electronically cap tured during school-based competition. All of this material may be used without permission or compensation specically related to the KHSAA and its events .

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

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 identiable information from the student’s education records including academic, nancial and health care information, to third parties including school representatives, coaches, athletic trainers, medical facilities, m edical stas, 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 rights under the Family Educational Rights and Privacy Act. The student and parent/legal guardian, individually and on behalf of this student, 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 identiable information, and agree to release to the high school, the KHSAA, and their representatives, upon request, the detailed and completed application for nancial aid.

The student and parent/legal guardian, individually and on behalf of the student, hereby acknowledge that they are aware of and will review if desired, the education materials availab le through the KHSAA, the Centers for Disease Control and other agencies regarding education all individuals with respect to nature and risk of concussion and head injury, including the continuance of play after concussion or head inj ury.

The student and parent/legal guardian, individually 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 ill ness while participating in interscholastic athletics, including, but not limited to, transportation of the student to a medical facility.

STUDENT AND PARENT/GUARDIAN ACKNOWLEDGMENT OF RISK, ELIGIBILITY RULES, LIABILITY WAIVER AND

CONSENT AND RELEASE AND

EMERGENCY PERMISSION FORM

 

 

 

 

 

Students’ Name (please print)

 

 

School

 

 

 

Student and Parent/Guardian Address including City, State and Zip

 

 

 

 

 

Signature of Student

 

 

 

Date

Please list above any health problems/concerns this student may have, including allergies (medications / others) and any medications presently being used

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

1

Clearance

PREPARTICIPATION PHYSICAL EVALUATION

MEDICAL ELIGIBILITY FORM

Name: _______________________________________________________ Date of birth: _________________________

Medically eligible for all sports/physical education activites without restriction

Medically eligible for all sports/physical education activites without restriction with recommendations for further evaluation or treatment of

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medically eligible for certain sports/physical education activites

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Not medically eligible pending further evaluation

Not medically eligible for any sports/physical education activites

Recommendations:___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

I have examined the student named on this form and completed the preparticipation physical evaluation. The student/athlete does not

have apparent clinical contraindications to practice and can participate in the sport(s)/activities as outlined on this form. A copy of the physical examination ndings are on record in my oce and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional (print or type): __________________________________________

Date: ____________________________

Address: _________________________________________________________________________

Phone: ___________________________

Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

SHARED EMERGENCY INFORMATION

Allergies: ____________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medications: ________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Other information: ____________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Emergency contacts: ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa- tional purposes with acknowledgment.

3/20/19 4:18 PM

KHSAA Form PPE02

Physical Exam Form

PREPARTICIPATION PHYSICAL EVALUATION

HISTORY FORM

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

Name: ________________________________________________________________ Date of birth: _____________________________

Date of examination: _______________________________ Sport(s): _____________________________________________________

Sex at birth (F, M): _________________

List past and current medical conditions. _____________________________________________________________________________

_______________________________________________________________________________________________________________

Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________

_______________________________________________________________________________________________________________

Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)

 

Not at all

Several days

Over half the days

Nearly every day

Feeling nervous, anxious, or on edge

0

1

2

3

Not being able to stop or control worrying

0

1

2

3

Little interest or pleasure in doing things

0

1

2

3

Feeling down, depressed, or hopeless

0

1

2

3

(A sum of ≥ 3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)

GENERAL QUESTIONS

 

 

(Explain “Yes” answers at the end of this form.

 

 

Circle questions if you don’t know the answer.)

Yes

No

1.Do you have any concerns that you would like to discuss with your provider?

2.Has a provider ever denied or restricted your participation in sports for any reason?

3.Do you have any ongoing medical issues or recent illness?

HEART HEALTH QUESTIONS ABOUT YOU

Yes

No

4.Have you ever passed out or nearly passed out during or after exercise?

5.Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

6. or skip beats (irregular beats) during exercise?

7.Has a doctor ever told you that you have any heart problems?

8.Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.

HEART HEALTH QUESTIONS ABOUT YOU

 

 

(CONTINUED )

Yes

No

9.Do you get light-headed or feel shorter of breath than your friends during exercise?

10.Have you ever had a seizure?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

Yes

No

11.Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?

12.Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic poly- morphic ventricular tachycardia (CPVT)?

13.Has anyone in your family had a pacemaker or

BONE AND JOINT QUESTIONS

Yes No

14.Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?

15.Do you have a bone, muscle, ligament, or joint injury that bothers you?

MEDICAL QUESTIONS

Yes

No

16. breathing during or after exercise?

17.Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

18.Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

19.Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistantStaphylococcus aureus (MRSA)?

20.Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?

21.Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?

22.Have you ever become ill while exercising in the heat?

23.Do you or does someone in your family have sickle cell trait or disease?

24.Have you ever had or do you have any prob- lems with your eyes or vision?

KHSAA Form PPE02

Physical Exam Form

MEDICAL QUESTIONS ( CONTINUED )

Yes

No

25.Do you worry about your weight?

26.Are you trying to or has anyone recommended that you gain or lose weight?

27.Are you on a special diet or do you avoid certain types of foods or food groups?

28.Have you ever had an eating disorder?

FEMALES ONLY

Yes

No

29. Have you ever had a menstrual period?

30. menstrual period?

31.When was your most recent menstrual period?

32.How many periods have you had in the past 12 months?

Explain “Yes” answers here.

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

Signature of student/athlete: ______________________________________________________________________________________________________

Signature of parent or guardian: __________________________________________________________________________________________

Date: ________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa- tional purposes with acknowledgment.

PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL EXAMINATION FORM

KHSAA Form PPE02 Physical Exam Form

Name: _________________________________________________________________ Date of birth: ____________________________

PHYSICIAN/STATUTORILY AUTHORIZED PROVIDER REMINDERS

1.Consider additional questions on more-sensitive issues.

Do you feel stressed out or under a lot of pressure?

Do you ever feel sad, hopeless, depressed, or anxious?

Do you feel safe at your home or residence?

Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snu, or dip?

During the past 30 days, did you use chewing tobacco, snu, or dip?

Do you drink alcohol or use any other drugs?

Have you ever taken anabolic steroids or used any other performance-enhancing supplement?

Have you ever taken any supplements to help you gain or lose weight or improve your performance?

Do you wear a seat belt, use a helmet, and use condoms?

2.Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).

EXAMINATION

Height:

 

 

 

 

Weight:

 

 

 

 

 

BP:

/

(

/

)

Pulse:

Vision: R 20/

L 20/

Corrected:

Y

N

MEDICAL

 

 

 

 

 

 

 

NORMAL

ABNORMAL FINDINGS

Appearance

Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,

Eyes, ears, nose, and throat

 

 

Pupils equal

 

 

Hearing

 

 

 

 

 

Lymph nodes

 

 

Heart **

 

 

• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)

 

 

Lungs

 

 

Abdomen

 

 

Skin

 

 

Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or

 

 

 

tinea corporis

 

 

Neurological

 

 

MUSCULOSKELETAL

NORMAL

ABNORMAL FINDINGS

Neck

 

 

 

 

 

Back

 

 

Shoulder and arm

 

 

Elbow and forearm

 

 

 

 

 

Hip and thigh

 

 

Knee

 

 

Leg and ankle

 

 

Foot and toes

 

 

Functional

Double-leg squat test, single-leg squat test, and box drop or step drop test

**Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination ndings, or a combi- nation of those.

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa- tional purposes with acknowledgment.

ASTHMA AUTHORIZATION FORM 2021-2022

If your daughter has asthma, this form must be completed, signed, and returned to the School Office by Thursday, July 29, 2021.

Kentucky House Bill 353 allows students with asthma to have unobstructed access to asthma medications. The key points of this law are as follows: Public and private school students are allowed to possess and use asthma medications provided that:

The student has written authorization from a parent and her health care provider to self-administer her asthma medications.

The written authorization is kept on file at school.

A parent or guardian must sign a statement acknowledging that the school has no liability from any injury sustained by a student from self-administration of medication.

Permission for self-administration of medications is effective for the current school year and must be renewed each school year.

If you have any questions regarding this law or any asthma issue, please contact the Director of Education & Advocacy, American Lung Association, at 363-2652.

STUDENT NAME: __________________________________________________________

STUDENT I.D. #________________

(PRINT):

Last

First

Middle

(office use only]

If your daughter has asthma, but does NOT need to self-administer asthma medications at school,

complete and sign only this section of the form and return the signed form to the School Office.

I,_______________________ , parent/guardian of the above named student, verify that my daughter has asthma, but does not need to

carry or self-administer any asthma medications at school, at school-sponsored activities or at any time that she is present on Assumption High School's property.

Signature: _______________________________________________

Date:_____________________________

If your daughter has asthma and must self-administer asthma medications at school,

the parent and the student's health care provider must complete and sign all sections below.

You must return the completed form to the School Office before she will be given permission to self-administer her asthma

medications on school property or at any school-sponsored activity.

I,_________________________, parent/guardian of the above named student, authorize Assumption High School to allow the student

to carry with her and self-administer her asthma medications.

Signature: _______________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student acknowledge that Assumption High School shall incur no

liability as a result of any injury sustained by the student from the self-administration of asthma medications. I agree to indemnify, hold harmless, waive and relinquish any and all claims I may have against Assumption High School and its officers, agents, employees, representatives or volunteers.

Signature: _______________________________________________ Date:_____________________________

If your daughter has asthma and she must self-administer asthma medications at school,

THE STUDENT'S PHYSICIAN MUST COMPLETE THIS SECTION AND SIGN WHERE INDICATED.

I, _________________________________________________, verify that ________________________________________________

Physician/Health Care Provider's Name (please print)

Print Student's Name

has asthma and that the student has been instructed in self-administration of the asthma medications listed below:

Name of Asthma Medication

Prescribed

Time(s), circumstances, any specific instructions under

Prescribed

Dosage

which medication must be administered

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Signature: ______________________________________________

Date: ____________________________

Physician/Health Care Provider

 

FOOD ALLERGY AND ANAPHYLAXIS MEDICATION AUTHORIZATION FORM 2021-2022

If your daughter has a severe food allergy or other allergy that could require the administration of emergency rescue medication,

this form must be completed, signed, and returned to the School Office by Thursday, July 29, 2021.

STUDENT NAME: __________________________________________________________

STUDENT I.D. #________________

(PRINT):

Last

First

Middle

(office use only]

If your daughter has a severe allergy and may need to self-administer anaphylaxis rescue medication

(epinephrine via EpiPen, Twinject, Auvi-Q, etc.) at school,

the parent and the student's health care provider must complete and sign all sections below.

You must return the completed form to the School Office before she will be given permission to self-administer her anaphylaxis

rescue medication on school property or at any school-sponsored activity.

I,_________________________, parent/guardian of the above named student, authorize Assumption High School to allow the student

to carry with her and self-administer her anaphylaxis rescue medication.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student, authorize Assumption High School personnel to

administer anaphylaxis rescue medication to the student in the event the student is unable to self-administer due to the severity of the allergic reaction/anaphylaxis or not having her rescue medication with her.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student acknowledge that Assumption High School shall incur no

liability as a result of any injury sustained by the student from the self-administration of anaphylaxis rescue medication or from Assumption High School personnel administering emergency rescue medication to her. I agree to indemnify, hold harmless, waive and relinquish any and all claims I may have against Assumption High School and its officers, agents, employees, representatives or volunteers.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student hereby give permission for the health care provider

completing and signing this form (below) to verify this information with Assumption High School and consult with AHS staff regarding this information.

Signature:________________________________________ Date:_____________________________

If your daughter has a severe allergy and may need to self-administer anaphylaxis rescue medication at school,

THE STUDENT'S PHYSICIAN MUST COMPLETE THIS SECTION AND SIGN WHERE INDICATED.

I, _________________________________________________, verify that __________________________________________________

Physician/Health Care Provider's Name (please print) _Print Student's Name

is extremely reactive to the following allergens (specify) _____________________________________________________________,

has been instructed in self-administration of her anaphylaxis rescue medication, and may carry it with her to self-administer if necessary.

In the event of mild symptoms (itchy mouth, runny nose, mild rash, etc.)., the student may self-administer or school personnel may administer

Antihistamine Brand or Generic: _________________________________________________ Dose ________________________________

In the event of severe symptoms (shortness of breath, tightness of throat, dizziness, etc.)., the student may self-administer or school personnel may administer

Antihistamine Brand or Generic: _________________________________________________ Dose ________________________________

Signature: ______________________________________________

Date: ____________________________

Physician/Health Care Provider

 

DIABETES MEDICATION AUTHORIZATION FORM 2021-2022

If your daughter has diabetes, this form must be completed and returned to the school office no later than Thursday, July 29, 2021.

Student Name: _____________________________________________________

Student I.D.# _________________________

(please print):

Last

First

Middle

(office use only)

If your daughter has Diabetes

but does NOT want to monitor her glucose level by herself or to self-administer her diabetes medication,

complete and sign only this section of the form and return it to the School Office.

I, ________________________parent/guardian of the above named student, verify that my daughter has Diabetes, but does not want at

this time to monitor her glucose level by herself or self-administer her diabetes medication at school, at school-sponsored activities, or any time she is present on Assumption High School's property.

Signature: _______________________________________________

Date:______________________________

 

 

If your daughter has Diabetes

and wants to monitor her glucose level by herself and self-administer her diabetes medication at school,

the parent and the student's physician must complete and sign all sections below.

You and your daughter will then meet with the school nurse and/or the Dean of Students

to ascertain her health condition and ability to self-administer her medications.

I,__________________________________________, parent/guardian of the above named student, authorize Assumption High School

to allow her to carry with her a meter to read her glucose level as well as her diabetes medication.

Signature: _____________________________________________________ Date:_________________________________

I,__________________________________________, parent/guardian of the above named student, acknowledge that Assumption High

School shall incur no liability as a result of any injury sustained by the student to herself from monitoring her glucose level or self- administration of diabetes medication or as a result of any injury inflicted on others while monitoring her glucose level or self- administering the diabetes medication. I agree to indemnify, hold harmless, waive and relinquish any and all claims I may have against Assumption High School and its officers, agents, employees, representatives, or volunteers.

Signature: _____________________________________________________ Date: __________________________________

THE STUDENT'S PHYSICIAN MUST COMPLETE THE FOLLOWING SECTION AND SIGN WHERE INDICATED.

I, ____________________________________________, verify that ___________________________________________________

Physician/Health Care Provider’s Name (please print)

Print Student’s Name

has Diabetes and the student has been instructed in self-administration of the diabetes medications listed below.

NAME OF MEDICATIONPRESCRIBED DOSAGE

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Signature: ______________________________________________ Date:________________________________________

Physician/Health Care Provider

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