Vhsl Details

The Virginia High School League (VHSL) has released the physical form that is required in order to participate in sports at the high school level. The form can be downloaded from the VHSL website, and must be completed by a health care provider. The physical form must be submitted to the school prior to participation in any practice or contest. There are a few changes this year, so it's important that you understand what's required. You don't want your child to miss out on an opportunity to participate because of something as simple as a missing document! Read on for more information about the VHSL physical form.

You'll find information about the type of form you would like to submit in the table. It will tell you the amount of time you'll need to complete vhsl physical form, exactly what parts you will need to fill in, and so forth.

QuestionAnswer
Form NameVhsl Physical Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesvhsl, vhsl form, halifax county va sports physical form, wise county va school physical

Form Preview Example

VIRGINIA HIGH SCHOOL LEAGUE, INC.

1642 State Farm Blvd., Charlottesville, Va. 22911

REVISED JANUARY 2021

Page 1 of 4

ATHLETIC PARTICIPATION/PARENTAL CONSENT/PHYSICAL EXAMINATION FORM

Separate signed form is required for each school year MAY 1 of the current year through JUNE 30 of the succeeding year.

For school year_________

PART I- ATHLETIC PARTICIPATION

Male___

 

 

 

(To be filled in and signed by the student)

Female___

PRINT CLEARLY

 

 

 

 

 

Name

_________________________________________________________________

Student ID#______________________________

 

(Last)

 

(First)

(Middle Initial)

 

Home Address

________________________________________________________________________________________________________

City/Zip Code

________________________________________________________________________________________________________

Home Address of Parents

________________________________________________________________________________________________

City/Zip Code

________________________________________________________________________________________________________

Date of Birth

____________________________________

Place of Birth

________________________________________________

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

semester I attended __________________________________ School and 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.

INDIVIDUALIZED ELIGIBILITY RULES

To be eligible to represent your 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 equivalent, offered for credit and which may be used for graduation the immediately preceding year or the immediately preceding semester for schools that certify credits on a semester basis. (Check with your principal for equivalent requirements.) May not repeat courses for eligibility purposes for which credit has been previously awarded.

For the second 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 equivalent, offered for credit and which may be used for graduation 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 corresponded with a family move. (Check with your principal for exceptions.)

Must not have reached your nineteenth birthday on or before the first day of August of the current school year.

Must not, after entering ninth grade for the first time, have been enrolled in or been eligible for enrollment in high school more than eight consecutive semesters.

Must have submitted to your principal before any kind of participation, including tryouts or practice as a member of any school athletic or cheerleading team, an Athletic Participation/Parent Consent/Physical Examination Form, completely filled in and properly signed attesting that you have been examined during this school year and found to be physically fit for competition and that your parents’ consent to your participation.

Must not be in violation of VHSL Amateur, Awards, All Star or College Team Rules. (Check with your principal for clarification about cheerleading.)

Eligibility to participate in interscholastic athletics is a privilege you earn by meeting not only the above-listed minimum standards, but also all other standards set by your League, district and school. If you have any question regarding your eligibility or are in doubt about the effect an activity might have on your eligibility, check with your principal for interpretations and exceptions provided under League rules. Meeting the intent and spirit of League standards will prevent you, your team, school and community from being penalized. Additionally, I give my consent and approval for my picture and name to be printed in any high school or VHSL athletic program, 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.

REVISED JANUARY 2021

Page 2 of 4

The pre-participation physical examination is not a substitute for a thorough annual examination by a student’s primary care physician.

PART II- MEDICAL HISTORY (Explain “YES” answers below)

This form must be complete and signed, prior to the physical examination, for review by examining practitioner.

Explain “YES” answers below with number of the question. Circle questions you don’t know the answers to.

 

GENERAL MEDICAL HISTORY

YES

NO

 

MEDICAL QUESTIONS CONTINUED

 

YES

NO

1.

Do you have any concerns that you would like to discuss with

24. Have you had mononucleosis (mono) within the last month?

 

 

your provider?

 

25.

Are you missing a kidney, eye, testicle, spleen or other

 

 

 

 

 

 

2.

Has a provider ever denied or restricted your participation in

 

internal organ?

 

 

 

 

 

 

sports for any reason?

 

26.

Do you have groin or testicle pain or a painful bulge or hernia

 

 

 

 

 

 

3.

Do you have any ongoing medical conditions? If so, please

 

 

 

in the groin area?

 

 

 

 

 

 

 

 

identify: Asthma Anemia Diabetes Infections

27.

Have you ever become ill while exercising in the heat?

 

 

Other: _________________________

 

 

28.

When exercising in the heat, do you have severe muscle

 

 

 

4.

Are you currently taking any medications or supplements on

 

cramps?

 

 

a daily basis?

 

29.

Do you have headaches with exercise?

 

 

 

 

 

 

5.

Do you have allergies to any medications?

30.

Have you ever had numbness, tingling or weakness in your

 

6.

Do you have any recurring skin rashes or rashes that come

 

 

 

arms or legs or been unable to move your arms or legs

 

 

and go, including herpes or methicillin-resistant

 

AFTER being hit or falling?

 

 

 

 

Staphylococcus aureus (MRSA)?

 

 

31.

Do you or does someone in your family have sickle cell trait

 

7.

Have you ever spent the night in the hospital? If yes, why?

 

or disease?

 

 

 

 

 

 

______________________________________

32.

Have you had any other blood disorders?

 

 

 

 

 

8.

Have you ever had surgery?

33.

Have you had a concussion or head injury that caused

 

 

HEART HEALTH QUESTIONS ABOUT YOU

YES

NO

 

confusion, a prolonged headache or memory problems?

 

 

 

 

 

 

9.

Have you ever passed out or nearly passed out DURING or

34.

Have you had or do you have any problems with your eyes

 

 

AFTER exercise?

 

 

or vision?

 

 

 

 

 

 

 

 

 

10.

Have you ever had discomfort, pain, tightness, or pressure in

35.

Do you wear glasses or contacts?

 

 

your chest during exercise?

36.

Do you wear protective eyewear like goggles or a face shield?

 

 

 

 

 

11.

Does your heart race, flutter in your chest or skip beats

37.

Do you worry about your weight?

 

 

(irregular beats) during exercise?

38.

Are you trying to or has anyone recommended that you gain

 

 

 

 

 

12.

Has a doctor ever ordered a test for your heart? For

 

or lose weight?

 

 

 

 

 

 

example, electrocardiography or echocardiography.

 

 

 

 

 

 

39.

Do you limit or carefully control what you eat?

 

 

 

 

 

13.

Has a doctor ever told you that you have any heart problems,

 

 

40.

Have you ever had an eating disorder?

 

 

including:

 

 

 

41.

Are you on a special diet or do you avoid certain types of

 

 

 

 

High blood pressure

A heart murmur

 

 

 

foods or food groups?

 

 

 

 

High cholesterol

A heart infection

42.

Allergies to food or stinging insects?

 

 

Kawasaki Disease

Other _______________

 

 

43.

Have you ever had a COVID-19 diagnosis? Date:

 

 

 

 

 

 

 

 

 

 

 

 

44.

What is the date of your last Tdap or Td (tetanus) immunization?

 

 

 

 

 

 

 

 

(circle type) Date: ____________

 

 

14.

Do you get light-headed or feel shorter of breath than your

 

 

 

 

 

 

friends during exercise?

 

 

FEMALES ONLY

 

YES

NO

 

 

 

 

 

 

15.

Have you ever had a seizure?

45.

Have you ever had a menstrual period?

 

 

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

YES

NO

46.

Age when you had your first menstrual period: ___________

 

 

16.

Does anyone in your family have a heart problem?

47.

Number of periods in the last 12 months: _______________

 

 

17.

Has any family member or relative died of heart problems or

 

 

48.

When was your most recent menstrual period? __________

 

 

 

had an unexpected or unexplained sudden death before age

 

EXPLAIN “YES” ANSWERS BELOW

 

 

 

35 (including drowning or unexplained car crash)?

 

 

#

>>

 

 

 

18.

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 polymorphic

 

 

 

 

 

 

 

 

ventricular tachycardia (CPVT)?

 

 

 

 

 

 

 

 

 

 

#

>>

 

 

 

 

 

 

 

 

 

 

 

19.

Has anyone in your family had a pacemaker or an implanted

 

 

 

 

 

 

defibrillator before age 35?

#

>>

 

 

 

 

 

 

 

 

 

 

BONE AND JOINT QUESTIONS

YES

NO

 

 

 

 

 

20.

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?

 

 

 

#

>>

 

 

 

21.

Do you currently have a bone, muscle or joint injury that

 

 

 

 

 

 

bothers you?

 

List medications and nutritional supplements you are currently taking here:

 

 

 

 

 

MEDICAL QUESTIONS

YES

NO

 

 

 

 

 

22.

Do you cough, wheeze or have difficulty breathing during or

 

 

 

 

 

 

after exercise?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.

Do you have asthma or use asthma medicine (inhaler,

 

 

 

 

 

 

nebulizer)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

→ Parent/Guardian Signature: _______________________ Date: ______ → Athlete’s Signature: _____________________

REVISED JANUARY 2021

PART III- PHYSICAL EXAMINATION

(Physical examination form is required each school year dated after May 1 of the preceding school year

and is good through June 30 of the current school year)**

Page 3 of 4

NAME__________________________________________ DATE OF BIRTH________________ SCHOOL____________________________________

Height

 

 

Weight

 

 

 

Male

 

Female

 

BP

/

Resting pulse

Vision R 20/

 

L 20/

 

 

Corrected Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL

 

 

NORMAL

 

 

ABNORMAL FINDINGS

 

Appearance (Marfan stigmata: kyphoscoliosis, high-arched palate, pectus

 

 

 

 

 

 

 

 

excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse, and

 

 

 

 

 

 

aortic insufficiency)

 

 

 

 

 

 

 

 

 

 

 

Eyes/ears/nose/throat (Pupils equal, hearing)

 

 

 

 

 

 

 

 

 

Lymph nodes

 

 

 

 

 

 

 

 

 

 

 

Heart (Murmurs: auscultation standing, supine, +/- Valsalva)

 

 

 

 

 

 

 

 

Pulses

 

 

 

 

 

 

 

 

 

 

 

 

Lungs

 

 

 

 

 

 

 

 

 

 

 

 

Abdomen

 

 

 

 

 

 

 

 

 

 

 

Skin (Herpes simplex virus, lesions suggestive of MRSA or tinea corporis)

 

 

 

 

 

 

 

 

Neurological

 

 

 

 

 

 

 

 

 

 

 

 

 

MUSCULOSKELETAL

 

 

NORMAL

 

 

ABNORMAL FINDINGS

 

Neck

 

 

 

 

 

 

 

 

 

 

 

 

Back

 

 

 

 

 

 

 

 

 

 

 

 

Shoulder/arm

 

 

 

 

 

 

 

 

 

 

 

Elbow/forearm

 

 

 

 

 

 

 

 

 

 

 

Wrist/hand/fingers

 

 

 

 

 

 

 

 

 

 

 

Hip/thigh

 

 

 

 

 

 

 

 

 

 

 

Knee

 

 

 

 

 

 

 

 

 

 

 

 

Leg/ankle

 

 

 

 

 

 

 

 

 

 

 

Foot/toes

 

 

 

 

 

 

 

 

 

 

 

Functional (i.e. Double leg squat, single leg squat, box drop or step drop test)

 

 

 

 

 

 

Emergency medications required on-site: Inhaler

Epinephrine

Glucagon

Other:

 

 

 

COMMENTS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have reviewed the data above, reviewed his/her medical history form and make the following

recommendations for his/her participation in athletics:

MEDICALLY ELIGIBLE FOR ALL SPORTS WITHOUT RESTRICTION

MEDICALLY ELIGIBLE FOR ALL SPORTS WITHOUT RESTRICTION WITH RECOMMENDATION FOR FURTHER EVALUATION OR TREATMENT OF:

_______________________________________________________________________________________________________________________

MEDICALLY ELIGIBLE ONLY FOR THE FOLLOWING SPORTS:______________________________________________________________________

Reason:_________________________________________________________________________________________________________

NOT MEDICALLY ELIGIBLE PENDING FURTHER EVALUATION OF: _________________________________________________________________

NOT MEDICALLY ELIGIBLE FOR ANY SPORTS

By this signature, I attest that I have examined the above student and completed this pre-participation

physical including a review of Part II- Medical History.

PRACTITIONER SIGNATURE: ____________________________________________ (MD, DO, NP or PA) + DATE**: ________________________

EXAMINER’S NAME AND DEGREE (PRINT): ___________________________________________ PHONE NUMBER: ___________________________

ADDRESS: ________________________________________ CITY: _________________________________ STATE: _________ ZIP: ______________

+Only signature of Doctor of Medicine, Doctor of Osteopathic Medicine, Nurse Practitioner or Physician’s Assistant

licensed to practice in the United States will be accepted.

Rule 28B-1 (3) Physical Examination Rule/Transfer Student (10-90)- When an out-of-state student who has received a current physical examination elsewhere transfers to Virginia and attaches proof of that physical examination to the League form #2, the student is in compliance with physical examination requirements.

REVISED JANUARY 2021

Page 4 of 4

PART IV- ACKNOWLEDGEMENTS OF RISK AND INSURANCE STATEMENT

(To be completed 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, swim/dive, tennis, track, volleyball, wrestling, other (identify sports): _______________________________

I have reviewed the individual eligibility rules and I am aware that with the participation in sports comes the risk of injury to my child/ward. I understand that the degree of danger and the seriousness of the risk varies significantly from one sport to another with contact sports carrying the higher risk. I have had an opportunity to understand the risk inherent in sports through meetings, written handouts or some other means. He/she has student medical/accident insurance available through the school (yes__ no__); has athletic participation 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 acknowledge and accept the risks inherent in the sport and with the travel involved and with this knowledge 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 participation in athletics/activities for his/her school during the school year covered by this form. I further consent to allow said physician(s) of health care provider(s) to share appropriate information concerning my child that is relevant to participation in athletics and activities with coaches 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, publication or video.

To access quality, low-cost comprehensive health insurance through FAMIS for your child, please contact Cover Virginia by going to www.coverva.org or calling 855-242-8282.

PART V- EMERGENCY PERMISSION FORM*

(To be completed and signed by the parent/guardian)

STUDENT’S NAME: ____________________________________________ GRADE: __________ AGE: _______ DOB: ______________

HIGH 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 THE STUDENT PRESENTLY TAKING ANY OTHER MEDICATION? _______ IF SO, WHAT? ____________________________________

DOES THE STUDENT WEAR CONTACT LENSES? ______________________ DATE OF LAST Tdap OR Td (TETANUS) SHOT: ___________

EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by the coaches and staff of ____________________________________ High School to hospitalize, secure proper treatment for and to

order the injection and/or anesthesia and/or surgery for the person named above.

DAYTIME PHONE NUMBER (WHERE TO REACH YOU IN AN EMERGENCY): _________________________________________________

EVENING TIME PHONE NUMBER (WHERE TO REACH YOU IN AN EMERGENCY): ____________________________________________

CELL PHONE NUMBER: ____________________________________________

SIGNATURE OF PARENT/GUARDIAN: ________________________________________________ DATE: _____________________

RELATIONSHIP TO STUDENT: ____________________________________________________________________________________

*Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency treatment in needed.

I CERTIFY ALL OF THE ABOVE INFORMATION IS CORRECT: __________________________________________________________

Parent/Guardian signature

The pre-participation physical examination is not a substitute for a thorough annual examination by a student’s primary care physician.