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.
Question | Answer |
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Form Name | Vhsl Physical Form |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | vhsl, vhsl form, halifax county va sports physical form, wise county va school physical |
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___ |
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(To be filled in and signed by the student) |
Female___ |
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PRINT CLEARLY |
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Name |
_________________________________________________________________ |
Student ID#______________________________ |
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(Last) |
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(First) |
(Middle Initial) |
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Home Address |
________________________________________________________________________________________________________ |
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City/Zip Code |
________________________________________________________________________________________________________ |
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Home Address of Parents |
________________________________________________________________________________________________ |
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City/Zip Code |
________________________________________________________________________________________________________ |
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Date of Birth |
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Place of Birth |
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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.
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
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
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.
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GENERAL MEDICAL HISTORY |
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MEDICAL QUESTIONS CONTINUED |
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1. |
Do you have any concerns that you would like to discuss with |
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24. Have you had mononucleosis (mono) within the last month? |
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your provider? |
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25. |
Are you missing a kidney, eye, testicle, spleen or other |
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2. |
Has a provider ever denied or restricted your participation in |
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internal organ? |
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sports for any reason? |
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26. |
Do you have groin or testicle pain or a painful bulge or hernia |
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3. |
Do you have any ongoing medical conditions? If so, please |
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in the groin area? |
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identify: Asthma Anemia Diabetes Infections |
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27. |
Have you ever become ill while exercising in the heat? |
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Other: _________________________ |
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28. |
When exercising in the heat, do you have severe muscle |
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4. |
Are you currently taking any medications or supplements on |
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cramps? |
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a daily basis? |
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29. |
Do you have headaches with exercise? |
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5. |
Do you have allergies to any medications? |
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30. |
Have you ever had numbness, tingling or weakness in your |
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6. |
Do you have any recurring skin rashes or rashes that come |
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arms or legs or been unable to move your arms or legs |
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and go, including herpes or |
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AFTER being hit or falling? |
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Staphylococcus aureus (MRSA)? |
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31. |
Do you or does someone in your family have sickle cell trait |
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7. |
Have you ever spent the night in the hospital? If yes, why? |
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or disease? |
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Have you had any other blood disorders? |
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8. |
Have you ever had surgery? |
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33. |
Have you had a concussion or head injury that caused |
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HEART HEALTH QUESTIONS ABOUT YOU |
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NO |
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confusion, a prolonged headache or memory problems? |
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9. |
Have you ever passed out or nearly passed out DURING or |
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34. |
Have you had or do you have any problems with your eyes |
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AFTER exercise? |
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or vision? |
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10. |
Have you ever had discomfort, pain, tightness, or pressure in |
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35. |
Do you wear glasses or contacts? |
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your chest during exercise? |
36. |
Do you wear protective eyewear like goggles or a face shield? |
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11. |
Does your heart race, flutter in your chest or skip beats |
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37. |
Do you worry about your weight? |
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(irregular beats) during exercise? |
38. |
Are you trying to or has anyone recommended that you gain |
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12. |
Has a doctor ever ordered a test for your heart? For |
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or lose weight? |
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example, electrocardiography or echocardiography. |
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39. |
Do you limit or carefully control what you eat? |
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13. |
Has a doctor ever told you that you have any heart problems, |
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40. |
Have you ever had an eating disorder? |
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including: |
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41. |
Are you on a special diet or do you avoid certain types of |
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High blood pressure |
A heart murmur |
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foods or food groups? |
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High cholesterol |
A heart infection |
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42. |
Allergies to food or stinging insects? |
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Kawasaki Disease |
Other _______________ |
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43. |
Have you ever had a |
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44. |
What is the date of your last Tdap or Td (tetanus) immunization? |
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(circle type) Date: ____________ |
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14. |
Do you get |
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friends during exercise? |
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FEMALES ONLY |
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YES |
NO |
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15. |
Have you ever had a seizure? |
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45. |
Have you ever had a menstrual period? |
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HEART HEALTH QUESTIONS ABOUT YOUR FAMILY |
YES |
NO |
46. |
Age when you had your first menstrual period: ___________ |
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16. |
Does anyone in your family have a heart problem? |
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47. |
Number of periods in the last 12 months: _______________ |
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17. |
Has any family member or relative died of heart problems or |
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48. |
When was your most recent menstrual period? __________ |
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had an unexpected or unexplained sudden death before age |
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EXPLAIN “YES” ANSWERS BELOW |
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35 (including drowning or unexplained car crash)? |
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18. |
Does anyone in your family have a genetic heart problem |
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such as hypertrophic cardiomyopathy (HCM), Marfan |
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syndrome, arrhythmogenic right ventricular cardiomyopathy |
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(ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), |
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Brugada syndrome, or catecholaminergic polymorphic |
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ventricular tachycardia (CPVT)? |
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19. |
Has anyone in your family had a pacemaker or an implanted |
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defibrillator before age 35? |
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BONE AND JOINT QUESTIONS |
YES |
NO |
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20. |
Have you ever had a stress fracture or an injury to a bone, |
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muscle, ligament, joint, or tendon that caused you to miss a |
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practice or game? |
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21. |
Do you currently have a bone, muscle or joint injury that |
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bothers you? |
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List medications and nutritional supplements you are currently taking here: |
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MEDICAL QUESTIONS |
YES |
NO |
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22. |
Do you cough, wheeze or have difficulty breathing during or |
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after exercise? |
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23. |
Do you have asthma or use asthma medicine (inhaler, |
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nebulizer)? |
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→ 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 |
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Weight |
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Male |
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Female |
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BP |
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Resting pulse |
Vision R 20/ |
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L 20/ |
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Corrected Yes |
No |
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MEDICAL |
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NORMAL |
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ABNORMAL FINDINGS |
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Appearance (Marfan stigmata: kyphoscoliosis, |
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excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse, and |
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aortic insufficiency) |
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Eyes/ears/nose/throat (Pupils equal, hearing) |
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Lymph nodes |
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Heart (Murmurs: auscultation standing, supine, +/- Valsalva) |
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Pulses |
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Lungs |
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Abdomen |
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Skin (Herpes simplex virus, lesions suggestive of MRSA or tinea corporis) |
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Neurological |
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MUSCULOSKELETAL |
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NORMAL |
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ABNORMAL FINDINGS |
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Neck |
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Back |
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Shoulder/arm |
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Elbow/forearm |
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Wrist/hand/fingers |
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Hip/thigh |
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Knee |
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Leg/ankle |
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Foot/toes |
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Functional (i.e. Double leg squat, single leg squat, box drop or step drop test) |
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Emergency medications required |
Epinephrine |
Glucagon |
Other: |
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COMMENTS: |
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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
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
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
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,
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
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