Printout this form and return completed copy to athletic coach or school office.  

To be completed by athlete and parent:

Date:______________

Student-Athlete's Name:(Last First Middle)___________________________________

Address:

Street_______________________________________________

City/State Zip ________________________________________________________

Phone (401) _________________

School: ________________________________________________ Grade:_________

Date of Birth: ___________________________________________ Age ____________

Emergency Contact Person:____________________________________

Emergency Phone: ( ) ____________________ Sport to be played:____________________________

Family Doctor: _________________________________________________

Address:

Street ______________________________________________________

City/State Zip ______________________________________________________

Phone: (401)___________________

PERMISSION

I give my son/daughter___________________ permission to participate in ____________________. I have received a copy of the North Kingstown Athletic Department policies and I agree to comply with the requirements as stated. A yearly physical examination is required for athletic participation and our own physician best completes the exam.

Date Signed:_______/_______/_______ Student Athlete Signature:______________________________

Parent/Guardian Signature: ________________________________

History

General Yes /No

1. Have you had a medical illness or injury since your last check up or sports physical? ___ ___

2. Do you have an ongoing or chronic illness? _______________________ ___ ___

3. Have you ever been hospitalized overnight? ___ ___

4. Have you ever had surgery? ___ ___

5. Are you currently taking any prescription or non-prescription (over the counter) ___ ___

Medications or pills?

a. Prescription ______________________ ___ ___

b. Non-prescription ______________________ ___ ___

(Over the counter) ___ ___

6. Do you have any allergies (for example: to pollen, medicine, or stinging insects)? ___ ___

If yes, which one(s)? _______________________________________________

7. Do you have any dental prosthetic devices (i.e., bridges, crowns)) ___ ___

8. Have you had any problems with your eyes or vision? __________________________ ___ ___

9. Do you wear glasses, contacts, or protective eyewear? __________________________ ___ ___

10. Do you have any current skin problems? _____________________________________ ___ ___

11. Have you ever fainted or become ill from exercising in the heat? ___ ___

12. Do you have only one of a normally paired organ (i.e. kidney, lung, eye, testicle)? ___ ___

If yes, which one(s)? _____________________________________

Heart

Yes / No

1. Have you ever passed out during or after exercise? ___ ___

2. Have you ever been dizzy after exercise? ___ ___

3. Have you ever had chest pain during or after exercise? ___ ___

4. Have you ever had racing of your heart or skipped heartbeats? ___ ___

5. Have you ever been told you have a heart murmur? ___ ___

6. Has any family member or relative died of heart problems or of sudden death before Age 50? ___ ___

7. Have you had a viral infection (for example: mononucleosis) within the last year? ___ ___

If yes, what? _______________________________

8. Has a physical ever denied or restricted your participation in sports for any heart problems? ___ ___

Lungs

Yes / No

1. Do you cough, wheeze, or have trouble breathing during or after activity? ___ ___

2. Do you have asthma? ___ ___

3. Do you use an inhaler? ___ ___

Musculo-Skeletal

Yes / No

1. Do you use any special protective or corrective equipment or devices that aren't usually used for your sport or position

(for example: knee brace, special neck roll,Foot orthotics, retainer on your teeth)?___ ___

2. Have you ever had a sprain, strain, or swelling after injury which prevented you from participation?___ ___

3. Have you broken or fractured any bones or dislocated any joints?___ ___

Head

Yes / No

1. Have you had a head injury or a concussion? ___ ___

2. Have you ever been knocked out, become unconscious, or lost your memory? ___ ___

3. Have you ever had a seizure? ___ ___

4. Have you ever had a stinger, burner, or numbness in your arms, hands, legs or feet? ___ ___

If yes, which one(s)? _____________________________________

Nutrition

Yes / No

1. Do you skip meals during the day? ___ ___

2. Do you use laxatives, diuretics, or stimulants to control your weight? ___ ___

If yes, which one(s)? ____________________________________

3. Do you feel disgusted, depressed, or guilty about your eating? ___ ___

4. Do you self-induce vomiting after eating? ___ ___

5. Do you restrict certain types of foods? ___ ___

If yes, which one(s)? ____________________________________

6. Have you ever taken nutritional supplements? ___ ___

If yes, which one(s)? ____________________________________

7. Do you have a food allergy? ___ ___

If yes, which one(s)? ____________________________________

8. Do you want to weigh more or less than you do now? ___ ___

Females Only

1. When was your last menstrual period? __________

2. How often do your periods occur? __________

3. Have you ever gone 4 months without getting a period? __________

Some type of medical insurance is REQUIRED of all students participating in any interscholastic athletic activity. For this reason, school insurance is offered at a nominal cost to all. Any student participating in the sport of football is required to take the provided football insurance policy. For full coverage of expenses resulting from the examination, diagnosis, treatment and rehabilitation (if needed) of an injury resulting from an injury occurring in an interscholastic sports event, school insurance is absolutely essential. If you do not purchase the school insurance, you should be aware of your policy deductible and limits on coverage for particular conditions. If you do not purchase school insurance and your medical carrier does not pay the entire bill, a claim can be made to the Rhode Island Interscholastic Injury Fund. If you do submit a claim for an injury, remember to be prompt. Claims should be submitted within 60 days of the Doctor's or hospital visit. Failure to do so may result in non-payment of claim. Please contact the Director of Athletics for paperwork needed to file this claim.

We hereby give our consent for __________________________________ to represent his/her school in interscholastic athletics. If in the event of injury or accident either en route to the event, at the event, or en route back from the event, we also give our consent for the school to obtain any and all medical care that is deemed reasonably necessary for the welfare of the student. We realize that all reasonable efforts will be made to contact us if the above does occur.

We further state that we have completed that part of this form which requires us to list all previous injuries or conditions that are known to us and that the form is completed correct and true.

Name of Primary Medical Insurance: ______________________________________________________________

Policy Number: ___________________________________ Expiration Date: ____________________________

I/We have purchased school insurance this school year: YES____ NO____

NOTE: if your answer is "NO", you must complete and sign statement which follows.

I am fully covered by my own insurance for any injury that my child _______________________ may incur during the time of participation in the sport of: _____________________ I have read the above information and understand that there may be limits to my coverage. I do not wish to purchase school insurance.

Parent or Guardian (Print): _____________________________________________________________________

Signature of Parent or Guardian: _________________________________________________________________

Date: ___________________________

Name: ___________________________________

Physical Examination Sport(s): __________________________________

Age: _______________

Height ______ Weight ______

Pulse _______ BP ______, ______, ______

Vision R ______ L ______ Corrected: Y N

	Normal	Explanation
Medical
General
Skin
Height
Lymph Nodes
Heart
Lungs
Abdomen
Genitalia (males only)
Pulses
Musculo-Skeletal
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Calf
Ankle/Foot
Neuralgic

Immunizations

1. When was your last tetanus shot? __________________

2. When was the date of your measles immunization? __________________

Identified Problems:

1. ________________________________________________________________________________ _____

2. ________________________________________________________________________________ _____

3. ________________________________________________________________________________ _____

Review by Physician:

____ No Athletic Participation

____ Limited Participation, e.g., ______________________________________________________________

____ Clearance Withheld Until: ______________________________________________________________

____ Full Unlimited Participation

Athlete requesting clearance in the following sport(s): __________________________________________

Cleared: Yes / / No / /

Recommendations _____________________________________________________________________________

Name of Physician, NP, or PA _________________________________________________ Date _____________

Address __________________________________________________________________ Phone _____________

Signature of Physician ________________________________________________________, MD or DO

rev. 02/00 (Physician's signature required if examination performed by nurse practitioner or physician's assistant)

The undersigned, being an adult student athlete or parent/legal guardian of the undersigned minor prospective student athlete, hereby acknowledge that said student seeks to participate in a student sports program sponsored by the Principals' Committee on Athletics - Grades 6 - 9. The undersigned specifically assert that said student athlete will comply with the rules and regulations governing athletic participation of the Principals' Committee on Athletics- Grade 6 - 9; the undersigned hereby authorize the release of information and reports concerning the academic standing, medical condition, financial aid, attendance record, and disciplinary record of the undersigned student to the Principals' Committee on Athletics - Grades 6 - 9 for the purpose of enforcing the rules and regulations of the athletic program; that they are aware that the athletic participation requires physical fitness; that the student possesses such fitness; and that some risk is involved in sports participation.

Now, therefore, pursuant to Rhode Island General Laws 7-6-9, as amended, the undersigned, in consideration of participation in a Principals' Committee on Athletics - Grades 6 - 9 sports program, herein grant to its officers, directors, trustees, agents(to include but not limited to the local School Committee or its parochial or private equivalent), servants and employees, a waiver of liability as regards to participation in the sports program sponsored by the Principals' Committee on Athletics - Grades 6 - 9. The undersigned specifically acknowledge that a risk of injury exists and assume said risk with respect to practicing for or participating in any contest or exhibition of an athletic or sports matter sponsored by the Principals' Committee on Athletics - Grades 6 - 9.

School(Print)______________________________________	Signature of Student_____________________________________
City or Town(Print)___________________________________	Signature of Parent or Guardian____________________________
Name of Student(Print)________________________________	Date of Signature_______________________________________
Age___ Grade Level_____Academic Year 20___/20___ __	Signature of Notary Public________________________________ SEAL

This form must be completed by all students intending to participate in any Principals' Committee on Athletics - Grades 6 - 9 sport. All minor students must sign and have a parent or legal guardian also sign. All forms are to be notarized and returned to the school principal. Failure to submit a duly executed form will cause the athlete to be declared ineligible. Only one form for each participant is necessary for the duration of one's eligibility in sports programs sponsored by Principals' Committee on Athletics - Grades 6 - 9