Physical Examination and Parent Permit for Athletic Participation - Part I

1a PHYSICAL EXAMINATION AND PARENT PERMIT FOR ATHLETIC PARTICIPATION - PART I I hereby certify that I have examined and that the student was found physically fit to engage in high school sports (except as listed on back). Student’s birth date Exp. Date (good for 365 days) PARENT OR GUARDIAN PERMIT WARNING: Although participation in supervised interscholastic athletics and activities may be one of the least hazardous in which any student will engage in or out of school, BY ITS NATURE, PARTICIPATION IN INTERSCHOLASTIC ATHLETICS INCLUDES A RISK OF INJURY WHICH MAY RANGE IN SEVERITY FROM MINOR TO LONG-TERM CATASTROPHIC INJURY. Although serious injuries are not common in supervised school athletic programs, it is impossible to eliminate this risk. PLAYERS MUST OBEY ALL SAFETY RULES, REPORT ALL PHYSICAL PROBLEMS TO THEIR COACHES, FOLLOW A PROPER CONDITIONING PROGRAM, AND INSPECT THEIR OWN EQUIPMENT DAILY. By signing this Permission Form, we acknowledge that we have read and understood this warning. PARENTS OR STUDENTS WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS PERMISSION FORM. By signing this form it allows my students medical information to be shared with appropriate medical staff when necessary in compliance with HIPPA (Health Insurance Portability and Accountability Act) Regulations. I hereby give my consent for to compete in athletics for High School in Colorado High School Activities Association approved sports, except as listed on back, and I have read and understand the general guidelines for eligibility as outlined in the Competitor’s Brochure. Parent or Guardian Signature Date I have read, understand and agree to the General Eligibility Guidelines as outlined in the Competitor’s Brochure. Student Signature Date No student shall represent their school in interschool athletics until there is on file with the superintendent or principal a statement signed by his parent or legal guardian and a signed physical certifying that he/she has passed an adequate physical examination within the past year, that in the opinion of the examining physician, physician’s assistant, nurse practitioner or a certified/registered chiropractor, he/she is physically fit to participate in high school athletics; and that he/she has the consent of his/her parents or legal guardian to participate. NOTE: It is strongly recommended by the Colorado Department of Health that individuals participating in athletic events have current tetanus boosters. Tetanus boosters are recommended every 10 years throughout life. Boosters are recommended at the time of injury if more than five years have elapsed since the last booster. If significant intervening illnesses and/or injuries have occurred, a more complete physical examination should be conducted. The physical examination form must be signed by a practicing physician, physician assistant, or nurse practitioner. If a student athlete has been injured in practice and/or competition, the nature of which required medical attention, the student athlete should not be permitted to return to practice and/or competition until he/she has received a release from a practicing physician. NOTE: The CHSAA urges an adequate physical examination be given when a student athlete changes levels of competition, i.e. Little League to Middle School, Middle School to High School. PHYSICIAN SIGNATURE REQUIRED ON BACK CONSENT FOR TREATMENT, ASSUMPTION OF RISK, AUTHORIZATION TO DISCLOSE PRIVATE HEALTH INFORMATION Consent for Treatment We hereby authorize the Certified Athletic Trainers and sports medicine staff acting on behalf of Regis Jesuit High School (“Regis Jesuit”) to evaluate and treat any injury/illness that occurs as a result of ____________’s (student’s name) participation in athletics at Regis Jesuit. This includes any and all reasonable and necessary preventative care, treatment, and rehabilitation for these injuries/illnesses. We understand that ____________’s (student’s name) must refrain from practice while injured and/or ill, whether or not receiving medical care. When under medical care ____________’s (student’s name) may not return to participation until ____________’s (student’s name) has been given permission by the Team Physician, his/her delegate, or a Certified Athletic Trainer. This may occur during or at the conclusion of medical treatment. We understand and agree that if ____________’s (student’s name) experiences an injury/illness or change in her health status it is her responsibility to inform my Head Coach and the Certified Athletic Trainer. ____________ (student’s name) also agrees to adhere to the established injury management guidelines including rehabilitation and reassessment before she is released to return to full participation. This authorization expires on the date of graduation for the Regis Jesuit student. It may be revoked at any time provided written documentation of the revocation is on file in the Athletic Training Room. ____________________________________________________________________________________________________ Student Printed Name Student Signature Date ____________________________________________________________________________________________________ Parent/Guardian Signature Date Parent/Guardian Signature Date Authorization to Disclose Private Health Information We grant permission to Regis Jesuit’s Certified Athletic Trainers to disclose ____________’s (student’s name) Personal Health Information (written and/or verbal), when requested to do so, for the purposes of health care treatment, payment for treatment, or for any other purpose which is permitted or required by law. Personal Health Information includes, but is not limited to: information involving the nature and treatment of an injury/illness, medical history, insurance coverage and copies of all hospital and medical records. This information will be released ONLY for the purposes of further treatment (referrals to specialists or other health care providers), or disclosure of participation status to the team’s coaches for ____________’s (student’s name) health and safety. In order to maintain continuity of care and provide participation status updates to athletic department personnel, we hereby authorize the Certified Athletic Trainers to disclose injuries/illness contained in ____________’s (student’s name) student- athlete medical file, including medical conditions(s), treatment and rehabilitation status, and participation restrictions to the following entities: a. Team Physicians b. Team Orthopedists c. Regis Jesuit coaching staff for my sport d. Neuropsychologist e. Regis Jesuit Athletic Director This authorization expires on the date of graduation for the Regis Jesuit student. It may be revoked at any time provided written documentation of the revocation is on file in the athletic training room. ____________________________________________________________________________________________________ Student Printed Name Student Signature Date ____________________________________________________________________________________________________ Parent/Guardian Signature Date Parent/Guardian Signature Date Please Complete the Back of This Form Assumption of Risk We understand that there are certain inherent risks involved in participating in high school athletics. Even though Regis Jesuit takes all reasonable precautions to minimize these risks, injury and illness do sometimes occur. We understand that participation in athletics at Regis Jesuit, and in particular ____________ (sport), may result in injury/illness, including without limitation concussions and brain injury, permanent physical or mental impairment, or even death. These injuries may be minor or career or life-threatening. We understand that Regis Jesuit cannot be held responsible for injuries or conditions caused by the actions of another athlete or the student athletes’s own failure to follow the safety procedures established by Regis Jesuit’s coaching staff, sports medicine staff, or other athletic department staff. We acknowledge the obligation to for the student athlete to notify her coaching staff of any injury she is experiencing and not to return to a game or practice until all symptoms are gone. We acknowledge that the coaches may misjudge circumstances related to whether or not a player is injured. We understand and accept that Regis Jesuit and its sports medicine staff will uphold their responsibility to minimize injury risks associated with athletic participation. We acknowledge that these risks may still exist and we hereby assume responsibility for any and all such risks while ___________(student’s name) is participating in athletics at Regis Jesuit High School. Additionally, we agree to the following: a. We accept that Regis Jesuit and its personnel are not to be held responsible for any pre-existing medical conditions or any medical conditions not disclosed disclose on ____________’s (student’s name) Health History. We understand that having passed the pre-participation physical exam does not necessarily mean ____________’s (student’s name) is physically qualified to participate in athletics at Regis Jesuit, but only that the evaluator did not find a medical reason to disqualify ____________’s (student’s name) at the time of the exam. This authorization expires on the date of graduation for the Regis Jesuit student. It may be revoked at any time provided written documentation of the revocation is on file in the athletic training room. ____________________________________________________________________________________________________

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