Pembroke School District Sports Participation Health Screening Form
| In accordance with NHIAA and Pembroke School District Rules & Regulations, this form must be completed each time a student goes out for a sport. | |||
| Name:__________________________________ | Date:__________________ | ||
| Address:________________________________ | Phone:_________________ | ||
| _________________________________ | Age:_____ DOB:________ | ||
| Sport:__________________________________ | Grade:____ Sex:_________ | ||
| Family Physician:________________________ | Phone:_________________ | ||
| In case of emergency:_____________________ | Phone:_________________ | ||
| All students participating in interscholastic athletics must be given a physical examination by a medical doctor (or qualified non-physician health practitioner under the direction of a physician) prior to his/her involvement in our program. For students entering grade 9, a medical note dated after March 1st of that year must be on file at the school. Upper classmen choosing to participate for the first time must similarly produce a medical note dated within the past six months. This is a requirement for membership on any school-sponsored athletic team and needs to be completed only once. However, prior to participation in each sport, all students are required to complete a medical history. The school nurse will review each medical history and reserve the right to require a physician’s approval to participate, for any student, based on information that may be generated by this medical history. (For purpose of this policy, participation means either practices of games.) | |||
| Health History: To be completed by athlete and parent/guardian for each sport the student participates in. (If YES to any question, please make a note on last page.) | |||
| 1. Have you ever had an illness that: | YES | NO | |
| a. required you to stay in the hospital? | ____ | ____ | |
| b. lasted longer than a week? | ____ | ____ | |
| c. caused you to miss 3 days of practice or competition? | ____ | ____ | |
| d. is related to allergies? (i.e. hives, asthma, bee stings) | ____ | ____ | |
| e. required an operation? | ____ | ____ | |
| f. is chronic? (i.e. asthma, diabetes, epilepsy) | ____ | ____ | |
| 2. | Have you ever had an injury that: | ||
| a. required you to go to an emergency room or doctor? | ____ | ____ | |
| b. required you to stay in the hospital? | ____ | ____ | |
| c. required x-rays? | ____ | ____ | |
| d. caused you to miss 3 days of practice or competition? | ____ | ____ | |
| 3. | Do you take any medication or pills? | ____ | ____ |
| 4. | Has any member of your family under the age of 50 died unexpectedly? | ____ | ____ |
| 5. | Have you ever had any: | ||
| a. hearing loss or difficulty with hearing? | ____ | ____ | |
| b. hernias? | ____ | ____ | |
| c. recurrent skin disease? | ____ | ____ | |
| d. heat exhaustion/stroke? | ____ | ____ | |
| 6. | Have you ever been: | ||
| a. dizzy or passed out during or after exercise? | ____ | ____ | |
| b. unconscious or had a concussion? | ____ | ____ | |
| 7. | Do you have any trouble running ½ mile (twice around the track) without stopping? | ____ | ____ |
| 8. | Do you: | ||
| a. wear contacts or glasses? | ____ | ____ | |
| b. wear dental bridges, plates or braces? | ____ | ____ | |
| 9. | Have you ever had a heart murmur, high blood pressure or a heart abnormality? | ____ | ____ |
| 10. | Have you ever had a heart murmur, high blood pressure or a heart abnormality? | ____ | ____ |
Explain any YES answers (date of injury, surgery, etc.)
INFORMED CONSENT: I, as parent/guardian of the above-named athlete, give my permission for him/her to participate in the sport listed above. I certify that the medical information requested has been answered accurately, that my son/daughter is in good health, and that permission has been given by a physician for him/her to participate in athletics. I understand that the school will not be held financially responsible for any sickness or injury that may result from athletic participation. Further, I give my permission for my son/daughter to be transported, by private vehicle operated by a faculty member/coach or by school bus, to an event, if necessary.
_________ __________________________ ________________________
Date Student/Athlete Parent/Guardian
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