Revised May 2010
PAUL VI CATHOLIC HIGH SCHOOL
10675 Fairfax Blvd., Fairfax, VA 22030-4314
Athletic Participation/Parental Consent/Physical
Examination Form
Separate examination 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___
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 below and believe I am eligible to represent my present high school in athletics.
INDIVIDUAL ELIGIBILITY RULES
To be eligible to represent Paul VI Catholic High school in any 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 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 the 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/Parental 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 athletic
competition and that your parents’ consent to your participation.
• must not be in violation of Amateur, Awards, All Star or College Team Rules. (Check with your principal for clarification
in regard to 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 athletic program,
publication or video.
LOCAL SCHOOL DIVISIONS AND STATE LEAGUES MAY REQUIRE ADDITIONAL STANDARDS TO THOSE LISTED ABOVE.
Student Athlete's Signature: _______________________________________ Date:_________________________
Providing false information will result in ineligibility for one year.
PART II - - MEDICAL HISTORY
MEDICAL HISTORY OF STUDENT & FAMILY
Yes
No
MEDICAL HISTORY OF STUDENT & FAMILY
Yes
No
1. Has a doctor ever denied or restricted your participation
in sports for any reason?
32. Do you have any rashes, pressure sores, or other skin
problems?
2. Do you have an ongoing medical condition (like diabetes or
asthma)?
33. Have you ever had herpes skin infection?
3. Are you currently taking any prescription or non prescription
(over the counter) medicines or pills?
34. Have you ever had a head injury or concussion?
4. Do you have allergies to medicines, pollens,
foods or stinging insects?
35. Date of last head injury or concussion:
Date:
5. Do you have prescriptions for use of epinephrine, adrenalin,
inhaler, or other allergy medications?
36. Have you ever been hit in the head and been confused or
lost your memory?
6. Have you ever passed out or nearly passed out during or after
exercise?
37. Have you ever been knocked unconscious?
7. Have you ever passed out or nearly passed out at any other
time?
38. Have you ever had a seizure?
8. Have you ever had discomfort, pain, or pressure in your chest
during exercise?
39. Do you have headaches with exercise?
9. Have you ever had to stop running after 1/4 to 1/2 mile for chest
pain or shortness of breath?
40. Have you ever had a numbness, tingling, or weakness in
your arms or legs after being hit or falling?
10. Does your heart race or skip beats during exercise?
41. Have you ever been unable to move your arms or legs
after being hit or falling?
11. Has a doctor ever told you that you have (check all that apply):
__High Blood Pressure ___Heart murmur
__High cholesterol __Heart infection
42. When exercising in heat, do you have severe
muscle cramps or become ill?
43. Has a doctor told you that you or someone in your
family has sickle cell trait or sickle cell disease?
12. Has a doctor ever ordered a test for your heart?
44. Have you had any other blood disorders or anemia?
13. Has anyone in your family died suddenly for no apparent
reason?
45. Have you had any problems with your eyes or vision?
14. Does anyone in your family have a heart problem?
46. Do you wear glasses or contact lenses?
15. Has any family member or relative died of heart problems or
sudden death before age 50? (This does not include accidental
death)
47. Do you wear protective eyewear, such as goggles or a
face shield?
16. Does anyone in your family have Marfan syndrome?
48. Are you happy with your weight?
17. Have you ever spent the night in a hospital?
49. Are you trying to gain or lose weight?
18. Have you ever had surgery?
50. Do you limit or carefully control what you eat?
19. Have you ever had an injury, like a sprain, muscle or ligament
tear, or tendonitis that caused you to miss a practice or game?
51. Has anyone recommended you change your weight or
eating habits?
20. Have you had any broken or fractured bones or dislocated
joints?
52. Do you have any concerns that you would like to discuss
with a doctor?
21. Have you had a bone or joint injury that required x-rays, MRI,
CT, surgery, injections, rehabilitation, physical therapy, a
brace, a cast, or crutches?
53. What is the date of your last Tetanus immunization?
Date:
FEMALES ONLY
54. Have you ever had a menstrual period?
22. Have you ever had a stress fracture?
55. Age when you had your first menstrual period? _______
23. Have you ever had an x-ray of your neck for atlanto-axial
instability? OR Have you ever been told that you have that
disorder or any neck/spine problem?
56. How many periods have you had in the last 12 months?
24. Do you regularly use a brace or assistive device?
57. Do you take a calcium supplement?
25. Have you ever been diagnosed with asthma or other allergic
disorders?
Explain “Yes” answers here:
26. Do you cough, wheeze, or have difficulty breathing during or
after exercise?
27. Is there anyone in your family who has asthma?
28. Have you ever used an inhaler or taken asthma medicine?
29. Were you born without or are you missing a kidney, an eye, a
testicle, or any other organ?
30. Have you had infectious mononucleosis (mono) within the last
three months?
31. Have you ever had mono or any illness lasting more than
two weeks?
Parent/Guardian Signature: ______________________________________________
Student Athlete Signature____________________________________________
PART III – PHYSICAL EXAMINATION
(Physical examination is required each school year after May 1 of the preceding school year and is good
through June 30
of the current school year).
NAME: SCHOOL:
HEIGHT:
WEIGHT: SEX: AGE: DOB:
*Tanner Stage or Maturation
*Percent Body Fat:
Index: (males only)
BP:
*
PULSE (rest)
*Audiogram
*PULSE(Exercise)
*PULSE (Recovery)
*Vision: Corrected (L)
Uncorrected (L)
(R) (Both)
*FEV or Peak Flow (rest)
*FEV(Exercise)
(R) (Both)
*FEV(Recovery)
N
ABNORMAL
N
ABNORMAL
Eyes
Cervical Spine/neck
Ears
Back
Nose
Shoulders
Throat
Arm/elbow/wrist/hand
Teeth
Knees/hips
Skin
Ankle/feet
Lymphatic
Marfan Screen
Lungs
*Urine
Heart
*Hemoglobin or HCT
and or Iron stores
Periphera
l pulses
^Echocardiogram
Abdomen
^Neuropsyc Testing
Genitalia/hernia
(male only)
^Pelvic Examination
*WHEN MEDICALLY INDICATED
(Physician judgment based on history, exam, and knowledge of other recent physical and laboratory evaluations)
^WITH SPECIAL INDICATIONS
(These studies may be recommended to the athlete because of history or physical findings and may or may not be required before making participation
decision.)
I have reviewed the data above, reviewed his/her medical history form and make the following
recommendations for his/her participation in athletics.
__ CLEARED WITHOUT RESTRICTIONS
__
Cleared AFTER further evaluation or treatment for:
__
Cleared for Limited participation (check and explain “reason” for all that apply):
__
Not cleared for (specific sports) __________________________________________
__
Cleared only for (specific sports) _________________________________________
Reason(s): ______________________________________________________________
__ NOT CLEARED FOR PARTICIPATION: _____________________________________
Reason(s): ______________________________________________________________
__ Other Recommendations: _____________________________________________________
__
Recommend close monitoring during early conditioning because of weight/fitness/other U
__
Recommend restrictions or monitoring of weight loss or gain
__
Other ____________________________________________________________
Reason(s): ___________________________________________________________
Physician Signature: _____________________________________________ + M.D. Date of Examination**
+
(MD, DO, LNP, PA)
Date Signed: _________________
Examiner’s Name and degree (print): _________________________________ Phone Number ________________
Address: ____________________________________ City _________________________ State ___________ Zip
PART IV
-- ACKNOWLEDGEMENT OF RISK AND INSURANCE STATEMENT
(To be completed and signed by parent/guardian)
I give permission for_______ ______________ (name of child/ward) to participate in any school sports with the exception of:
_________________________________________________________________________________________________________
.
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 risks vary significantly from one sport to another with
contact sports carrying the higher risk. I have had an opportunity to understand the risks inherent in sports through meetings, written
forms or some other means.
Name of parent’s/guardian’s 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 participating in athletics/activities for his/her school during the school year covered by this form. I further
consent to allow said physician(s) or heath 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 athletic program, publication or video.
PART V - EMERGENCY PERMISSION FORM
(To be completed and signed by parent/guardian)
STUDENT'S NAME ________________________________________ GRADE ___________ AGE_____
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.
Has student been prescribed an inhaler or epipen? ______________________________________________________
Is student presently taking medication? _________ If so, what type? ____________________________________
Does student wear contact lenses? __________________ Please list date of last 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 injection and/or anesthesia and/or surgery for the person named above.
___________________________Daytime phone for emergency
___________________________Evening phone for emergency
Signature of parent or guardian_____________________________________ Date
Relationship to student ________________________________________________________________________
*Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency
treatment if needed.
I certify all the above information is correct _______________________________________________________
Parent/Guardian Signature