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For many incoming high school students in Kentucky, transitioning into a new phase of their academic and athletic life involves a crucial step: submitting a comprehensive Medical Information and Physical Examination Form. The form is an essential requirement for students aiming to participate in sports, marking their readiness for the challenges ahead in the 2021-2022 school year. It encompasses a detailed medical history check, adhering to the latest KHSAA regulations, and ensures that students are medically fit to engage in athletic activities. The importance of this document extends beyond mere formality; it's a safeguard, ensuring that every student athlete is equipped to handle the physical demands of sports while prioritizing their health and safety. Additionally, the form acts as a conduit for essential medical information, including immunization records in line with KRS 158.035, KRS 214.0, and KAR 2:060, effectively preventing any health-related barriers that might impede a student's participation in sports. Beyond the requirements for general sports participation, the form addresses specifics for cheerleading and dance tryouts, stressing the need for a physical examination within a defined timeline to ensure eligibility. Equally, the document extends its relevance to emergency situations, granting authorized medical personnel the ability to act swiftly and efficiently, providing necessary care in case of an injury or illness during school or athletic events. The integration of recent immunization law changes underscores the evolving nature of health requirements in the educational system, ensuring that students not only meet the criteria for school entry but are also in line with health regulations that safeguard the communal well-being within the school environment. Hence, the Kentucky High School Sports form is more than just paperwork; it's a comprehensive measure designed to foster a safe and healthy sporting environment for students, marking the beginning of an exciting journey in high school athletics.

Kentucky High School Sports Sample

MEDICAL INFORMATION AND PHYSICAL EXAMINATION FORM

FOR INCOMING STUDENTS 2021-2022

ALL INCOMING STUDENTS MUST SUBMIT A PHYSICAL EXAMINATION FORM—

PHYSICALS COMPLETED PRIOR TO APRIL 2021 WILL NOT BE ACCEPTED.

In compliance with KRS 158.035, KRS 214.0, and KAR 2:060

the original certificate of immunization against diphtheria, tetanus, poliomyelitis, measles, rubella, hepatitis A, and meningitis

must be submitted by every student and kept on file by the school.

Student's final admission status is not complete until the physical examination form and the required

certificate of immunization status have been submitted.

Important Information for Incoming Students Planning to Participate in Athletics

In accordance with KHSAA regulations, the student’s medical history and physical must be reported on the KHSAA form which follows.

Students trying out for CHEERLEADING AND DANCE: physical examination must be completed and health forms turned in prior to tryouts in mid-April. If the physical was conducted between April 2020 and March 2021, it will satisfy the KHSAA requirement, but a current physical examination, conducted April-July 2021, is required by July 29, 2021, to meet the school requirement.

PART 1 - STUDENT INFORMATION

Student's Full Legal Name: _____________________________________________________________________________________

LastFirstMiddle2021-2022 Grade

Student’s Home Address: ______________________________________________________________________________________

Number & Street

City

State

Zip Code

Student’s Date of Birth: ______________________________

Student's Social Security #: ________________________________

Primary Physician _________________________________

Office Phone # ___________________________

Family Dentist ____________________________________

Office Phone # ___________________________

PART 2 – PARENTAL PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATION/ PARENTAL CONSENT/PERMISSION TO TREAT AUTHORIZATION – 2021-2022

Parent/guardian signatures are required in order for your daughter

to receive any necessary medical treatment or medication (including Tylenol, Advil, etc.).

In the event of an injury or illness during the school day or at a school event or, if applicable, an athletic event or practice session, I give

permission for my daughter,, to receive proper/necessary care from the school nurse, staff member, certified athletic trainer, or coach. In addition, I authorize treating physicians and/or their representatives to release medical information to representatives of the Assumption Administration, Athletic Department, and coaching staff, as applicable.

In the event of an emergency during the school day or at a school event or, if applicable, an athletic event or practice session, I give

permission for my daughter,, to be transported to an appropriate medical facility for treatment. Furthermore, I give permission for the staff at the medical facility to render any and all treatment that is necessary for the well-being of my daughter. In addition, I authorize treating physicians and/or their representatives to release medical information to representatives of the Assumption Administration, Athletic Department, and coaching staff, as applicable.

Signature: _____________________________________________________ Date: __________________________________

New Kentucky Immunization Laws

The following is a summary of the recent changes, effective June 21, 2017, to 902 KAR 2:060:

Immunizations schedules for attending child day care centers, certified family child care homes, other licensed facilities which are for children, preschool programs, and public and private primary and secondary schools, https://www.lrc.ky.gov/kar/902/002/060.htm . This amended Kentucky Administrative Regulation requires all children to have a current immunization certificate on file, contains the required immunizations schedule for attending, and has a process to obtain a religious exemption from the required immunizations.

One new age-specific immunization requirement and one booster dose requirement effective for the school year beginning on or after July 1, 2018:

2-Dose Series of Hep A ( Age: 12 months through 18 years, to be compliant for the series the second Hep A is given six months after the first inject.)

Quadrivalent meningococcal vaccine (MenACWY) booster dose (Age: 16 years)

Homeschooled children are required to submit to current immunization certificate to participate in any public or private school activities (classroom, extra curriculum activity, or sports).

All vaccines administered are printed on the Commonwealth of Kentucky Certificate of Immunization Status now including immunizations not required for school entry.

Out of state immunization certificates may be accepted if they meet the same age – specific requirements as outlined in this regulation.

A Commonwealth Certificate of Immunization Status printed from the Kentucky Immunization Registry (KYIR) does not require a signature

Routine certificate reviews are to occur at enrollment in a day care center, kindergarten, new enrollment at any grade; upon legal name change; and at a school required examination pursuant to 702 KAR 1:160.

A child whose certificate has exceeded the date for the certificate to be valid shall be recommended to visit the child’s medical provider or local health department to receive immunizations required by this administrative regulation. An updated and current certificate shall be provided to the:

Day care center, certified family child care home, or other licensed facility that cares for the children by a parent or guardian within thirty (30) days from when the certificate was found to be invalid.

School by a parent or guardian within fourteen (14) days from when the certificate was found to be invalid.

Physical Education/Athletic Participation Form

Parental and Student Consent and Release For High School Level (grades 9 - 12) participation

KHSAA Form GE04

High School Parental Permission and Consent

Rev.7/20, page 1 of 2

© KHSAA, 20 20

The student and parents/guardian must read this statement carefully and sign where required. By signing this form, all parties agree that they have accurately completed all sections of the form and have read and agree to the terms of this form as detailed. This form must be completed before the student participates (hereinafter including try out for, practice and/or compete) in interscholastic athletics/physical education. This form should be kept in a secure location until the student has exhausted eligibility, graduated from high school and reached the age of 19.

STUDENT/ATHLETE INFORMATION (This part must be completed by the student and family.)

Name (Last, First, Initial)

 

 

 

 

 

 

 

 

School Year

 

 

 

 

Home Address (Street, City, State, Zip):

 

 

 

 

 

 

 

 

 

 

 

 

Gender

 

 

 

Grade

 

 

 

School

 

 

 

 

 

Date of Birth:

 

 

 

 

Birth Place (County, State):

 

 

 

 

 

School Attendance History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varsity Play –

 

Grade

School Name

 

 

 

 

 

School Year

 

 

(Yes/No)?

 

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am planning to participate in the following

 

NONE

 

Basketball

 

 

Soccer

 

Softball

 

 

Wrestling

 

Archery

 

 

Esports

 

Other __________

 

EMERGENCY CONTACT INFORMATION

(check

all you might try to play):

Cross Country

 

 

Football

Swimming

 

 

Tennis

Bass Fishing

 

 

Bowling

Golf

Track and Field

Competitive Cheer

Lacrosse

Volleyball

Dance

 

 

Name (please print)

 

 

 

 

 

Relation to Student

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact Address, including City, State and Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone

 

 

 

 

 

Cell Phone

 

 

 

 

FOR ATHLETES: REQUIRED INSURANCE INFORMATION (KHSAA Bylaw 12)

 

Prior to participation in practice or contests (including trying for a place on a team)

in any sport or sport activity during the limitation of seasons

 

as defined in Bylaw 23 , all students are required to have medical insurance with coverage limits of at least $25,000. If this coverage is

 

provided through the school, contact the Principal or Athletic Director regarding any potential claim.

Individual schools and districts may

 

impose additional requirements for insurance or coverage during additional periods for activities outside of Bylaw 23.

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Carrier

 

Policy Number / ID Number

 

Group Number

 

 

 

Plan

 

 

 

 

FOR ATHLETES: EMERGENCY TREATMENT INFORMATION

 

The following information is

recorded solely for potential hospitalization and emergency care needs and is not required to be recorded on this

form. However, those failing to provide this information should be aware that this might be required by emergency treatment facilities prior to rendering service, and failure to provide could result in lack of appropriate care.

Social Security Number

 

Birth Date

FOR ATHLETES: CONSENT INFORMATION TO PARTICIPATE, ACKNOWLEDGMENT OF RISK, ACKNOWLEDGEMENT OF ELIGIBILITY RULES, LIABILITY WAIVER AND CONSENT AND RELEASE

As parent/legal guardian, I agree to allow my child to participate in interscholastic athletics..

 

The student and parent/legal guardian recognize that participation in interscholastic athletics involves

some inherent risks for potentially severe

injuries, including but not limited to

death, serious neck, head and spinal injuries which may result in complete or partial paralysis, brain damage,

serious injury to internal organs, serious injury to bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system, and

serious injury or impairment to other aspects of the body, or eects to the general health and well being of the child. Because of these inherent risks, the student and parent/legal guardian recognize the importance of the student obeying the coaches’ instructions regarding playing techniques, training and other team rules . By signing this form, the student and parent/legal guardian acknowledge that the stude nt’s participation is wholly voluntary and to having read and understood this provision.

The student and parent/legal guardian individually and on behalf of the student, hereby irrevocably, and unconditionally release, acquit, and forever discharge the KHSAA and its ocers, agents, attorneys, representatives and employees (collectively, the “Releasees” ) from any and all losses, claims, demands, actions and causes of action, obligations, damages, and costs or expenses of any nature (including a ttorney’s fees) that the student and/or parent/legal guardian incur or sustain to person, property or both, which arise out of, result from, occur during or are otherwise connected with the student’s participation in interscholastic athletics if due to the ordinary ne gligence of the Releasees.

The student and parent/legal guardian acknowledge that they have read and understood the KHSAA Bylaws by distribution under the handbook links at http://khsaa.org/. Please be aware that a student is subject to the one-year period of ineligibility the bylaw commonly referred to as the "Transfer Rule," upon participation in any varsity contest regardless of the amount of participation or lack thereof.

The student and parent/legal guardian agree to abide by the KHSAA Bylaws and Due Process Procedure as now enacted or later amended. The student and parent/legal guardian further acknowledge that they agree to abide by the rulings of the Commissioner, Assistant Commissioner, Hearing Ocer and Board of Control.

The student and parent/legal guardian acknowledge that the student must have medical insurance coverage up to a limit of $25,000 in order to be eligible to participate in interscholastic athletics.

The student and parent/legal guardian, individually and on behalf of this student, give the high school, the KHSAA and their representatives permission to release this student’s demographic information (including motion picture and still photographic images) and participation statistics (including height, weight and year in school, participation history and other performance based statistics) and other informa tion as may be requested, and agree that the student may be photographed or otherwise digitally or electronically cap tured during school-based competition. All of this material may be used without permission or compensation specically related to the KHSAA and its events .

The student and parent/legal guardian consent to this student receiving a physical examination as r equired by the KHSAA.

The student and parent/legal guardian, individually and on behalf of this student, consent to the high school and the KHSAA and their representatives to use and disclose the necessary personally identiable information from the student’s education records including academic, nancial and health care information, to third parties including school representatives, coaches, athletic trainers, medical facilities, m edical stas, KHSAA legal counsel and the media, for the purpose of receiving proper/necessary medical care and complying with the KHSAA bylaws, including making determinations regarding eligibility to participate in interscholastic athletics and any administrative or legal proceedings resulting from participation or attempted participation in interscholastic athletics, without such disclosure constituting a violation of rights under the Family Educational Rights and Privacy Act. The student and parent/legal guardian, individually and on behalf of this student, further release the high school, the KHSAA and their representatives from any and all claims arising out of the use and disclosure of said necessary personally identiable information, and agree to release to the high school, the KHSAA, and their representatives, upon request, the detailed and completed application for nancial aid.

The student and parent/legal guardian, individually and on behalf of the student, hereby acknowledge that they are aware of and will review if desired, the education materials availab le through the KHSAA, the Centers for Disease Control and other agencies regarding education all individuals with respect to nature and risk of concussion and head injury, including the continuance of play after concussion or head inj ury.

The student and parent/legal guardian, individually and on behalf of the student, hereby consent to allow the student to receive medical treatment that may be deemed advisable by the high school, the KHSAA, and their representatives in the event of injury, accident or ill ness while participating in interscholastic athletics, including, but not limited to, transportation of the student to a medical facility.

STUDENT AND PARENT/GUARDIAN ACKNOWLEDGMENT OF RISK, ELIGIBILITY RULES, LIABILITY WAIVER AND

CONSENT AND RELEASE AND

EMERGENCY PERMISSION FORM

 

 

 

 

 

Students’ Name (please print)

 

 

School

 

 

 

Student and Parent/Guardian Address including City, State and Zip

 

 

 

 

 

Signature of Student

 

 

 

Date

Please list above any health problems/concerns this student may have, including allergies (medications / others) and any medications presently being used

Name of Parent(s)/Guardian(s) who has/have custody of this student (please print)

 

Emergency Phone Number

 

 

 

Signature of Parent(s)/Guardian(s) who has/have custody of this student

 

Date

1

Clearance

PREPARTICIPATION PHYSICAL EVALUATION

MEDICAL ELIGIBILITY FORM

Name: _______________________________________________________ Date of birth: _________________________

Medically eligible for all sports/physical education activites without restriction

Medically eligible for all sports/physical education activites without restriction with recommendations for further evaluation or treatment of

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medically eligible for certain sports/physical education activites

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Not medically eligible pending further evaluation

Not medically eligible for any sports/physical education activites

Recommendations:___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

I have examined the student named on this form and completed the preparticipation physical evaluation. The student/athlete does not

have apparent clinical contraindications to practice and can participate in the sport(s)/activities as outlined on this form. A copy of the physical examination ndings are on record in my oce and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional (print or type): __________________________________________

Date: ____________________________

Address: _________________________________________________________________________

Phone: ___________________________

Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

SHARED EMERGENCY INFORMATION

Allergies: ____________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medications: ________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Other information: ____________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Emergency contacts: ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa- tional purposes with acknowledgment.

3/20/19 4:18 PM

KHSAA Form PPE02

Physical Exam Form

PREPARTICIPATION PHYSICAL EVALUATION

HISTORY FORM

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

Name: ________________________________________________________________ Date of birth: _____________________________

Date of examination: _______________________________ Sport(s): _____________________________________________________

Sex at birth (F, M): _________________

List past and current medical conditions. _____________________________________________________________________________

_______________________________________________________________________________________________________________

Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________

_______________________________________________________________________________________________________________

Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)

 

Not at all

Several days

Over half the days

Nearly every day

Feeling nervous, anxious, or on edge

0

1

2

3

Not being able to stop or control worrying

0

1

2

3

Little interest or pleasure in doing things

0

1

2

3

Feeling down, depressed, or hopeless

0

1

2

3

(A sum of ≥ 3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)

GENERAL QUESTIONS

 

 

(Explain “Yes” answers at the end of this form.

 

 

Circle questions if you don’t know the answer.)

Yes

No

1.Do you have any concerns that you would like to discuss with your provider?

2.Has a provider ever denied or restricted your participation in sports for any reason?

3.Do you have any ongoing medical issues or recent illness?

HEART HEALTH QUESTIONS ABOUT YOU

Yes

No

4.Have you ever passed out or nearly passed out during or after exercise?

5.Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

6. or skip beats (irregular beats) during exercise?

7.Has a doctor ever told you that you have any heart problems?

8.Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.

HEART HEALTH QUESTIONS ABOUT YOU

 

 

(CONTINUED )

Yes

No

9.Do you get light-headed or feel shorter of breath than your friends during exercise?

10.Have you ever had a seizure?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

Yes

No

11.Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?

12.Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic poly- morphic ventricular tachycardia (CPVT)?

13.Has anyone in your family had a pacemaker or

BONE AND JOINT QUESTIONS

Yes No

14.Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?

15.Do you have a bone, muscle, ligament, or joint injury that bothers you?

MEDICAL QUESTIONS

Yes

No

16. breathing during or after exercise?

17.Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

18.Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

19.Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistantStaphylococcus aureus (MRSA)?

20.Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?

21.Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?

22.Have you ever become ill while exercising in the heat?

23.Do you or does someone in your family have sickle cell trait or disease?

24.Have you ever had or do you have any prob- lems with your eyes or vision?

KHSAA Form PPE02

Physical Exam Form

MEDICAL QUESTIONS ( CONTINUED )

Yes

No

25.Do you worry about your weight?

26.Are you trying to or has anyone recommended that you gain or lose weight?

27.Are you on a special diet or do you avoid certain types of foods or food groups?

28.Have you ever had an eating disorder?

FEMALES ONLY

Yes

No

29. Have you ever had a menstrual period?

30. menstrual period?

31.When was your most recent menstrual period?

32.How many periods have you had in the past 12 months?

Explain “Yes” answers here.

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

Signature of student/athlete: ______________________________________________________________________________________________________

Signature of parent or guardian: __________________________________________________________________________________________

Date: ________________________________________________________

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa- tional purposes with acknowledgment.

PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL EXAMINATION FORM

KHSAA Form PPE02 Physical Exam Form

Name: _________________________________________________________________ Date of birth: ____________________________

PHYSICIAN/STATUTORILY AUTHORIZED PROVIDER REMINDERS

1.Consider additional questions on more-sensitive issues.

•Do you feel stressed out or under a lot of pressure?

•Do you ever feel sad, hopeless, depressed, or anxious?

•Do you feel safe at your home or residence?

•Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snu, or dip?

•During the past 30 days, did you use chewing tobacco, snu, or dip?

•Do you drink alcohol or use any other drugs?

•Have you ever taken anabolic steroids or used any other performance-enhancing supplement?

•Have you ever taken any supplements to help you gain or lose weight or improve your performance?

•Do you wear a seat belt, use a helmet, and use condoms?

2.Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).

EXAMINATION

Height:

 

 

 

 

Weight:

 

 

 

 

 

BP:

/

(

/

)

Pulse:

Vision: R 20/

L 20/

Corrected:

Y

N

MEDICAL

 

 

 

 

 

 

 

NORMAL

ABNORMAL FINDINGS

Appearance

•Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,

Eyes, ears, nose, and throat

 

 

•

Pupils equal

 

 

•

Hearing

 

 

 

 

 

Lymph nodes

 

 

Heart **

 

 

• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)

 

 

Lungs

 

 

Abdomen

 

 

Skin

 

 

•

Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or

 

 

 

tinea corporis

 

 

Neurological

 

 

MUSCULOSKELETAL

NORMAL

ABNORMAL FINDINGS

Neck

 

 

 

 

 

Back

 

 

Shoulder and arm

 

 

Elbow and forearm

 

 

 

 

 

Hip and thigh

 

 

Knee

 

 

Leg and ankle

 

 

Foot and toes

 

 

Functional

•Double-leg squat test, single-leg squat test, and box drop or step drop test

**Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination ndings, or a combi- nation of those.

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa- tional purposes with acknowledgment.

ASTHMA AUTHORIZATION FORM 2021-2022

If your daughter has asthma, this form must be completed, signed, and returned to the School Office by Thursday, July 29, 2021.

Kentucky House Bill 353 allows students with asthma to have unobstructed access to asthma medications. The key points of this law are as follows: Public and private school students are allowed to possess and use asthma medications provided that:

•The student has written authorization from a parent and her health care provider to self-administer her asthma medications.

•The written authorization is kept on file at school.

•A parent or guardian must sign a statement acknowledging that the school has no liability from any injury sustained by a student from self-administration of medication.

•Permission for self-administration of medications is effective for the current school year and must be renewed each school year.

If you have any questions regarding this law or any asthma issue, please contact the Director of Education & Advocacy, American Lung Association, at 363-2652.

STUDENT NAME: __________________________________________________________

STUDENT I.D. #________________

(PRINT):

Last

First

Middle

(office use only]

If your daughter has asthma, but does NOT need to self-administer asthma medications at school,

complete and sign only this section of the form and return the signed form to the School Office.

I,_______________________ , parent/guardian of the above named student, verify that my daughter has asthma, but does not need to

carry or self-administer any asthma medications at school, at school-sponsored activities or at any time that she is present on Assumption High School's property.

Signature: _______________________________________________

Date:_____________________________

If your daughter has asthma and must self-administer asthma medications at school,

the parent and the student's health care provider must complete and sign all sections below.

You must return the completed form to the School Office before she will be given permission to self-administer her asthma

medications on school property or at any school-sponsored activity.

I,_________________________, parent/guardian of the above named student, authorize Assumption High School to allow the student

to carry with her and self-administer her asthma medications.

Signature: _______________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student acknowledge that Assumption High School shall incur no

liability as a result of any injury sustained by the student from the self-administration of asthma medications. I agree to indemnify, hold harmless, waive and relinquish any and all claims I may have against Assumption High School and its officers, agents, employees, representatives or volunteers.

Signature: _______________________________________________ Date:_____________________________

If your daughter has asthma and she must self-administer asthma medications at school,

THE STUDENT'S PHYSICIAN MUST COMPLETE THIS SECTION AND SIGN WHERE INDICATED.

I, _________________________________________________, verify that ________________________________________________

Physician/Health Care Provider's Name (please print)

Print Student's Name

has asthma and that the student has been instructed in self-administration of the asthma medications listed below:

Name of Asthma Medication

Prescribed

Time(s), circumstances, any specific instructions under

Prescribed

Dosage

which medication must be administered

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Signature: ______________________________________________

Date: ____________________________

Physician/Health Care Provider

 

FOOD ALLERGY AND ANAPHYLAXIS MEDICATION AUTHORIZATION FORM 2021-2022

If your daughter has a severe food allergy or other allergy that could require the administration of emergency rescue medication,

this form must be completed, signed, and returned to the School Office by Thursday, July 29, 2021.

STUDENT NAME: __________________________________________________________

STUDENT I.D. #________________

(PRINT):

Last

First

Middle

(office use only]

If your daughter has a severe allergy and may need to self-administer anaphylaxis rescue medication

(epinephrine via EpiPen, Twinject, Auvi-Q, etc.) at school,

the parent and the student's health care provider must complete and sign all sections below.

You must return the completed form to the School Office before she will be given permission to self-administer her anaphylaxis

rescue medication on school property or at any school-sponsored activity.

I,_________________________, parent/guardian of the above named student, authorize Assumption High School to allow the student

to carry with her and self-administer her anaphylaxis rescue medication.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student, authorize Assumption High School personnel to

administer anaphylaxis rescue medication to the student in the event the student is unable to self-administer due to the severity of the allergic reaction/anaphylaxis or not having her rescue medication with her.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student acknowledge that Assumption High School shall incur no

liability as a result of any injury sustained by the student from the self-administration of anaphylaxis rescue medication or from Assumption High School personnel administering emergency rescue medication to her. I agree to indemnify, hold harmless, waive and relinquish any and all claims I may have against Assumption High School and its officers, agents, employees, representatives or volunteers.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student hereby give permission for the health care provider

completing and signing this form (below) to verify this information with Assumption High School and consult with AHS staff regarding this information.

Signature:________________________________________ Date:_____________________________

If your daughter has a severe allergy and may need to self-administer anaphylaxis rescue medication at school,

THE STUDENT'S PHYSICIAN MUST COMPLETE THIS SECTION AND SIGN WHERE INDICATED.

I, _________________________________________________, verify that __________________________________________________

Physician/Health Care Provider's Name (please print) _Print Student's Name

is extremely reactive to the following allergens (specify) _____________________________________________________________,

has been instructed in self-administration of her anaphylaxis rescue medication, and may carry it with her to self-administer if necessary.

In the event of mild symptoms (itchy mouth, runny nose, mild rash, etc.)., the student may self-administer or school personnel may administer

Antihistamine Brand or Generic: _________________________________________________ Dose ________________________________

In the event of severe symptoms (shortness of breath, tightness of throat, dizziness, etc.)., the student may self-administer or school personnel may administer

Antihistamine Brand or Generic: _________________________________________________ Dose ________________________________

Signature: ______________________________________________

Date: ____________________________

Physician/Health Care Provider

 
Free Kentucky High School Sports File

Form Features

Fact Name Description
Submission Deadline for Physical Examination Form All physical examinations must be completed after April 2021 for the 2021-2022 school year.
Immunization Compliance The form mandates compliance with KRS 158.035, KRS 214.0, and KAR 2:060, requiring the original certificate of immunization for diphtheria, tetanus, poliomyelitis, measles, rubella, hepatitis A, and meningitis.
Admission Requirement Student's final admission status depends on the submission of both the physical examination form and the required certificate of immunization status.
KHSAA Form Requirement For incoming students planning to participate in athletics, medical history and physical must be reported on the KHSAA form.
Cheerleading and Dance Requirement Physical examination and health forms for cheerleading and dance must be submitted prior to tryouts in mid-April, with current physical examination required by July 29, 2021.
Kentucky Immunization Law Amendments According to 902 KAR 2:060, effective June 21, 2017, there are new age-specific immunization requirements and processes for obtaining a religious exemption.
Homeschooled Students’ Participation Homeschooled children must submit a current immunization certificate to participate in any school activities, including sports.
Parental Permission and Emergency Information The form requires parental consent for medical treatment, emergency contact information, insurance details, and a comprehensive emergency treatment authorization.

Detailed Steps for Using Kentucky High School Sports

Completing the Kentucky High School Sports Physical Examination and Medical Information Form is a crucial step for incoming students who plan to participate in athletics. This form ensures that students meet the health and safety requirements set by the Kentucky High School Athletic Association (KHSAA) and their school. Providing accurate and up-to-date medical information helps to protect students during athletic participation. Below are the detailed steps to properly fill out the form.

  1. Part 1 - Student Information:
    • Enter the student's full legal name, including last, first, and middle names.
    • Fill in the grade for the 2021-2022 school year.
    • Provide the student's home address, including the number, street, city, state, and zip code.
    • Enter the student's date of birth and social security number.
    • List the primary physician and family dentist, including their office phone numbers.
  2. Part 2 - Parental Permission, Consent, and Emergency Information:
    • Read and understand the section regarding the administration of over-the-counter medication and consent for treatment.
    • Parents/guardians must sign and date this section, granting permission for medical treatment and agreeing to the release of medical information.
  3. New Kentucky Immunization Laws Summary:
    • Review the summary of new immunization requirements effective from June 21, 2017.
    • Ensure the student meets all current immunization requirements before submitting the form.
  4. Athletic Participation Consent:
    • Fill in the student-athlete information section, specifying the sport(s) the student plans to participate in.
    • Complete the emergency contact information.
    • Provide required insurance information, ensuring the coverage limit is at least $25,000.
    • Read and acknowledge the sections regarding consent to participate, acknowledgment of risk, eligibility rules, liability waiver, consent, and release.
    • The student and parent/guardian must sign and date this section.
  5. Pre-participation Physical Evaluation (Medical Eligibility Form):
    • A healthcare professional must complete this section after examining the student.
    • Indicate whether the student is medically eligible for all sports/activities without restriction, with recommendations, for certain sports/activities, or not medically eligible.
    • Include any recommendations for further evaluation or treatment.
    • The healthcare professional must provide their name, address, phone number, and signature, along with the date of examination.
  6. Shared Emergency Information:
    • List any allergies, medications, and other important health information that the school should be aware of in case of an emergency.
    • Provide emergency contact information, ensuring it is accurate and up-to-date.

After completing all sections of the form, review it for accuracy and completeness. Remember, the form must be submitted before the student participates in any athletics. This includes tryouts, practices, or competitions. Submitting this form on time and accurately filled out ensures that the student's health and safety are prioritized, allowing for a positive and safe athletic experience.

Obtain Clarifications on Kentucky High School Sports

  1. Who is required to submit the Kentucky High School Sports Physical Examination Form?

    All incoming students who plan to participate in athletics must submit a physical examination form. This requirement ensures that students are medically cleared to safely participate in sports activities according to Kentucky High School Athletic Association (KHSAA) regulations and school policies.

  2. When should the physical examination be completed?

    The physical examination must be completed after April 1, 2021, for the 2021-2022 school year. Physicals conducted before April 2021 will not be accepted. This ensures that the medical evaluation is current and provides an accurate assessment of the student’s ability to participate in sports activities safely.

  3. What are the immunization requirements?

    Students must submit the original certificate of immunization against diphtheria, tetanus, poliomyelitis, measles, rubella, hepatitis A, and meningitis. These immunizations are required to protect the health and safety of all students participating in school activities. The submitted documentation must comply with Kentucky Revised Statutes (KRS) and Kentucky Administrative Regulations (KAR) governing student health requirements.

  4. Are there any specific requirements for students trying out for cheerleading and dance?

    Yes, students planning to try out for cheerleading and dance must have their physical examination completed and health forms submitted prior to mid-April tryouts. While a physical conducted between April 2020 and March 2021 satisfies the KHSAA requirement, a current physical examination conducted between April and July 2021 is necessary by July 29, 2021, to meet the school's requirement.

  5. Can out-of-state immunization certificates be accepted?

    Yes, out-of-state immunization certificates may be accepted if they meet the same age-specific requirements as outlined by the Kentucky Administrative Regulation. This ensures that students from other states meet Kentucky's health safety standards for participation in sports and other school activities.

  6. What happens if a student's immunization certificate is found to be invalid or expired?

    If a student’s immunization certificate is invalid or has expired, the parent or guardian is required to provide an updated and current certificate to the school within 14 days from when the certificate was found to be invalid. This rule helps maintain a healthy and safe environment for all students participating in school and sports activities.

Common mistakes

Completing the Kentucky High School Sports form accurately is essential for ensuring incoming students can participate in athletic programs. Unfortunately, mistakes can be made that delay or complicate this process. Here are five common errors:

  1. Failing to Acknowledge the Physical Examination Date Requirement
  2. Omitting the Certificate of Immunization
  3. Incorrect or Incomplete Student Information
  4. Parental Permission Sections Left Blank
  5. Insurance Information Errors

The first mistake often encountered involves overlooking the requirement that physical examinations must be conducted after a specific date. In this situation, it's critical that physicals are completed after April 2021 to be accepted for the 2021-2022 school year. Students and parents sometimes miss this detail, submitting outdated forms that are then rejected.

The second common error is not submitting the required certificate of immunization against diseases like diphtheria, tetanus, and meningitis, as mandated by Kentucky law. This oversight can prevent the student's final admission from being approved. Ensuring all required immunizations are up to date and properly documented is crucial.

An often seen third mistake is submitting forms with incorrect or incomplete student information, such as the student's full legal name, home address, or date of birth. Accurate and complete student information is foundational for the school's records and for compliance with state regulations.

Another recurrent issue involves the sections requiring parental permission. These parts of the form are crucial, as they allow the student to receive medical treatment if necessary during school hours or athletic participation. Leaving these sections blank can cause unnecessary delays in processing the paperwork.

Last, families sometimes enter incorrect insurance information or fail to provide these details altogether. Since all students participating in athletics are required to have medical insurance with coverage limits of at least $25,000, incorrect or missing insurance details can render a student ineligible to participate.

By avoiding these common mistakes, students and parents can streamline the process of completing the Kentucky High School Sports form, ensuring a smoother transition into athletic participation.

Documents used along the form

Alongside the Kentucky High School Sports Form, a comprehensive approach to student athlete registration often includes various additional documents. These documents ensure a safe, compliant, and supportive environment for student participation in high school athletic programs. The forms range from emergency contact information to consent forms, each playing a crucial role in fostering a secure athletic environment. Below is a list of other forms and documents frequently paired with the Kentucky High School Sports Form, detailing each one’s purpose.

  • Emergency Medical Authorization Form: This document is essential for gathering emergency contact information and medical authorization in case a student requires urgent medical care during school activities or sports events. It enables immediate action in emergencies, providing peace of mind for parents and guardians.
  • Concussion Acknowledgment Form: Acknowledges that the student and their parent or guardian have received information about the risks of concussions and head injuries. This form serves as a crucial educational tool and consent form, reflecting awareness and understanding of concussion protocols.
  • Athletic Code of Conduct: Outlines the expectations and standards for student behavior in athletic programs. By signing this, students agree to adhere to the code of conduct, emphasizing commitment, sportsmanship, and respect throughout their participation.
  • Proof of Insurance: A document or card from the student’s health insurance company that verifies coverage, ensuring that the student has medical insurance as required for participation in sports activities. Proof of insurance is vital to cover any potential medical treatments that may arise from sports-related injuries.
  • Academic Eligibility Form: Confirms that the student meets the academic standards set forth by the educational institution and athletic association, maintaining a balance between academic responsibilities and athletic involvement. This form is crucial for promoting scholastic achievement alongside athletic participation.
  • Travel Consent Form: This form is used when sports teams travel for away games or events, requiring parental consent for student transportation and participation. It addresses details such as travel arrangements, accommodations, and emergency protocols during trips.

Together, these documents work in harmony with the Kentucky High School Sports Form to ensure a comprehensive preparatory process for student-athletes. Their collective purpose is to safeguard the well-being of the participants, uphold academic and athletic standards, and ensure clear communication and understanding among students, parents, and school officials. By meticulously gathering and reviewing these documents, schools lay the groundwork for a successful and rewarding athletic season for all involved.

Similar forms

The General Medical History and Physical Examination Form for school admission closely resembles the Kentucky High School Sports form, as both are crucial for assessing a student’s health status and physical fitness before participating in school activities. Both forms require detailed personal information, a comprehensive medical history, and a physical examination documented by a healthcare professional. These documents ensure that students are physically capable of engaging in academic and extracurricular activities, safeguarding their well-being within the school environment.

College Athletic Participation Health Forms share a significant similarity with the Kentucky High School Sports form, focusing on evaluating athletes' health and physical condition before they join college sports teams. Like the high school form, they often necessitate a detailed medical history, immunization records, and a recent physical examination. These measures are in place to minimize health risks during athletic participation and ensure a safe and competitive environment for all student-athletes at the collegiate level.

The Pre-Employment Physical Examination Form used by many employers mirrors aspects of the Kentucky High School Sports form by requiring health assessments before undertaking a new job. Both documents ensure individuals are physically and medically fit for their intended roles – whether it be for sports or professional employment. This process aids in preventing workplace accidents and ensures that employees can safely meet the physical demands of their positions.

Summer Camp Health and Medical Forms also resemble the high school sports form by requiring a complete health history and a physical examination for campers. These forms ensure the safety and well-being of participants by identifying any health issues that may require attention or accommodation during camp activities. Like the sports form, they help staff prepare for and manage potential health-related issues, providing a safer environment for all campers.

Travel Health Forms needed for international travel, particularly those requiring medical clearance, bear similarities to the Kentucky High School Sports form. Travelers, like student athletes, must often provide detailed health information and evidence of required immunizations. This ensures they are fit to travel and have taken necessary precautions against diseases, analogous to preventing health risks in school sports.

The Vaccine Exemption Form for school and daycare exemptions shares elements with the sports form regarding immunization records, despite serving a different purpose. Both forms interact with public health policies, albeit from different angles—the Kentucky High School Sports form by ensuring compliance with vaccination requirements for participation in sports, and the exemption form by documenting legal exemptions from these requirements.

Driver's License Health Assessment Forms, required in some jurisdictions for individuals with medical conditions that may affect driving abilities, also parallel the Kentucky High School Sports form. Both are preventive measures, with the former aiming to ensure safe driving conditions and the latter seeking to prevent health-related incidents in sports. These forms require a health professional's assessment and acknowledgment of an individual's physical and medical capability to undertake certain activities safely.

Boy Scouts of America (BSA) Annual Health and Medical Record Form, required for participation in scouting events and activities, mirrors the comprehensive health review and physical examination of the Kentucky High School Sports form. Both are designed to safeguard participants during physically demanding activities by ensuring they are medically and physically prepared for the challenges they will face.

The Military Entrance Processing Station (MEPS) Medical Pre-Screen Form, required for individuals seeking to join the military, shares similarities with the sports form in its thorough evaluation of an individual’s medical history and physical fitness. This process is vital in both contexts to ensure that candidates can safely meet the physical demands placed upon them, whether in competitive sports or military service.

Finally, the Workforce Safety and Insurance Worker's Compensation Form, required for employees who sustain injuries on the job, while serving a different primary function, does relate to the high school sports form in terms of medical documentation. Both forms require detailed medical information to process health-related claims, whether it's for ensuring a student’s ability to participate in sports or an employee's claim for injury compensation.

Dos and Don'ts

When filling out the Kentucky High School Sports form, it's important to be thorough and accurate. Here are some do's and don'ts to guide you through the process:

Do's:

  1. Ensure the physical examination is completed after April 2021, as physicals conducted prior to this date will not be accepted.
  2. Accurately fill in the student's full legal name, including the last, first, and middle name, to avoid any confusion or delays.
  3. Provide up-to-date immunization records, including the new age-specific and booster dose requirements, to comply with Kentucky's immunization laws.
  4. Include a reliable emergency contact with current phone numbers to ensure prompt communication in case of an emergency.
  5. Verify that the insurance information is correct and provides coverage of at least $25,000 as required by KHSAA Bylaw 12.
  6. Read and understand the consent information, acknowledgment of risk, and liability waiver sections before signing.
  7. Ensure that both the student's and parent/guardian's signatures are on the form where required.
  8. List any health problems, concerns, allergies, and medications the student is currently using in the specified section.
  9. Check that the form is filled out in accordance with the stipulated deadlines, especially for students trying out for cheerleading and dance.
  10. Keep a copy of the completed form for your records and future reference.

Don'ts:

  • Don't ignore the requirement for cheerleaders and dancers to have their physical examination and health forms submitted before tryouts in mid-April.
  • Don't fill in the form without consulting the official KHSAA guidelines and your school's specific requirements.
  • Don't forget to provide the primary physician's and family dentist's contact information for emergency situations.
  • Don't overlook the section requiring parental permission for over-the-counter medication administration.
  • Don't submit outdated immunization records or fail to comply with the new Kentucky Immunization Laws effective June 21, 2017.
  • Don't leave out any sections of the form blank, especially the student/athlete information and emergency treatment sections.
  • Don't underestimate the importance of disclosing any pre-existing health conditions or allergies that could affect participation.
  • Don't fail to provide consent for emergency treatment and understand the release of information policy detailed in the form.
  • Don't ignore the shared emergency information section, which is crucial for the safety and well-being of the student.
  • Don't forget to review all the information for accuracy before submission to avoid delays in the student's participation in athletics.

Misconceptions

Many people often have misconceptions about the Kentucky High School Sports form, leading to confusion and misinformation. Here are ten common misunderstandings and the facts to set them straight.

  • Physicals can be completed at any time before the school year starts: Physicals must be conducted after April 1 for the upcoming school year to be accepted, ensuring they are current and comprehensive for the sports season.
  • All students must submit the same health forms: Incoming students must submit a specific medical information and physical examination form, along with their immunization records, to participate in athletics. The requirements might vary for returning students or based on the specific sport.
  • Immunization records are not important for sports eligibility: A current certificate of immunization is crucial and must be on file with the school as part of the health requirements for all incoming students wishing to participate in sports.
  • Cheerleading and dance are not considered sports: Students trying out for cheerleading and dance must meet the same physical examination and health form submission requirements as other sports, emphasizing the school's regard for these activities as competitive sports.
  • Outdated forms are acceptable if personal information hasn't changed: All students must use the latest forms provided for the current school year, as they may include updates in compliance with new health and safety regulations.
  • Students transferring from out-of-state schools don't need to comply with the Kentucky requirements: Out-of-state immunization certificates can be accepted but must meet Kentucky's specific age-appropriate requirements in order to participate in athletics.
  • Homeschooled students are exempt from submitting health forms: Homeschooled students are also required to submit a current immunization certificate if they wish to participate in any public or private school sports or activities.
  • Insurance information is optional for athlete participation: Before participating in any sport, students must provide proof of medical insurance with a minimum coverage limit, ensuring that they are protected in the case of sports-related injuries.
  • Parental permission is not needed for over-the-counter medication administration: Parent or guardian signatures are mandatory to administer any medication, including over-the-counter drugs, highlighting the importance of parental consent in medical decisions.
  • The risk acknowledgment section is just a formality and doesn't need careful consideration: This section is crucial as it informs the student and parent/legal guardian about the inherent risks of sports participation, including severe injuries, and the importance of following coaching instructions for safety. It also involves legal agreements, such as liability waivers, making it essential reading material.

Understanding these points ensures students, parents, and guardians are fully informed about the requirements and implications of submitting the Kentucky High School Sports form, facilitating a smoother process for sports participation.

Key takeaways

Filling out and utilizing the Kentucky High School Sports form is an essential process for incoming students who wish to participate in athletics. Here are nine key takeaways to consider:

  1. Physical examinations are mandatory for all incoming students planning to participate in athletics and must be documented on the KHSAA Form. Physicals conducted prior to April of the current year will not be accepted.
  2. Students interested in cheerleading and dance must have their physical examination completed and health forms submitted prior to mid-April tryouts. Physicals conducted between April of the previous year and March of the current year are valid for KHSAA requirements, but a current examination is necessary by July 29 to meet school requirements.
  3. It’s essential to submit the original certificate of immunization against specific diseases as required by Kentucky law. Without it, the student’s final admission to participate in athletics is incomplete.
  4. New immunization laws effective from June 21, 2017, have introduced additional requirements, including one new age-specific immunization and a booster dose requirement for students.
  5. Students, including those who are homeschooled but wish to participate in any school activities, must submit a current immunization certificate.
  6. All vaccines administered must be recorded on the Commonwealth of Kentucky Certificate of Immunization Status, and this document doesn’t require a signature if printed from the Kentucky Immunization Registry (KYIR).
  7. Parental or guardian consent is necessary for a student to receive medical treatment or medication. This includes over-the-counter medications like Tylenol or Advil during school events or athletic participation.
  8. Before participating in any sports, students must have medical insurance coverage with a minimum limit of $25,000. This insurance is a prerequisite for participation in practice or contests in any sport.
  9. Completing the consent and release sections of the form acknowledges the inherent risks involved in athletic participation, including the potential for severe injuries. It also includes permission for necessary medical treatment in case of injury or illness during participation.

These takeaways underscore the importance of thorough preparation and adherence to regulations for students wishing to engage in high school sports within Kentucky. By following these guidelines, students and parents can ensure a smooth process in meeting all requirements for athletic participation.

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