The Kentucky High School Sports form is a critical document for incoming students planning to participate in athletics, detailing the necessary medical information, physical examination records, and immunization status required for eligibility. This comprehensive form ensures the safety and readiness of student-athletes in line with Kentucky state laws and Kentucky High School Athletic Association (KHSAA) regulations. To ensure a smooth start to your athletic journey, make sure to fill out and submit this form by clicking the button below.
The Kentucky High School Sports form, officially known as the Medical Information and Physical Examination Form for Incoming Students 2021-2022, serves a critical function in ensuring the health and safety of students participating in athletic activities. State laws and regulations require every incoming student to submit this form, complete with a physical examination and immunization status, to partake in high school sports. Specifically, the form adheres to statutes such as KRS 158.035, KRS 214.0, and KAR 2:060, mandating the submission of an original certificate of immunization against several diseases. This documentation is a prerequisite for a student’s final admission and eligibility to engage in athletics, according to the Kentucky High School Athletic Association (KHSAA) regulations. Notably, the form outlines requirements for cheerleading and dance participants, emphasizing the necessity of physical examinations before tryouts. Moreover, parental permission for both medical treatment and participation in sports, details of the student’s medical insurance coverage, and acknowledgment of the risks associated with sports participation are integral components of the form. Additionally, it serves as a medical eligibility certificate, specifying any restrictions or recommendations for a student's participation in sports activities. This comprehensive approach, incorporating both medical and parental consent aspects, underscores the commitment to student athletes' well-being in Kentucky’s educational institutions.
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 ____________________________________
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 –
School Name
(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)
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
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
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
2
3
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
(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
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.
(CONTINUED )
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
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
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?
MEDICAL QUESTIONS ( CONTINUED )
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
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: ________________________________________________________
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
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.
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.
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
Dosage
which medication must be administered
______________________________________________________________________________________________________________
Signature: ______________________________________________
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.
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,
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.
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.
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.
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.
If your daughter has a severe allergy and may need to self-administer anaphylaxis rescue medication at school,
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
Filling out the Kentucky High School Sports Form is a critical step for incoming students who plan to participate in athletics. This form is not only a requirement for those wishing to join cheerleading and dance teams but also serves as a necessary document for all students aspiring to engage in any sports activities. Making sure each section is accurately completed and submitted on time will ensure the student's eligibility for participation and adherence to both Kentucky state regulations and the Kentucky High School Athletic Association (KHSAA) guidelines.
Once all parts of the form have been carefully completed, ensure to keep a copy for personal records before submitting the original documents to the appropriate school officials. Timely submission is essential for the processing of this form and for maintaining the student’s eligibility for high school sports participation. It is advisable to check with the school’s athletic department for any further requirements or clarification on the process.
Who needs to submit the Medical Information and Physical Examination Form?
All incoming students who plan to enroll in the 2021-2022 school year must submit this form. This requirement applies to students who wish to participate in athletics as well. The physical examination must have been completed after April 2021 to be accepted.
What are the immunization requirements for school admission?
Students must submit the original certificate of immunization against diphtheria, tetanus, poliomyelitis, measles, rubella, hepatitis A, and meningitis. Final admission status depends on submission of both the physical examination form and the certificate of immunization status.
Are there specific requirements for students interested in cheerleading and dance?
Yes, students trying out for cheerleading and dance must complete their physical examination and submit health forms prior to mid-April tryouts. For these activities, a physical conducted between April 2020 and March 2021 meets the KHSAA requirement. However, a current physical examination, conducted between April-July 2021, is required by July 29, 2021, to meet the school's requirements.
What happens if the student's certificate of immunization is found to be invalid or expired?
If a student's certificate of immunization is found to be invalid, parents or guardians must provide an updated and current certificate to the school within fourteen (14) days from the discovery of the invalid certificate. For daycare centers, certified family child care homes, or other licensed facilities, the updated certificate must be provided within thirty (30) days. Failure to comply may result in the student being unable to attend school or participate in school activities until the updated certificate is submitted.
When filling out the Kentucky High School Sports Form, individuals often encounter several common mistakes that can potentially delay or complicate the admission and eligibility process for student athletes. Capturing accurate and complete information on this form is vital for ensuring student athletes meet all health and regulatory requirements to participate in sports. Here, we outline ten frequently observed errors and provide guidance on how to avoid them.
To navigate these processes successfully, it’s important for parents, guardians, and student athletes to thoroughly review all parts of the Kentucky High School Sports Form, ensure all sections are completed accurately, and comply with all health and regulation requirements. Taking these steps helps in ensuring a smooth and compliant process that safeguards the health and eligibility of student athletes to participate in high school sports.
When engaging in high school sports in Kentucky, ensuring that the necessary paperwork and forms are completed and submitted is crucial. The Kentucky High School Sports form, a vital document for any student-athlete's participation, is just the beginning. Other forms and documents often accompany this main form to ensure a comprehensive understanding of the student's health, eligibility, and acknowledgment of the risks involved in sports participation. Below are four such forms and documents that are commonly required alongside the Kentucky High School Sports Form.
Together with the Kentucky High School Sports form, these documents create a framework that supports safe and responsible participation in high school athletics. They ensure that students, parents, schools, and sporting organizations are on the same page regarding healthcare, sportsmanship, and legal responsibilities. Ensuring each of these documents is properly completed and submitted helps pave the way for a positive and safe sports experience for all involved.
The Kentucky High School Sports form shares similarities with various other standard documentation required in educational and athletic settings, each serving to ensure the safety, health, and compliance with regulations for student participation. These similar documents range from medical clearances to consent forms, each playing a crucial role in the student's eligibility and preparedness for school activities.
Comparable to the Kentucky High School Sports form is the Preparticipation Physical Evaluation (PPE). The PPE is a comprehensive assessment aimed at identifying any health conditions that could make athletic participation unsafe for the student. Like the form for Kentucky high school athletes, the PPE includes a medical history review and a physical examination, concluding with a healthcare professional's determination of the student's ability to participate in sports without restrictions.
Another document akin to the Kentucky form is the Immunization Record requirement found in many schools. These records ensure that students have received vaccinations against diseases such as measles, mumps, and tetanus, mirroring Kentucky’s requirement for immunization against specific illnesses such as diphtheria and hepatitis A. The objective is to protect the health of the student population by preventing the outbreak of vaccine-preventable diseases.
The Emergency Medical Authorization form is also similar in purpose to parts of the Kentucky High Sports form. It grants school officials the authority to seek medical treatment for a student in case of an emergency when parents or guardians cannot be reached. The Kentucky form's segment requesting parental consent for emergency treatment and the provision of important health information shares this goal, prioritizing student safety in critical situations.
Medication Administration Consent forms found in schools nationwide resemble a section of the Kentucky form as well. These forms allow school personnel to administer over-the-counter or prescription medication to students during school hours. The necessity for parental consent and clear instructions is a common thread with the Kentucky form’s requirement for parent or guardian signatures to authorize medical treatment, including medication administration.
Athletic Eligibility Forms, required by many high school athletic associations, align with the Kentucky form's role in confirming a student's eligibility to participate in sports. These forms often include sections on academic standing, adherence to behavioral standards, and physical fitness for sports, emphasizing the holistic criteria for student athletes’ participation in school sports programs.
The Consent and Release from Liability Agreement is another document sharing elements with the Kentucky High School Sports form. This agreement, often signed by students and parents, outlines the risks associated with participation in athletic activities and absolves the school of liability for injuries sustained during participation. The Kentucky form includes similar acknowledgments and releases, making athletes and guardians aware of the risks and the school’s policies on liability.
Finally, the Annual Health and Medical Update forms required by many schools at the beginning of each academic year share goals with the Kentucky High School Sports form. These updates ensure that schools have the most current health information about their students, including new diagnoses, allergies, or changes in medication that can impact school attendance or participation in sports and activities. This parallels the Kentucky form’s use as a tool for gathering up-to-date health information to support student safety and well-being both in and out of the athletic arena.
When completing the Kentucky High School Sports form, ensuring that the process is handled accurately and respectfully is pivotal for both the safety and eligibility of the student athlete. Attention to detail when filling out medical and consent information will not only protect the student but also ensure compliance with Kentucky High School Athletic Association (KHSAA) regulations and state laws.
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By attentively following these guidelines, parents, guardians, and students can ensure a smooth process for high school sports participation eligibility in Kentucky, safeguarding the student’s health and athletic opportunities.
When it comes to the Kentucky High School Sports physical examination and immunization form, there are several common misconceptions that can create confusion for students, parents, and guardians. Here are six of the most common misunderstandings, clarified to help ensure the process is as smooth as possible.
Understanding these key points can help students and families navigate the process of preparing for participation in school sports programs more efficiently, by dispelling common myths and focusing on the actual requirements as outlined in the physical examination and immunization form.
The Kentucky High School Sports form is essential for all incoming students who plan to engage in athletic activities. Here are eight key takeaways regarding the form's completion and usage:
This comprehensive approach ensures that all student athletes are physically fit, properly immunized, and have consent for medical treatment, facilitating a safe environment for high school sports activities.
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