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Fill Out Your Kentucky High School Sports Form

The Kentucky High School Sports form is a vital document required for all incoming students who plan to participate in athletics. This form ensures that students have undergone a physical examination and have received necessary immunizations, confirming their fitness to engage in sports activities. Completing this form accurately is essential for students to be eligible to join athletic teams, so it is important to fulfill all requirements by the specified deadlines.

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Fill Out Your Kentucky High School Sports Form

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The Kentucky High School Sports form is an essential document that ensures the health and safety of incoming athletes. This form requires all new students to submit a physical examination report alongside vaccination records, maintaining compliance with state laws and regulations. The health examination must have been conducted on or after April 2021, with prior examinations being deemed invalid. Parents are responsible for ensuring their child meets immunization requirements against several diseases, including polio, measles, and meningitis, and for providing a signed permission slip for administering over-the-counter medications during school hours or events. Furthermore, if a medical issue arises, this form allows school staff to seek necessary medical attention for the student athlete. It encompasses sections for basic student information, parental consent for treatment, and acknowledgment of inherent risks associated with athletic participation. The student's insurance details must also be provided to guarantee adequate coverage. This form ultimately underscores the significance of health management in school athletics and serves as a safeguard for both students and faculty involved in sports programs.

Kentucky High School Sports Example

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

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)?

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

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

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

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

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

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

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: ________________________________________________________

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.

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

Get Kentucky High School Sports PDF Form

Form Characteristics

Fact Name	Description
Physical Examination Requirement	All incoming students must submit a physical examination form, with physicals completed prior to April 2021 not being accepted.
Immunization Certificate	Students must provide an original certificate of immunization against specified diseases as per KRS 158.035 and KRS 214.0.
Final Admission Status	A student's admission is incomplete until both the physical examination and immunization certificate have been submitted.
KHSAA Compliance	The student's medical history and physical must be reported on the KHSAA form as required by athletics regulations.
Immunization Law	New immunization laws effective June 21, 2017, mandate specific vaccination schedules for children enrolled in schools as per 902 KAR 2:060.
Insurance Requirement	Students must have medical insurance providing coverage of at least $25,000 prior to participating in any sports practices or contests.
Emergency Treatment Consent	Parents must consent to allow their child to receive medical treatment during school or athletic events as part of the required forms.

Guidelines on Utilizing Kentucky High School Sports

Completing the Kentucky High School Sports form requires careful attention to detail. It is essential to provide accurate information for each section to ensure your student's participation in sports activities. Gather the necessary information before you begin to facilitate a smoother process.

Student Information: Write the student's full legal name, grade, address, date of birth, and Social Security number in the designated fields.
Primary Physician and Dentist: Include the names and office phone numbers for both the primary physician and the family dentist.
Parental Permission: Sign the section that grants permission for medical treatment and administration of over-the-counter medications.
Insurance Information: Provide details of the medical insurance carrier, policy number, and group number. Ensure the coverage meets or exceeds the $25,000 requirement.
Emergency Contact: List an emergency contact, including their relationship to the student, and include a daytime phone number and cell phone number.
Consent and Release: Both the student and a parent or guardian must sign to acknowledge understanding of the risks involved in sports and consent to medical treatment as necessary.
Preparticipation Physical Evaluation: Ensure a healthcare professional completes this section to evaluate the student’s medical eligibility for sports participation.
Shared Emergency Information: Fill in any known allergies, current medications, and any additional relevant information about the student's health.

After completing each section, verify that all details are correct and legible. Submit the form and required immunization documents to complete the student's enrollment for sports activities. Prompt submission will help to confirm eligibility for participation in the upcoming athletic season.

What You Should Know About This Form

What documents do I need to submit to participate in high school sports in Kentucky?

To participate in high school sports in Kentucky, every incoming student must submit a completed physical examination form and a current certificate of immunization. It is essential that the physical examination form is dated after April 2021, as earlier physicals will not be accepted. The immunization certificate must include vaccinations for diphtheria, tetanus, poliomyelitis, measles, rubella, hepatitis A, and meningitis. Students must ensure that these documents are submitted to the school before final admission status is granted.

What is the deadline for submitting the physical examination form?

The deadline for submitting the physical examination form is specific to the school's requirements. For students trying out for cheerleading and dance, the physical examination must be completed and submitted prior to tryouts, which take place in mid-April. All other incoming students must provide a current physical examination, conducted between April and July 2021, by July 29, 2021, to comply with school participation requirements.

What if my child has allergies or health concerns?

If your child has allergies or other health concerns, it is important to document this information on the pre-participation physical evaluation form. This section allows parents to disclose any significant medical conditions, prescribed medications, and allergies that might affect the student's participation in sports. Emergency contacts should also be listed to ensure swift communication in case of an incident.

Is insurance required for student-athletes?

Yes, having medical insurance is a requirement for student-athletes. Specifically, students must have coverage with a minimum limit of $25,000 before they can participate in practices or contests. If the coverage is provided through the school, it is advisable to contact the principal or athletic director for further clarification on how to proceed with claims.

What should parents know about permission for medical treatment?

Parents must provide permission for their child to receive necessary medical treatment during school hours, including injuries or illnesses occurring during school events or athletic practices. By signing the relevant forms, parents grant authority for school staff, nurses, or coaches to act in the best interest of their child’s health. This encompasses permission for transportation to medical facilities in emergencies as well as releasing medical information to appropriate healthcare providers or school officials.

Common mistakes

Filling out the Kentucky High School Sports form can be a straightforward process, but mistakes can occur. One common error is the submission of an outdated physical examination. The form clearly states that only physicals conducted after April 2021 will be accepted. If a parent's or student's physical examination is older than this date, it will not meet the requirements.

Another mistake involves incomplete medical history information. The form requires detailed medical history, including any allergies or conditions. Omitting any relevant details can delay the approval process. This information is crucial for ensuring the safety of the student during athletic activities.

Failure to secure parent or guardian signatures in the appropriate sections is also a frequent error. The form mandates that both the student and a parent or guardian must sign it to grant permission for medical treatment and participation in athletics. Without these signatures, the student may not be allowed to participate.

Moreover, some families may overlook the immunization requirements outlined in the form. A current immunization certificate is necessary, and the specifics of required vaccinations need to be strictly followed. Not attaching this documentation can lead to incomplete admission status, preventing participation in school activities.

Lastly, individuals often make mistakes by not providing necessary emergency contact details. Emergency contact information is critical in case of injuries or health complications during activities. Not specifying an emergency contact could hinder medical professionals from making quick decisions in critical situations.

Documents used along the form

The Kentucky High School Sports form is an essential document for incoming students wishing to participate in athletics. Along with this form, several other important documents are often required to ensure student safety and compliance with regulations. The following is a comprehensive list of these forms and documents, detailing their significance in the context of school athletics.

Immunization Certificate: This document confirms that students have received the required vaccinations, such as those for diphtheria, tetanus, and meningitis. Schools maintain this record to ensure the health and safety of all students.
Emergency Contact Form: Parents or guardians must complete this form to provide important contact information in case of an emergency. This allows school officials to reach out quickly if the student requires immediate attention during a school event.
Parental Consent Form: Often required for extracurricular activities, this document grants consent for the student to participate in sports. It also allows school staff to administer medical treatment or medication if necessary.
Physical Examination Form: A current physical is mandatory for athletic participation. This form must be completed by a certified health care provider, ensuring that students are medically fit to engage in sports activities.
Sports Medicine Release Form: This document gives permission for medical professionals to share a student's health information with relevant school personnel. It helps in making informed decisions regarding the student’s health and participation in sports.
Accident or Injury Report Form: In the event of an injury during athletic activities, this form must be completed to document the incident. It is crucial for tracking injuries and facilitating appropriate medical responses.
Insurance Verification Form: Students participating in sports must provide proof of adequate insurance coverage. This ensures that they can receive necessary medical care without financial complications in case of an injury.
Concussion Awareness Form: Schools require this document to ensure that parents and students understand the risks associated with concussions. It emphasizes the importance of recognizing symptoms and taking appropriate actions.
Participant Agreement Form: This form outlines the expectations for students participating in athletics, including conduct, commitment, and responsibilities. It ensures that both students and parents understand the requirements of the program.

These documents are vital in facilitating a safe and organized athletic environment within Kentucky high schools. They not only protect the wellbeing of students but also ensure that educational institutions adhere to state regulations. By submitting the necessary forms, parents and students can help create an environment conducive to both competitive sports and personal growth.

Similar forms

Immunization Certificate: Like the Kentucky High School Sports form, this certificate confirms a student's vaccinations. Schools require it for enrollment, ensuring students are protected against common illnesses.
Medical History Form: This document captures a student's past health issues, similar to how the sports form gathers medical history before participation in athletics.
Emergency Contact Form: This form is similar in purpose, as it includes vital contact information for parents or guardians in the event of student injuries or emergencies.
Parental Consent Form: Just like the High School Sports form, this document requires a parent’s signature to give permission for their child to engage in specific activities, stressing the need for oversight in both cases.
Physical Exam Form: Both documents require a physical examination to ensure students are healthy enough for participation in school-related activities.
Insurance Information Form: This form collects information on a student’s health insurance, paralleling the insurance requirements stated in the Kentucky High School Sports form for athletic participation.
Student Health Information Form: This document gathers health-related information about students, similar to the data requested in the sports form regarding allergies and medications.

Dos and Don'ts

When filling out the Kentucky High School Sports form, it's essential to keep in mind both the dos and don'ts to ensure a smooth process.

Do provide accurate and complete information regarding your student’s medical history.
Do ensure that the physical examination form is filled out by a qualified healthcare professional.
Do double-check submission dates to ensure all required documents are submitted on time.
Do obtain necessary parental signatures for medical treatment consent.
Do keep copies of all submitted forms for your records.

Don't submit any physical examinations that occurred before April 2021, as they will not be accepted.
Don't leave any sections of the form blank; incomplete forms can delay the process.
Don't forget to check for any additional requirements specific to your child’s school.
Don't overlook the importance of current immunization records; these are mandatory.
Don't wait until the last minute to gather required information; early preparation is key.

Misconceptions

Misconceptions can lead to confusion about the Kentucky High School Sports form. Here are five common misconceptions, along with clarifications:

Physical exams from previous years are valid. Many believe that an older physical exam can be used. However, physicals completed prior to April 2021 are not accepted, and a current physical examination is essential.
Only athletes need to submit immunization records. Some think that only students participating in sports must provide immunization records. In fact, every incoming student, regardless of athletic participation, must submit a current certificate of immunization.
A single form covers all medical needs. There is a misconception that one form is enough to address all medical requirements. Each student must complete separate forms for parental permission, physical examination, and emergency treatment. All of these forms are essential.
Parents can withhold medical information. Some parents assume they can choose not to disclose their child’s medical history. This is incorrect. It's crucial to provide a complete medical history to ensure the safety and well-being of the student during sports participation.
Emergency contacts are optional. Some believe that including emergency contact information is not mandatory. This is a mistake. Providing emergency contact details is necessary for swift action in case of an injury or emergency during school events or practices.

Key takeaways

Every incoming student must complete a physical examination form, as prior physicals from April 2021 and earlier will not be accepted.
Students must also submit a certificate of immunization, which includes vaccinations for diphtheria, tetanus, polio, measles, rubella, hepatitis A, and meningitis.
The student's admission status will remain incomplete until both the physical examination form and immunization certificate are submitted.
For cheerleading and dance, physical examinations need to be completed and health forms submitted before tryouts in mid-April.
The physical examination must be current, conducted between April and July 2021, to meet school requirements.
Insurance coverage of at least $25,000 is mandatory for athletic participation.
Parents/guardians must provide consent for medical treatment, medication administration, and emergency transportation for their child.

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