Initial Physical Exam Form (Page 2 of 3) in pdf

Health Exam Form B, Updated September, 2011

Participant & Parental Disclosure and Consent Document

PLEASE NOTE: It is the responsibility of the parent/guardian to notify the school if there are any unique

individual problems that are not listed on Health Examination Form A or B.

____________________________________________ ___________________________________________

Name of Student

School

Is the student covered by health/accident insurance?

Yes

____________________________________________________

Name of health insurance provider

___________________________________________________________

If no insurance provider, explain

____________________________________________________________________________________

CONSENT FORM

Parent or Guardian Statement of Permission, Approval, and Acknowledgement

By signing below, I the parent or legal guardian of the above named student do:

•

Hereby consent to the above named student participating in the interscholastic athletic program at the

school listed above. This consent includes travel to and from athletic contests and practice sessions.

•

Further consent to treatment deemed necessary by health care providers designated by school

authorities for any illness or injury resulting from his/her athletic participation.

•

Recognize that a risk of possible injury is inherent in all sports participation. I further realize that

potential injuries may be severe in nature including such conditions as: fractures, brain injuries,

paralysis or even death.

•

Acknowledge and give consent that a copy of this form will remain in the student’s school. I agree that

if my student’s health changes and would alter this evaluation, I will notify the school as soon as

possible but within no longer than 10 days.

•

Hereby acknowledge having received education including receiving written information regarding the

signs, symptoms, and risks of sport related concussion. I also acknowledge that I have read,

understand and agree to abide by the UHSAA Concussion Management Policy and/or the policy of the

school listed above.

_____________________________________

_________________________________________

Parent or Guardian Name

Parent or Guardian Signature

__________________________

Date

Student Statement

By signing below I acknowledge:

•

This application to compete in interscholastic athletics for the above school is entirely voluntary on my

part and is made with the understanding that I have not violated any of the eligibility rules and

regulations of the Utah High School Activities Association.

•

My responsibility to report to my coaches and parent(s)/guardian(s) illness or injury I experience.

•

Having received education including receiving written information regarding signs, symptoms, and

risks of sport related concussion. I also acknowledge my responsibility to report to my coaches and

parent(s)/guardian(s) any signs or symptoms of a concussion.

_________________________________________

________________________________

Signature of Student

Date

THIS FORM MUST BE ON FILE AT THE MEMBER HIGH SCHOOL PRIOR TO PARTICIPATION.

Form B, Updated September, 2011

Page 2 of 3

Initial Physical Exam Form Page 2

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