Parent Recertification Form
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1
2S
7: R
-C
P
/G
ECTION
E
ERTIFICATION BY
ARENT
UARDIAN
This form must be completed not earlier than six weeks prior to the first Practice day of the sport(s) in the sports season(s)
identified herein by the parent/guardian of any student who is seeking to participate in Practices, Inter-School Practices,
Scrimmages, and/or Contests in all subsequent sport seasons in the same school year. The Principal, or the Principal’s
designee, of the herein named student’s school must review the SUPPLEMENTAL HEALTH HISTORY.
If any SUPPLEMENTAL HEALTH HISTORY questions are either checked yes or circled, the herein named student shall submit
a completed Section 8, Re-Certification by Licensed Physician of Medicine or Osteopathic Medicine, to the Principal, or
Principal’s designee, of the student’s school.
S
H
H
UPPLEMENTAL
EALTH
ISTORY
Student’s Name
Male/Female (circle one)
Date of Student’s Birth: ______/______/_________ Age of Student on Last Birthday: ______ Grade for Current School Year: ______
Winter Sport(s): ________________________________________ Spring Sport(s): ________________________________________
CHANGES TO PERSONAL INFORMATION (In the spaces below, identify any changes to the Personal Information set forth in
the original Section 1: P
E
I
):
ERSONAL AND
MERGENCY
NFORMATION
Current Home Address
Current Home Telephone # (
)
Parent/Guardian Current Cellular Phone # (
)
CHANGES TO EMERGENCY INFORMATION (In the spaces below, identify any changes to the Emergency Information set forth
in the original Section 1: P
E
I
):
ERSONAL AND
MERGENCY
NFORMATION
Parent’s/Guardian’s Name
Relationship
Address
Emergency Contact Telephone # (
)
Secondary Emergency Contact Person’s Name
Relationship
Address
Emergency Contact Telephone # (
)
Medical Insurance Carrier
Policy Number
Address
Telephone # (
)
Family Physician’s Name
, MD or DO (circle one)
Address
Telephone # (
)
SUPPLEMENTAL HEALTH HISTORY:
Explain “Yes” answers at the bottom of this form.
Circle questions you don’t know the answers to.
Yes
No
Yes
No
1.
Since completion of the CIPPE, have you
4.
Since completion of the CIPPE, have you
sustained an illness and/or injury that
experienced any episodes of unexplained
required medical treatment from a licensed
shortness of breath, wheezing, and/or chest
physician of medicine or osteopathic
pain?
medicine?
5.
Since completion of the CIPPE, are you
2.
Since completion of the CIPPE, have you
taking any NEW prescription medicines or
pills?
had a concussion (i.e. bell rung, ding, head
6.
Do you have any concerns that you would
rush) or traumatic brain injury?
like to discuss with a physician?
3.
Since completion of the CIPPE, have you
experienced dizzy spells, blackouts, and/or
unconsciousness?
#’s
Explain “Yes” answers here:
I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Student’s Signature _________________________________________________________________________Date____/____/_____
I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Parent’s/Guardian’s Signature _________________________________________________________________Date____/____/_____
Revised: July 26, 2012
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