2005 Pre-Participation Physical Evaluation Form (Page 4 of 4) in pdf

Student’s Name _______________________________________________

(PLEASE PRINT CLEARLY)

To be eligible for participation in interscholastic athletics/spirit groups, a student must have on ﬁle with the superintendent or principal, a signed

statement by a practicing physician or registered physicians assistant certifying the student has passed an adequate physical examination and is

physically ﬁt to participate. (See KSHSAA Handbook, Rule 7.) A complete history and physical examination must be performed upon a student’s

initial entrance into KSHSAA interscholastic athletics/cheerleading.

The annual history and the physical examination shall not be taken earlier than May 1 preceding the school year for which it is

applicable. The KSHSAA recommends completion of this evaluation by athletes/cheerleaders at least one month prior to the ﬁrst practice to allow

time for correction of deﬁciencies and implementation of conditioning recommendations.

Parent or Guardian Consent

I do not know of any existing physical or any additional health reasons that would preclude participation in

activities. I certify that the answers to the questions in the HISTORY part of the Preparticipation Physical

Examination (PPE), are true and accurate. I approve participation in activities. I hereby authorize release to the

KSHSAA, the school nurse, trainer, coach and medical provider of information contained in this document. Upon

written request, I may receive a copy of this document for my own personal health care records.

I acknowledge that there are risks of participating, including the possibility of catastrophic injury.

I hereby give my consent for the above student to compete in KSHSAA approved activities, and to accompany

school representatives on school trips and receive emergency medical treatment when necessary. It is understood

that neither the KSHSAA nor the school assumes any responsibility in case of accident. The undersigned agrees

to be responsible for the safe return of all equipment issued by the school to the student.

The above named student and I have read the

KSHSAA Eligibility Check List

and how to retain eligibility information listed in this form.

For Middle/Junior High and Senior High School Students to Determine Eligibility When Enrolling

If a negative response is given to any of the following questions, this enrollee should contact his/her administrator in charge of evaluating

eligibility. This should be done before the student is allowed to attend his/her ﬁrst class and prior to the ﬁrst activity practice. If questions

still exist, the school administrator should telephone the KSHSAA for a ﬁnal determination of eligibility. (Schools shall process a Certiﬁcate

of Transfer Form T-E on all transfer students.)

YES

Are you a bona ﬁde student in good standing in school? (If there is a question, your principal will make that determination.)

Did you pass at least ﬁve new subjects (those not previously passed) last semester? (The KSHSAA has a minimum

regulation which requires you to pass at least ﬁve subjects of unit weight in your last semester of attendance.)

Are you planning to enroll in at least ﬁve new subjects (those not previously passed) of unit weight this coming semester?

(The KSHSAA has a minimum regulation which requires you to enroll and be in attendance in at least ﬁve subjects of unit weight.)

Did you attend this school or a feeder school in your district last semester? (If the answer is “no” to this question, please answer

Sections a and b.)

a. Do you reside with your parents?

b. If you reside with your parents, have they made a permanent and bona ﬁde move into your school’s attendance center?

Parent or Guardian’s Signature

Date

Student’s Signature

Date

2005 Pre-Participation Physical Evaluation Form Page 4

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