Minnesota Sports Qualifying Physical Examination Clearance Form (Page 4 of 4) in pdf

Revised 4/9/13

Page 4 of 4

Minnesota State High School League

2013-2014 PI ADAPTED ATHLETICS PHYSICAL EXAM FORM Addendum

(Use only for Adapted Athletics - PI Division)

The MSHSL has competitive interscholastic Physically Impaired (PI) competition. Students who are deemed fit to

participate in competitive athletics from a MSHSL sports qualifying exam should meet the criteria below to participate in

Adapted Athletics – PI Division.

The MSHSL Adapted Athletics PI Division program is specifically intended for students with physical impairments who

have medical clearance to compete in competitive athletics. A student is eligible to compete in the PI Division with one

of the following criteria:

The student must have a diagnosed and documented impairment specified from one of the two sections below:

(Must be diagnosed and documented by a Physician and/or Physicians Assistant.)

Neuromuscular

Postural/Skeletal

Traumatic

Growth

Neurological Impairment

Which:

affects Motor Function

modifies Gait Patterns

(Optional)

Requires the use of prosthesis or mobility device, including but not limited to canes,

crutches, walker or wheelchair.

_____ Cardio/Respiratory Impairment that is deemed safe for competitive athletics, but limits the intensity

and duration of physical exertion such that sustained activity for over five minutes at 60% of maximum heart

rate for age results in physical distress in spite of appropriate management of the health condition.

(NOTE:) A condition that can be appropriately managed with appropriate medications that eliminate

physical or health endurance limitations WILL NOT be considered eligible for adapted athletics.

Specific exclusions to PI competition:

The following health conditions, without coexisting physical impairments as outlined above, do not qualify the student to

participate in the PI Division even though some of the conditions below may be considered Health Impairments by an

individual’s physician, a student’s school, or government agency. This list is not all-inclusive and the conditions are

examples of non-qualifying health conditions; other health conditions that are not listed below may also be non-qualifying

for participation in the PI Division.

Attention Deficit Disorder (ADD), Attention Deficit Hyperactive Disorder (ADHD), Emotional Behavioral Disorder (EBD),

Autism spectrum disorders (including Asperger’s Syndrome), Tourette’s Syndrome, Neurofibromatosis, Asthma,

Reactive Airway Disease (RAD), Bronchopulmonary Dysplasia (BPD), Blindness, Deafness, Obesity, Depression,

Generalized Anxiety Disorder, Seizure Disorder, or other similar disorders.

Student Name __________________________________________________________________________________

Attending Physician/Physician Assistant

__________________________________________________________

(PRINT)

Attending Physician/Physician Assistant

______________________________________________________

(SIGNATURE)

Date of Physical Exam ____________________________________________________________________________

Minnesota Sports Qualifying Physical Examination Clearance Form Page 4

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