Medical Consent Form - Downingtown Area Schools (Page 3 of 3) in pdf

Section 6: C

ERTIFICATION BY

ICENSED

HYSICIAN OF

EDICINE OR

STEOPATHIC

EDICINE

This Form must be completed for any student who, subsequent to completion of Sections 1 through 4 of this CIPPE Form,

required medical treatment from a licensed physician of medicine or osteopathic medicine. This Section 6 may be

completed at any time following completion of such medical treatment. Upon completion, the Form must be turned in to

the Principal, or the Principal’s designee, of the student's school.

NOTE: The physician completing this Form must first review Sections 3 and 4 of the herein named student's

previously completed CIPPE Form. Section 5 must also be reviewed if both 1) this Form is being used by the

herein named student to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in a

subsequent sport season in the same school year AND 2) the herein named student either checked yes or

circled any Supplemental Health History questions in Section 5.

If the physician completing this Form is clearing the herein named student subsequent to that student sustaining

a concussion or head injury, that physician must be sufficiently familiar with current concussion management

such that the physician can certify that all aspects of evaluation, treatment, and risk of that injury have been

thoroughly covered by that physician.

Student's Name:

Age

Grade

Enrolled in __________________________________________________________________________________School

Condition(s) Treated Since Completion of the Herein Named Student’s CIPPE Form:

A. GENERAL CLEARANCE: Absent any illness and/or injury, which requires medical treatment, subsequent to the

date set forth below, I hereby authorize the above-identified student to participate for the remainder of the current school

year in additional interscholastic athletics with no restrictions, except those, if any, set forth in Section 4 of that student’s

CIPPE Form.

Physician’s Name (print/type)__________________________________________________ License #_______________

Address___________________________________________________________________ Phone (

)____________

Physician’s Signature _____________________________________________MD or DO (circle one) Date____________

B. LIMITED CLEARANCE: Absent any illness and/or injury, which requires medical treatment, subsequent to the date

set forth below, I hereby authorize the above-identified student to participate for the remainder of the current school year

in additional interscholastic athletics with, in addition to the restrictions, if any, set forth in Section 4 of that student’s

CIPPE Form, the following limitations/restrictions:

Physician’s Name (print/type)__________________________________________________ License #_______________

Address__________________________________________________________________ Phone (

)____________

Physician’s Signature _____________________________________________MD or DO (circle one) Date____________

Revised: May 20, 2010

Medical Consent Form - Downingtown Area Schools Page 3