Palo Alto High School Physical Form printable pdf download

PALO ALTO HIGH SCHOOL PHYSICAL FORM

NAME___________________________________

SPORT___________________

1. Have you ever had a head or neck injury? ____________________________________

If yes to head injury, did you loose consciousness? ________________________________

If yes to neck injury, did you have weakness, tingling or numbness? ___________________

How long before you returned to your sport? _____________________________________

2. Have you/do you have eye problems? ________________________________________

Do you wear glasses or contacts? _____________________________________________

3. Do you have a history of asthma? _______________________

If yes, do you take medication? ___________________________

Name of the medication_________________________________

4. Do you have a history of diabetes? ______________________

If yes, do you control it with medication? ___________________

Name of the medication________________________________

5. Do you or have you had a history of foot/ankle injury? ______; knee injury? ______; hip injury? ______; back injury

?_____; shoulder injury ?______; elbow injury ?______; wrist/hand injury ?_____. If you answered yes to any of the

above, please explain

_________________________________________________________________________________________________

6. Do you have allergies to: medication, insects, grass, and food? ___________________________ If you

answered yes to any of the above, do you take medication for the reaction and what is the name of the medication

_____________________________________________________________

7. Do you take medication, regularly? ___________________; If you do, what medication/s do you take?

_________________________________________________________________________

8. Is there any other information that the athletic trainer or your sports coaching staff needs to know?

____________________________________________________________________________________

TRANSPORTATION: Only transportation authorized by the school district may be used by teams traveling to and from

places of practice or athletic events. The faculty sponsor or coach will accompany the team and has complete authority on

such trips.

PERFORMANCE ENHANCING DRUGS/STERIODS: Students must not be taking performance enhancing substances or

steroids, doing so may jeopardize his/her eligibility.

EQUIPMENT AND SUPPLIES: The student and his/her parent/guardian are responsible for the safe return of all

equipment and uniforms issued to the student. The student will be charged for any misuse or loss of such

equipment/uniform.

REQUIREMENTS FOR INTERSCHOLASTIC SPORTS PARTICIPATION INCLUDE:

1. An annual physical examination, including physician verification of the student’s ability to participate

2. Accident insurance with proper coverage.

3. Minimum of 2.00 GPA for previous grading period, which includes all courses

4. Must pass 20 units from the preceding semester.

5. Must be enrolled as a full-time student during the sport’s season.

This form read, understood and signed

The parent/guardian of ________________________ signify that the above rules, regulations and information are

acceptable and give full permission for my student to, with authorized personnel, participate and travel with the Team

during the entire season of ________________.

__________________________

________________________________

Student Signature

Parent/Guardian Signature

Palo Alto High School Physical Form

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