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Dear Parents or Guardians:
Our Lady of Mt. Carmel High School requires that all students entering the school have a physical examination before admission. Also all students who are to participate in interscholastic sports must have a physical examination each year.
This form consists of three parts: Part I is to be filled out by the parent/guardian; Part II to be signed by the parent if the student is to play interscholastic sports; Part III is to be filled out by the physician conducting the physical examination.
THIS FORM IS TO BE RETURNED TO THE MAIN OFFICE
Thank you for your cooperation.
PART I: To be completed by Parent/Guardian.
Student Name:___________________________________________________________
Address:________________________________________________________________
Date of Birth:______________ Phone Number:_________________
In case of emergency contact:
Mother's Name:______________________________ Work #:__________________
Father's Name:_____________________________ Work #:____________________
Persons other than parent to contact in case of emergency or if student needs to be dismissed from school for illness:
Name:_________________________ Relationship:____________________
Phone #:____________________
Name:_________________________ Relationship:____________________
Phone #:____________________
During the year it may be necessary to administer first aid to your student. Please sign below to authorize first aid treatment by the school staff if necessary.
Parent Signature:______________________________Date:_______________
In certain cases it may be deemed necessary by the school nurse or administration that emergency care is needed. Please sign below to give your permission for the school to call an ambulance if such a measure is needed. In such a case a parent or guardian would be notified immediately.
Parent Signature:______________________________Date:_______________
Please note that if a student is above the age of 18, the student has the right to request or deny emergency treatment without parental permission. If a student should refuse emergency medical treatment against the advice of the nurse or administration, the student will be sent home immediately until it is determined he/she is healthy enough to return to school.
PART I - TO BE FILLED OUT BY PARENT
Personal health of student: YES NO
1. Has had injury or accident requiring medical attention ___ ___
2. Has had a surgical operation _____ ____
3. Has been in a hospital ___ ___
4. Has had sickness lasting longer than one week ___ ___
5. Takes medicine now or regularly ___ ___
6. Has a condition that requires physician care ___ ___
7. Has a defect in hearing or eyesight (ie., wears glasses) ___ ___
8. Is there any reason this student should not take part in
any sport ___ ___
If you answered yes to any of the above questions, explain here with names and dates:
_______________________________________________________________________________
YES NO
9. Has had completed poliomyelitis immunization by
injections (Salk) or vaccine by mouth (Sabin) ___ ___
10. Has had tetanus toxoid and booster innoculation
Date of last booster ___/___/___ ___ ___
11. Has seen a dentist within the past six months ___ ___
12. To my knowledge the paired organs that follow are
present and healthy: (Please circle)
Eyes: YES NO Ears (Hearing): YES NO
Lungs: YES NO Kidneys: YES NO
Arms/Legs: YES NO Fingers/Toes: YES NO
Testicles or Ovaries: YES NO
If you answered no to any of the above questions, explain here with names and dates:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Student's Physician:_________________________________________________
Physician's Phone:________________________________
Does this student have an Orthopedic Physician:
If so, name of physician:_______________________________________________
Physician's Phone:_________________________________
Does your student suffer from asthma? YES NO
If yes, how frequent and severe are the episodes:_______________________________________
______________________________________________________________________________
______________________________________________________________________________
Is the student on medication for asthma, and if so what medication:_________________________
_______________________________________________________________________________
PART II - PARENTAL CONSENT FORM INTERSCHOLASTIC ATHLETICS
I hereby acknowledge that my son/daughter will take part in interscholastic athletics. I understand that athletics involves physical contact and that the proper use of equipment and/or facilities, and the teaching and use of proper techniques does not prevent the possibility of physical injury to participants. I further understand that MT. Carmel High School does not furnish any medical, hospital, dental, or liability insurance except that which is offered through Warfield Dorsey Co. for purchase by students. Interscholastic sports includes not only games with other schools but also practice sessions, and possibly off-season programs.
I also give my consent for medical care prescribed by a duly licensed doctor of medicine, or other medical facility or provider, for my child in the event of illness or injury during the course of the sports event or in transportation to and from such event. This medical care may be given under whatever conditions may exist to preserve the life, limb, or well-being of my child.
Acknowledging the above, I state that my child has my permission to play interscholastic sports while attending MT. Carmel High School and to engage in any practices or activities relating to these sports.
I also absolve MT. Carmel High School, it's employees, and it's coaches from liability for any injuries sustained by my student as a result of participation in interscholastic sports and any activity pertaining to the sport, or in transportation to or from the sport, unless the injury is caused by gross negligence.
Athlete's Signature:__________________________________
Father's/Guardian's Signature:____________________________________________
Mother's/Guardian's Signature:___________________________________________
PART III - TO BE FILLED OUT BY PHYSICIAN
I give my permission for the physician to complete Part III for confidential use in meeting my child's health and educational needs in school.
_______________________________________
Parent's Signature
Significant past illnesses or injuries:_________________________________________________________
______________________________________________________________________________________
PHYSICIAN'S EXAMINATION: (Circle and explain any abnormal findings)
Height__________ Weight__________ Blood Pressure__________ Pulse Rate__________
Eyes_________________________________ Visual acuity R / ; L /
Ears_________________________________ Hearing R / ; L /
Nose (deformities) ___________________________
Oropharynx __________________________
Teeth (cavities, dentures, braces) ____________________
Respiratory ______________________
Breasts (M & F) ____________________
Cardiovascular (pedal pulse) _____________________
Abdomen (hernia, spleen, liver) ___________________
Genitals and anus ____________________
Neuromuscular __________________________________
Skin _____________________________
Spine (cervical, thoracic, lumbar) _________________________________
Extremities (special attention to knees, ankles) ____________________________________
Laboratory: Urinalysis: protein__________ sugar __________ other __________
· Tuberculin Test _______________
Or
· Chest X-ray Result _____________
· Other laboratory tests ______________________________________________________
· If ordered by a Physician
Additional explanations of abnormal findings ____________________________________________
____________________________________________
I have on this date personally examined this pupil, reviewed the history and other data recorded in this form, and find this pupil physically able to compete in supervised activities listed below which are circled:
Baseball Basketball Cross Country
Football Golf Gymnastics
Soccer Lacrosse Softball
Tennis Track Volleyball
Physician's Signature:________________________________ Date:___________________