a. Side A
-- the Sports Participation Health Record -- must be completely filled out
and signed by the parent and/or athlete.
b. Side B --
the Sports Participation Medical Examination record -- must be filled out and
signed by the student's physician.
c. This
form is handed in ONE time per year. The physical examination is valid for
ONE year from the date of the exam. For example, an exam completed by
the physician on October 20, 2007 will be valid until October 20, 2008. If
the student does not hand in a new Form A & B on or before October 20, 2008,
he or she will not be able to participate in sport practice or competitions
after October 20th until such time as the athlete hands in a new (current)
properly executed Form A & B. If timing of the physical examination is
an issue due to health insurance restrictions, please contact one of us for
assistance.
d. ONLY the Staples High
School Form A & B will be accepted to meet this eligibility requirement.
Therefore, please remember to take it with you to the physician on the day
of the exam.
e. This
form may be handed into the school nurses or to Gaetana "G" DiLeo, the head
athletic trainer or Erin Guertin, Assistant Athletic Trainer. One of the
school nurses must review it before the student will be medically cleared
for participation.
f. Please note: The State of Connecticut's health assessment form (HAR-3,
also known as the "blue form") will NOT be accepted in lieu of
Form A & B. While the HAR-3 form is used to meet the state’s tenth
grade requirement for general school attendance, it does not meet medical
standards for a pre-sports participation examination.
2.
Seasonal Sport
Permission/Emergency Information - Form C:
Form C needs to be completed and handed in for each and every sport
the athlete plans to try out for EACH sport season. Form C is a
carbon-copy GOLD form that includes emergency contact information and
permission for emergency medical treatment in the event that a student is
injured at an away game and needs to be transported to a medical facility.
- This form should be
"verified" by the Athletic Trainer s or the school nurses. The
coach will receive the top copy of form C and the bottom copy will
reside with the Athletic Trainers.
- These forms will NOT
be accepted if they are handed in to a coach or person other than those
designated above. There have been too many errors, including lost
forms and delays in student participation, when forms are not brought to
the proper place for review and processing.
Form A & B
can be downloaded.
Both forms must be filled out using a pen. A form that is filled out in
pencil will not be accepted. The forms are also available
from 9 AM - 3 PM in the Athletic Office, Nurses' Office and Guidance.
Please note we will need 2 copies of
Form C
if it is downloaded. Both forms
must be filled out using a pen. A form that is filled out in pencil will not
be accepted. If you complete the forms and turn them in as described above,
your student athlete should have a smooth start each sport season.
If you have any further questions regarding
these instructions, please call “G” at (203) 341-1264. If you have a
question regarding your student’s medical clearance or a medical issue,
please contact the Health Office staff, at (203) 341-1231. Forms can be
mailed or handed in at the Health Office. Thank you for your cooperation.
