ALABAMA INDEPENDENT SCHOOL ASSOCIATION MEDICAL HISTORY FORM
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1 (Please Print) ALABAMA INDEPENDENT SCHOOL ASSOCIATION MEDICAL HISTORY FORM DATE / / FULL NAME OF STUDENT BIRTHDATE / / First Middle Last AGE SEX RACE: BLACK WHITE OTHER ADDRESS PHONE ( Street City State Zip ) SCHOOL GRADE SPORT/ACTIVITY HISTORY (COMPLETED AND SIGNED TO THE BEST OF THEIR KNOWLEDGE BY PARENT/GUARDIAN AND STUDENT PRIOR TO PHYSICAL EXAMINATION. WITHOLDING OR FALSIFYING INFORMATION COULD LEAD TO SERIOUS MEDICAL COMPLICATIONS.) 1. HAS THE STUDENT EVER: CHECK ONE IF YES, EXPLAIN a. been knocked out? Yes ( ) No ( ) b. had a concussion? Yes ( ) No ( ) c. stayed overnight in a hospital? Yes ( ) No ( ) d. had an operation? Yes ( ) No ( ) e. had heat exhaustion or heat stroke? Yes ( ) No ( ) f. had a head or neck injury? Yes ( ) No ( ) g. had a back or spinal injury? Yes ( ) No ( ) h. had a heart murmur? Yes ( ) No ( ) i. had high blood pressure? Yes ( ) No ( ) j. had a heart problem? Yes ( ) No ( ) k. fainted while doing exercise? Yes ( ) No ( ) 2. DOES THE STUDENT: a. take medicine every day? Yes ( ) No ( ) b. wear glasses or contact lenses? Yes ( ) No ( ) c. wear dental appliances? Yes ( ) No ( ) d. wear hearing aids? Yes ( ) No ( ) e. have any allergies? Yes ( ) No ( ) f. have any chronic illnesses (i.e. diabetes, asthma, seizures)? Yes ( ) No ( ) g. have any body parts missing (i.e. kidney, finger)? Yes ( ) No ( ) 3. HAS THE STUDENT S MOTHER, FATHER, BROTHER OR SISTERS EVER HAD ANY HEART PROBLEMS BEFORE 50 YEARS OF AGE? Yes ( ) No ( ) 4. HAS ANY PHYSICIAN LIMITED THE STUDENT S ATHLETIC PARTICIPATION? Yes ( ) No ( ) 5. HAS THE STUDENT EVER BROKEN A BONE OR HAD A CAST ON THE: a. hand? Yes ( ) No ( ) b. wrist? Yes ( ) No ( ) c. arm? Yes ( ) No ( ) d. foot? Yes ( ) No ( ) e. ankle? Yes ( ) No ( ) f. leg? Yes ( ) No ( ) g. other? Yes ( ) No ( ) 6. IN THE PAST YEAR HAS THE STUDENT BROKEN A BONE WHILE PLAYING SPORTS? Yes ( ) No ( ) Activity The examination performed for this participation is limited and designed to identify common conditions or infirmities that would limit or prevent a student form participating in athletic activities. This examination is NOT intended to be comprehensive and may not detect some types of latent or hidden medical conditions. All athletes should receive periodic comprehensive medical examinations and prompt treatment for illnesses/injuries. This is to certify that I have read and understand the above information and hereby give permission and consent to emergency and/or medical treatment for my son ( ), daughter ( ), ward ( ) and that the responses to the preceding questions are correct. SIGNED: PARENT ( ) OR GUARDIAN ( ) DATE
2 ALABAMA INDEPENDENT SCHOOL ASSOCIATION PHYSICAL EXAMINATION FORM (Completed by Physician) HEIGHT WEIGHT BLOOD PRESSURE PULSE (SYSTOLIC/DIASTOLIC) (BEATS/MIN) VISION: RIGHT 20/ LEFT 20/ CORRECTED UNCORRECTED DATE OF LAST MENSTRUAL PERIOD CHECK ONE IF ABNORMAL, EXPLAIN 1. Skin Normal ( ) Abnormal ( ) 2. Head & Neck Normal ( ) Abnormal ( ) 3. Eyes Normal ( ) Abnormal ( ) 4. Ears, Nose, & Throat Normal ( ) Abnormal ( ) 5. Teeth & Mouth Normal ( ) Abnormal ( ) 6. Lungs & Chest Normal ( ) Abnormal ( ) 7. Cardiovascular Normal ( ) Abnormal ( ) 8. Abdomen & Lymphatics Normal ( ) Abnormal ( ) 9. Genitalia/Hernia Normal ( ) Abnormal ( ) 10. Orthopedic Screening: a. upper extremities Normal ( ) Abnormal ( ) b. lower extremities Normal ( ) Abnormal ( ) c. spine & back Normal ( ) Abnormal ( ) 11. Neurological Normal ( ) Abnormal ( ) ADDITIONAL COMMENTS: No pupil shall be eligible to represent their school in interscholastic athletics unless there is on file in the Headmaster s office a physician s statement for the current year certifying that the pupil has passed and adequate physical examination, and that in the opinion of the examining physician he/she is fully able to participate in high school athletics. This is to certify that on this day of, 20, I performed the above limited examination on of the School/Academy and based upon an evaluation of the medical history provided and upon my limited examination, I am of the opinion that he/she IS IS NOT physically able to participate in ALL *LIMITED athletic events of the school. *EXPLAIN LIMITATIONS/EXCLUSION (M.D. or D.O.) PHYSICIAN
3 STUDENT/ATHLETE Medical Release Form Alabama Independent School Association Federal guidelines under HIPAA now requires a signed release form to be on file before any medical or financial information can be given on the named patient. Student/Athlete: Permission to discuss the medical condition of above named patient with the following people is granted for all school related health problems: 1). Athletic Director; 2). Coaches; 3). Trainers; 4). School Administration; 5). Insurance agent (Planned Benefits services) School: The medical condition of the above named patient is not to be discussed with any person other than the patient and parents or guardians.
4 Monroe Academy Athletics The following rules are intended to improve the appearance, conduct, and physical well-being of all Monroe Academy athletics. In all cases the Monroe Academy Handbook will be adhered to. Appearance: Conduct: Equipment: 1. All Monroe Academy athletes are encouraged to dress neatly when attending school function. 2. Monroe Academy athletes will not have facial hair, long hair, or outlandish hairstyles. Hair will be kept neat. 3. Athletes are urged to remove hats when entering a building. 1. Do what is right. 2. Profanity will not be tolerated. 3. Always be respectful to administration and teachers, as well as other elders. 4. Make every effort to encourage closeness on your team by encouraging teammates. Always be positive in your comments- never criticize a teammate. 5. Sportsmanship will be of utmost importance in all games. 6. Be prompt to all practices, meetings, and school. 7. Do not embarrass Monroe Academy. All equipment issued is property of Monroe Academy. You will sign an agreement that states that you will not alter or lost the equipment. Any lost or damaged equipment is your responsibility to replace or reimburse. Training Rules: Any use of drugs, tobacco or alcohol is strictly prohibited. All injured or sick players will attend practice unless excused by the head coach. All discipline for infractions of the preceding rules will be handled by the Head coach. A discipline committee will be established for ruling on repeated or serve infractions. The discipline committee will consist of the Athletic Director, Headmaster, and Head Coach of the respective sport in question. The consequences will be determined by the committee. Parents will be notified of any disciplinary action concerning their child. Parent s Signature Student s Signature
5 AISA PARTICIPATION PERMIT We, the undersigned, have read, discussed and understand the following: I. The school agrees to provide: A. Supervision B. Instruction C. Proper Equipment (This includes all equipment or uniforms provided by the participant.) D. A safety orientation program for all participants E. An in-excess, supplemental, scheduled payment insurance policy. Any differences in the basic coverage, deductibles, or other related expenses will be paid by the parent(s) /guardian(s). F. A rules orientation program covering: 1. rules of the sport; 2. rules of behavior, dress and appearance; 3. rules promoting safety and injury prevention; 4. rules regulating conduct, procedures and action following an injury. G. (For local use) H. I. II. I was given an opportunity to attend a scheduled seminar where the following specific areas were addressed and discussed: A. Coaching Techniques B. Rules of the game C. Injury prevention and safety precaution D. Player equipment care and purpose E. Physical conditioning F. Transportation G. Player accountability H. School s insurance program I. The hazards connected with the use of chemicals (steroids) to enhance performance J. The possibility of injury, even serious injury, while participating K. (For local use) L. M. My (son / daughter) has my permission to participated in (Sport) at. (School) Signed: Parent ( ) or Guardian ( ) Signed: Participant Date Date
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