CAPISTRANO UNIFIED SCHOOLDISTRICT 2023-24 PhysicalClearanceForm
SPORTS:(fall) (winter) (spring)
Father/GuardianWorkphone
Mother/GuardianWorkphoneCellphone
EmergencyContact
***Iherebygivemyconsentfortheabovenamedstudent(son/daughter/ward)tocompeteinsportsandtogowitharepresentativeoftheschoolonany trips.Incaseofinjury,youareauthorizedtohavehim/hertreated. *SIGNATURE
Problemswithvision
Blackingoutorfainting Brokenbones
Unconsciousness Bodypart,date
Convulsions, Kneeorankleproblems seizures Requiresupport/brace
Heartproblems
Rheumaticfever
Bleedingdisorders
Bloodsugarproblems
Allergies–type
Beeorinsectstings
Hospitalizations
Anyhistoryofchestpainwithexercise?
Anyhistoryof"racing"heartorskippedbeats?
Needformedication
OTHERHEALTHASPECTSTHEDOCTOR ANDSCHOOLSHOULDBEAWAREOF:
Doyouexperiencepassingout,nearpassingoutorunexpectedtirednessduringexercise?
Anyfamilyhistoryofsuddencardiacdeathinafamilymemberundertheageof50?
AnyfamilyhistoryofMarfan'ssyndromeOrprolongedQTsyndrome?
Anyhistoryoftemporarynumbnessorparalysisof both armsand/orlegsfollowinghead/spinetrauma?
Anyhistoryofrecentsevereviralillness,infectiousmononucleosis,orhepatitis?
Anyhistoryofthefollowing:absenceofonekidney?
males:absenceofonetesticle?
Anyhistoryofblindnessinoneeye?
Anycurrentactiveskininfection? PHYSICALEXAM:DATE
Special doctor recommendationsor restrictions
I have examined the above student and do recommend that he/she is physically fit for full participation in sports. (Must be signed by a PHYSICIAN,PHYSICIAN'S ASSISTANT orNURSEPRACTITIONER)
NameofphysicianM.D/DO/PA/NPDate_ SignaturePhone
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Name Gradein2023-24MaleFemaleDateofbirth// AddressCity&ZipCodePhone
Cellphone
PhoneInsurance
OF PARENT/GUARDIAN* Date HEALTHHISTORY: TO BE COMPLETED BY PARENT BEFORE DOCTOR EXAM
Yes No Yes No
Anypastorpresent:
Eyeglasses
Dentalproblems
Braces
Surgeries
Contacts
Problemswithhearing Hearingaid. Falseteeth Painfuljoints
Hypoglycemia Diabetes Name
Menstruationproblems Hernias Asthma
HEIGHT WEIGHT PULSE: RESTING AFTERACTIVITY B.P.
EYES THROAT ABDOMEN ORTHOPEDIC EARS LYMPHGLANDS HERNIA SKIN TEETH THYROID POSTURE OTHER BRACES HEART MUSCLETONE NOSE LUNGS REFLEXES
Sign Here
CAPISTRANOUNIFIEDSCHOOL DISTRICT ATHLETICINSURANCEVERIFICATION
EducationCodeSection32221.5.Understatelaw,schooldistrictsarerequiredtoensurethatall membersofschoolathleticteamshaveaccidentalbodilyinjuryinsuranceprovidingatleast$1500of scheduledmedical/hospitalbenefits.Thisinsurancerequirementcanbemetbytheschooldistrict offeringinsuranceorotherhealthbenefitsthatcovermedicalandhospitalexpenses.Somepupilsmay qualifytoenrollinno-costorlow-costlocal,state,orfederallysponsoredhealthinsuranceprograms. Informationabouttheseprogramsmaybeobtainedbycalling:1(800)281-9799.
If you haveatleast $1500,accidentalbodily injury insurance,pleaseuploadyourmedical insurancecarddirectlyto www.athleticclearance.com.
If youdonothaveaccidentallybodily injury benefits foryoursonordaughter,youcanpurchase amedicaland/ordentalinsuranceplanthroughMyers-Stevens &Toohey.Signupat www.myersstevens.com.Proofofsubscriptiontotheappropriateinsuranceplanwillneedtobeuploadedto www.athleticclearance.com.
Availableplansinclude:
o InterscholasticTackleFootball(Grades9-12)
o *FullTime(24/7)AccidentPlan
o *SchoolTimeAccidentPlan
o DentalPlan
o (Note:FullTimeandSchoolTimeAccidentPlansincludeallinterscholasticsportsexcept tacklefootball)
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