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ATHLETIC PERMISSION/PHYSICAL FORMS PROCEDURES

SCHOLASTIC STUDENT-ATHLETE SAFETY ACT INFORMATION FACT SHEET FOR PARENTS/GUARDIANS

Prior to participation on a school-sponsored interscholastic or intramural athletic team or squad, each student-athlete in grades six through 12 must present a completed Preparticipation Physical Evaluation (PPE) form to the designated school staff member. Important information regarding the PPE is provided below, and you should feel free to share with your child’s medical home health care provider.

1. The PPE may ONLY be completed by a licensed physician, advanced practice nurse (APN) or physician assistant (PA) that has completed the Student-Athlete Cardiac Assessment professional development module. It is recommended that you verify that your medical provider has completed this module before scheduling an appointment for a PPE.

2. The required PPE must be conducted within 365 days prior to the first official practice in an athletic season. The PPE form is available in English and Spanish at http://www.state.nj.us/education/students/safety/health/records/athleticphysicalsform.pdf.  It is also found in the White Packet.

3. The parent/guardian must complete the History Form (page one), and insert the date of the required physical examination at the top of the page.

4. The parent/guardian must complete The Athlete with Special Needs: Supplemental History Form (page two), if applicable, for a student with a disability that limits major life activities, and insert the date of the required physical examination on the top of the page.

5. The licensed physician, APN or PA who performs the physical examination must complete the remaining two pages of the PPE, and insert the date of the examination on the Physical Examination Form (page three) and Clearance Form (page four).

6. The licensed physician, APN or PA must also sign the certification statement on the PPE form attesting to the completion of the professional development module. Each board of education and charter school or nonpublic school governing authority must retain the original signed certification on the PPE form to attest to the qualification of the licensed physician, APN or PA to perform the PPE.

7. The school district must provide written notification to the parent/guardian, signed by the school physician, indicating approval of the student’s participation in a school-sponsored interscholastic or intramural athletic team upon review of the medical report, or must provide the reason(s) for the disapproval of the student’s participation.

8. For student-athletes that had a medical examination completed more than 90 days prior to the first official practice in an athletic season, the Health History Update Questionnaire (HHQ) form must be completed, and signed by the student’s parent/guardian. The HHQ must be reviewed by the school nurse and, if applicable, the school’s athletic trainer. The HHQ is available at http://www.state.nj.us/education/students/safety/health/records/HealthHistoryUpdate.pdf.

For more information, please review the Frequently Asked Questions which are available at http://www.state.nj.us/education/students/safety/health/services/athlete/faq.pdf. You may also direct questions to Jill Scully, RN, our school nurse at jscully@lakeland.k12.nj.us or 973-835-1900 ext 131.

A NEW procedure for collecting Sports forms has been initiated. Please read all the directions carefully.

The New Jersey State Law mandates that the school physician approves all physicals and signs off on the form PRIOR to a student participating on any athletic team. No student will be allowed to participate in any interscholastic sport (including tryouts and practice) until the school physician has signed the students physical form. If physical forms are not returned to the NURSE (ONLY) by the due date we cannot guarantee that the school physician will sign them prior to the start of the season and this will delay the athlete from trying out or participating in practice. (resulting in Participation Penalties)

If this is your 1st sport of the school year please complete the white packet.

This packet includes:

1. Pre-participation form (part A) – to be filled out by the parent or guardian and brought to your physician to review.

2. NJSIAA Steroid Testing form- signed by both parent and student

3. Physical examination form (part B) –Physicals are good for 365 days. This form needs to be filled out in it’s entirety by your physician. All areas on the form must be completed (this includes, height, weight, BP, pulse and vision). Incomplete forms will be returned for completion. The NJ Department of Education guidelines recommend sports physical be performed by the students own physician. If there is an issue regarding the ability to have a physical by your own physician please contact the school nurse.

4. Permission/Sportsmanship Form – signed by both parent and student

5. Concussion Policy Form- signed by both parent and student

6. Random Drug testing Form- signed by both parent and student

If you already played a sport this year, please complete the blue packet.

This packet includes:

1. Pre-participations form (part A). This form is valid for 60 days prior to the start each season. This form needs to be completed for each sport.

2. Permission/Sportsmanship form - signed by both parent and student.

3. Concussion Form - signed by both parent and student.

WHITE PACKET

First sport of the school year

BLUE PACKET

If already have played a sport