Date: ______________________________ Date of Last Physical ______________________________________

Student-Athlete’s Name: ______________________________________________________________________

Address: ___________________________________________________________________________________

________________________________________________________ Phone (401) _____

School: ________________________________________________ Grade: __________________________

Date of Birth: ___________________________________________ Age ____________ Sex __________

Emergency Contact Person: _____________________________________________________________________

Emergency Phone: ( ) ____________________ Sport to be played:____________________________

Family Doctor: _________________________________________________

Address: ______________________________________________________

______________________________________________________

Phone: ( )

I give my son/daughter___________________ permission to participate in ____________________. I have received a copy of the North Kingstown Athletic Department policies and I agree to comply with the requirements as stated. A yearly physical examination is required for athletic participation and our own physician best completes the exam.

Date Signed:_______/_______/_______ Student Athlete Signature:______________________________

Parent/Guardian Signature: ________________________________

1. Have you had a medical illness or injury since your last check up or sports physical? ___ ___

2. Do you have an ongoing or chronic illness? _______________________ ___ ___

3. Have you ever been hospitalized overnight? ___ ___

4. Have you ever had surgery? ___ ___

5. Are you currently taking any prescription or non-prescription (over the counter) ___ ___

Medications or pills?

a. Prescription ______________________ ___ ___

b. Non-prescription ______________________ ___ ___

(Over the counter) ___ ___

6. Do you have any allergies (for example: to pollen, medicine, or stinging insects)? ___ ___

If yes, which one(s)? _______________________________________________

7. Do you have any dental prosthetic devices (i.e., bridges, crowns)) ___ ___

8. Have you had any problems with your eyes or vision? __________________________ ___ ___

9. Do you wear glasses, contacts, or protective eyewear? __________________________ ___ ___

10. Do you have any current skin problems? _____________________________________ ___ ___

11. Have you ever fainted or become ill from exercising in the heat? ___ ___

12. If you smoke, how many packs per day? ________

13. Do you have only one of a normally paired organ (i.e. kidney, lung, eye, testicle)? ___ ___

If yes, which one(s)? _____________________________________

1. Have you ever passed out during or after exercise? ___ ___

2. Have you ever been dizzy after exercise? ___ ___

3. Have you ever had chest pain during or after exercise? ___ ___

4. Have you ever had racing of your heart or skipped heartbeats? ___ ___

5. Have you ever been told you have a heart murmur? ___ ___

6. Has any family member or relative died of heart problems or of sudden death before ___ ___

Age 50?

7. Have you had a viral infection (for example: mononucleosis) within the last year? ___ ___

If yes, what? _______________________________

8. Has a physical ever denied or restricted your participation in sports for any heart problems? ___ ___

1. Do you cough, wheeze, or have trouble breathing during or after activity? ___ ___

2. Do you have asthma? ___ ___

3. Do you use an inhaler? ___ ___

1. Do you use any special protective or corrective equipment or devices that aren’t ___ ___

Usually used for your sport or position (for example: knee brace, special neck roll,

Foot orthotics, retainer on your teeth)?

2. Have you ever had a sprain, strain, or swelling after injury which prevented you from ___ ___

Participation? ________________________________________________________

3. Have you broken or fractured any bones or dislocated any joints?

____________________________________________________________________

1. Have you had a head injury or a concussion? ___ ___

2. Have you ever been knocked out, become unconscious, or lost your memory? ___ ___

3. Have you ever had a seizure? ___ ___

4. Have you ever had a stinger, burner, or numbness in your arms, hands, legs or feet? ___ ___

If yes, which one(s)? _____________________________________

1. Do you skip meals during the day? ___ ___

2. Do you use laxatives, diuretics, or stimulants to control your weight? ___ ___

If yes, which one(s)? ____________________________________

3. Do you feel disgusted, depressed, or guilty about your eating? ___ ___

4. Do you self-induce vomiting after eating? ___ ___

5. Do you restrict certain types of foods? ___ ___

If yes, which one(s)? ____________________________________

6. Have you ever taken nutritional supplements? ___ ___

If yes, which one(s)? ____________________________________

7. Do you have a food allergy? ___ ___

If yes, which one(s)? ____________________________________

8. Do you want to weigh more or less than you do now? ___ ___

1. When was your last menstrual period? __________

2. How often do your periods occur? __________

3. Have you ever gone 4 months without getting a period? __________

Some type of medical insurance is REQUIRED of all students participating in any interscholastic athletic activity. For this reason, school insurance is offered at a nominal cost to all. Any student participating in the sport of football is required to take the provided football insurance policy. For full coverage of expenses resulting from the examination, diagnosis, treatment and rehabilitation (if needed) of an injury resulting from an injury occurring in an interscholastic sports event, school insurance is absolutely essential. If you do not purchase the school insurance, you should be aware of your policy deductible and limits on coverage for particular conditions. If you do not purchase school insurance and your medical carrier does not pay the entire bill, a claim can be made to the Rhode Island Interscholastic Injury Fund. If you do submit a claim for an injury, remember to be prompt. Claims should be submitted within 60 days of the Doctor’s or hospital visit. Failure to do so may result in non-payment of claim. Please contact the Director of Athletics for paperwork needed to file this claim.

We hereby give our consent for __________________________________ to represent his/her school in interscholastic athletics. If in the event of injury or accident either en route to the event, at the event, or en route back from the event, we also give our consent for the school to obtain any and all medical care that is deemed reasonably necessary for the welfare of the student. We realize that all reasonable efforts will be made to contact us if the above does occur.

We further state that we have completed that part of this form which requires us to list all previous injuries or conditions that are known to us and that the form is completed correct and true.

Name of Primary Medical Insurance: ______________________________________________________________

Policy Number: ___________________________________ Expiration Date: ____________________________

I/We have purchased school insurance this school year: YES____ NO____

NOTE: if your answer is "NO", you must complete and sign statement which follows.

I am fully covered by my own insurance for any injury that my child _______________________ may incur during the time of participation in the sport of: _____________________ I have read the above information and understand that there may be limits to my coverage. I do not wish to purchase school insurance.

Parent or Guardian (Print): _____________________________________________________________________

Signature of Parent or Guardian: _________________________________________________________________

Date: ___________________________

Age: _______________

Height ______ Weight ______

Pulse _______ BP ______, ______, ______

Vision R ______ L ______ Corrected: Y N

1. When was your last tetanus shot? __________________
2. When was the date of your measles immunization? __________________

1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________

____ No Athletic Participation

____ Limited Participation, e.g., ______________________________________________________________

____ Clearance Withheld Until: ______________________________________________________________

____ Full Unlimited Participation

Cleared: Yes / / No / /

Recommendations _____________________________________________________________________________

Name of Physician, NP, or PA _________________________________________________ Date _____________

Address __________________________________________________________________ Phone _____________

Signature of Physician ________________________________________________________, MD or DO