ioe | VIRGINIA HIGH SCHOOL LEAGUE, INC. ae 5 ‘1642 State Farm Blvd, Charlottesville, Va, 22911 ‘Athletic Participation/Parental Consent/Physical Examination Form sci sn tear MAY 1 oe cureivntraeb JUNG 30 fe snc td Yer PAR: ATHLETIC PARTICIPATION a Nae Sse 1D# om ‘emit Hoe Ades Ciytip Cae, ome Ades of Pact Givin Cote Dato ith Pi of ih Misys Tigh Sol wc yw cg pl. Lak seer ted Shoot yased __ceitbecs; anda aing —__ edt lesen ee coed vi lg as othe Vga High Soo! League aparece a represent my pseu lh st ats, INDIVIDUAL ELIGIBILITY RULES. ‘Tobe tigbe to represent your sto! in any VHSLinterscholstie athlete contest, you ‘must be ela bon ie sent in pod standing ofthe shoo you represen ‘must ero nthe ast four years of high eho. (Eight stents maybe lige fr univ.) ‘+ musthave earl nt ater than he cent day ofthe cent seeste ‘forthe fist samestr mast be eae salle in ot ever ha ive subjects, o tir equiva, feed for ere and which may be sel fr graduation and bye pase fie sbjes, ots equiva for eet and which may be used for graduation ie immeinely preceding year or he immediatly preceding semester fr hoos that ceri reds on a stmese bass (Chek with {your principal for equivalent requirements) May nat repeat courses for eligilty purposes for which erelt has been previously avarded. + forthe second semester mst be cure ele in not ewer than five boss, othe equivalent, of for rit and which may be used for graduation and have pased five sje or ter eguvatet offered for ert and which may be used for _rauation the immediately preceding semester (Check wth your pincpal fr equivalent requirements) ‘ts ot all VSL compettion for 355 conacutve calendar days lng choo sfr unos the nsf corresponded witha amily move: (Check with your pnp for exceptions) 4 mustoot have cache you nineteenth Dirty ono ef the st day of August ofthe cent sebaa year {tno refering the ninth grade fr the Hat ime, have ben enol nor ben eligible or nent high school more ‘hang consecutive semester. ‘+ ust have submited to your principal befre any kid of prcpton, including nyous or practice as a ember of any schoo! | ‘hei or chercaing Team, at Atlee PaticpationParenal Consen/Physkal Examination For, completly ied in and ‘opel signed atest tat ou have been cxamined during his school year found tobe pial ft fr alte competion {tht your pars conseat io you partipaton. ‘+ ustnot be mt volition of VASL Amer, Ava, AI Star or Colkge Team Rules. (Check wit you principale aiteaton in regard cheeleadng) | lily to participate in interscblasti leis sa pevilege you eam by meting nat only the sbovetisted minimum standards, bat ls al other Sadar set by your Leagoe, ditt and school. Ifyou have any question rearing your eighty or arin dob about the eet an atvy might have on your cgi, check with your principal for Interpretations and exception provided under League res Mecing the intent end spintof League stats wil prevent you, yur et, schol sod community fom being pecalzed. Additionally give my const and appoval or my pictur ad name abe eed in any high schol or VHS. progam, publication or video. LOCAL SCHOOL DIVISIONS AND VIS DISTRICTS MAY REQUIRE ADDITIONAL STANDARDS TO THOSE LISTED ABOVE, side Sign Dat - Providing false information will result in ineligibility for one year.Se better raph ros een by sen ply ne phn Truly? Of ne are nl aoe vedere pen? St. Ave who you bad re nl or 7A Do oF Bu a, ‘MEDICAT- QUESTIONS 3e ben TE A NT FC De ye ar na ited) PART Il -- MEDICAL HISTORY- Explain “Yes” answers below rata ‘This form must be completed nd signe, prior to the phsial examination, for review by examining practtone. Explain "Yes answers below with number of tue question. Circe questions you dont know the SRSWers fo. ‘GENERAL MEDICAL THSTORY Yer] As | SIEDICAL QUESTIONS (ai Yee ‘iets ter ed a a a RT 29. Doyoclne panes oooh eater |G J igeinans! ojo ‘usclaty Cae Cf Ane 3M, ttre yout enomont (mam) wiinttenst | | Finca Wout OO Oy 0 |e = THe pe eT Oo [RETR PTR Te Lo RET aT TO AOC tive arate ar ReER? — “CE [HEART HEALTH QUESTIONS ABOUT YOU Sd ER ReGeenemn mae |p Py ame aRTTERmETES Te |G Chee aa ERTS | py | teenie eA TO |g Das er an ise ipa aig TU fae Bop wi ca” Too 1 pe te ns a ‘heyent ues anode] art ma | o | taeymrertonsnsiconmeyuramcecier | oy | inex Ear ein ‘Seager nee Cte e oe “fore BOUEKG oc) Of oO | cect 5lo cualaineccie OO | icecimeessectane | oO | oO Te ore on pel eee [UI] a Hine yer ld IE ET HET ESTOS TOT YORE a Rea aa at winraanicat — TOT TT Samticeteinon ies Qiermrcy [C1 || 2. Deyn gncercnatnst ola baer pra eet oes TO |e age rcinomermsmewees fo] a isan wri FEET yee ey a ole 1S De aS a A NTT TT] Aeon yaeto arpa | caso Cre on apa ofc euro a GET HR TH [UT] ob Deyo ctl ot wnt ofa [BONE AND JOINT QUISTIONS Te [| A bine sreomtaar mnie TE Tieywaaaia ny aah amatame | |_| © veniriedn aaa Ti aca TH tan yore Bers Br da ‘Saye ar rai ch Sn sans ofo |i “et lola ee tinct | | C1 | eyed anen t ofa ala ofa oho ofo ofo ofa ole oo o tote spear oreps ss PART IIl-PHYSICAL EXAMINATION Tevet (po mati engin ry a inal gh ef cae = NAME Date of Birth Sena igi Wei Tine rami BP 7 Reng Pu Vision E207 20 Conedied Cer CNe ‘MEDICAT. NORMAL, ‘ABNORMAL FINDINGS Tyesesirat Pa Aba enti a ni) ‘si ‘Neale ‘MUSCULOSKELETAL | NORMAL. “ABNORMAL FINDINGS Nek Soa howe ‘Whang pti Legale Fintona ‘Medical Practitioner to School taf (plea indicate any instructions or recommendations her®) Teer metas eed orale (lini Cenc Cases [ote Comments: “ave viewed the dlabove, eve Ne ede kor em nd ke he filing romeo or ihr parsipon i alis (UW CLEARED WITHOUT RESTRICTIONS D CLEARED WiTi FOLLOWING NOTATION: Gc APTER documented futher evahation or teximen oe ion (Chek and explain “waton or al hat app: "ied Ul at when apreriae C__Noteteed for (psi sports) st Dae east: D_NOT CLEARED FOR PARTICIPATION Reason year ae a ssn pp a cer ee sy Free sommee pr. Pa nin’ de pi “einer pot hel eommncn ee expe Tom eee hl cman pene aye PART IV - ACKNOWLEDGEMENT OF RISK AND INSURANCE STATEMENT (oe compere end stg by parenuaraan) [aive poison for {ome of chiar) to ppt in any ofthe flowing spot sre not erossed utes Gaskell, cierening, cos county, eld hockey, fot, gl gymnasts, cross, soccer, sft, ‘rimmingvig tenn, tack, vlleyal resting ther Gent spo). "uve reviewed the individ lig ras an Lam aware tht with he atpation in sports comes the sk injury tomy ctilvarTundtstond tha th Gore of dager and the seriousness of the rik aries om one spt anche wih anit sports eying the higher isk have hd an opportunity to unde the rik nero! spots hough meetings, writen Ido, o some oer means. Helse hos sont medeaacidn insurance avalabe through he shoo (es no); hs alec iiption insane eoverge through the school (jes no is insued by orf pole wth ame of Masia Imuranee Company —————————————— Paley Number ‘Nae of Poly Holler an avare ht prtcpating in sports wlinvlve vel wih dhe tea. acknowledge and ace the rhs inherent inthe sport ud wits the el involved snd wth this knowledge In mind, pnt persion for my childward to pricpte nthe sport and ave, ‘vs the ea, By ths signature, {ashy consent tallow the pyc) and ther heath ear rider) sls by myself othe solo perf a pre-pacpaton examination on my hid and to provide teatment fer any injryorcodton resin from partiating t Utlecfstvies fr hsher school dating the schol yes Cover by ths frm. I frther coment allow aid physicians) or bel ‘ore provider) fo she apyopr iafmatonconceraing my eid ta seve t pation ia ubletes and actives wih ‘aces td ter shoo personel as deri necessary. “Addon Ive my conse al apval fo th above named student’ picture and name toe printed any high seo! or ‘VHS. tlt rogram, publication o vide. "To acess quay, low-oe comprehensive health insurance tough FAMIS for your child, please contact Cover Virginia by ing to won cover. orealling 8552428282 PART V- EMERGENCY PERMISSION FORM (lobe complete nl sect prin) STUDENT'S NAME, Grape Acr___por mucnscHoon ey ‘Pc ty OER a iia pn ong ou co aa EE Plea a any leet medion, isthe student curently resrbed an inhaler or Epi-Pon?_— List the emery medication; Isstudent presently taking any ether medication? Tso, what type? Does stent wear contac loses? Date of last dap of T (tama) shat EMERGENCY AUTHORIZATION: | ths event! canot be reseed in an meen, I hereby ave prison to physics Selected by the couches ndstafol igh Scholl sci proper teament fant dr njeeton alr anus anor surge for peso pamed abo. Daytine phone nanber (whee oath you in emery) Evening time pone umber (hereto ech you in emergency) Cet phone 4b b Signature of parent or guardian Dat Relationship to student __ "Tmergeny Pemision For may Be reproduced o Wave wih espaive tans and is ascepable or emergency Wetnet fost 1 certify all the above information is correct a Parent/Guardian Signature ‘he repro phys nmi atte ovata amin ytd’ ener phys.