RCS ATHLETIC DEPARTMENT

SPORTS UPDATE

NAME_______________________________GR_____SPORT__________________________

DATE____________________________ DATE OF LAST PHYSICAL_______________

Medical history-IN THE PAST YEAR:

YES NO

1. Any injuries requiring medical attention? ____ ____

2. Any illness lasting more that 5 days? ____ ____

3. Taking any medications or under a physicians care at this time? ____ ____

4. Any feeling of faintness, dizziness or fatigue after heavy

exertion? ____ ____

5. Any surgery, fractures or dislocations? ____ ____

6. Treated in a hospital or emergency room? ____ ____

MEDICAL HISTORY IN GENERAL:

1. Wears glasses or contact lenses? ____ ____

2. Any known allergies? ____ ____

3. Any chronic diseases? ____ ____

If YES to any of the above questions above please describe in detail including dates__________

_____________________________________________________________________________

To my knowledge, there is no medical reason that my child cannot participate in interscholastic sports.

Signature of Parent/Guardian __________________________________ Date______________

In accordance with school district medication policy, students needing prescribed or over the counter medications during the school day or during after-school activities are required to have parent and physician permission forms on file with the school nurse.

SPORTS UPDATES REQUIRED: AT THE START OF EACH SPORT SEASON AND FOR SCHOOL PHYSICIAN’S REVIEW BEFORE SCHOOL PHYSICAL APPRAISAL.

PLEASE RETURN TO THE NURSE’S OFFICE AT YOUR CHILD’S SCHOOL