Section 8: Re-Certification by Parent/Guardian (Winter)

Items marked with an asterisk (*) are required.

Form Requirement(s)

Required for Athlete Overall Approval.
Student Athlete Signature Required.
Parent Signature Required.
Staff Signature Required.
Use of the Previous Year Form is allowed as long as it is not expired.

Auto Approval: Auto-Approve enabled with the EXCEPTION of all Uploaded forms and History Forms with Yes answers.

This form must be completed not earlier than six weeks prior to the first Practice day of the sport(s) in the sports season(s) identified herein by the parent/guardian of any student who is seeking to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in all subsequent sport seasons in the same school year. The Principal, or the Principal’s designee, of the herein named student’s school must review the SUPPLEMENTAL HEALTH HISTORY.

If any SUPPLEMENTAL HEALTH HISTORY questions are either checked yes or circled, the herein named student shall submit a completed Section 8 , Re-Certification by Licensed Physician of Medicine or Osteopathic Medicine, to the Principal, or Principal’s designee, of the student’s school.

* Student's Name

* Gender

* Age of Student on Last Birthday

* Grade for Current School Year

CHANGES TO PERSONAL INFORMATION

In the spaces below, identify any changes to the Personal Information set forth in the original Section 1: PERSONAL AND EMERGENCY INFORMATION

Current Home Address

Current Home Telephone #

Parent/Guardian Current Cellular Phone #

CHANGES TO EMERGENCY INFORMATION

In the spaces below, identify any changes to the Emergency Information set forth in the original Section 1: PERSONAL AND EMERGENCY INFORMATION

Parent’s/Guardian’s Name

Relationship

Address

Emergency Contact Telephone #

Secondary Emergency Contact Person’s Name

Relationship

Address

Emergency Contact Telephone #

Medical Insurance Carrier

Policy Number

Group Number

Address

Telephone #

Family Physician’s Name

Title

Address

Telephone

SUPPLEMENTAL HEALTH HISTORY		Yes	No
1.	* Since completion of the CIPPE, have you sustained an illness and/or injury that required medical treatment from a licensed physician of medicine or osteopathic medicine?
2.	* Since completion of the CIPPE, have you had a concussion (i.e. bell rung, ding, head rush) or traumatic brain injury?
3.	* Since completion of the CIPPE, have you experienced dizzy spells, blackouts, and/or unconsciousness?
4.	* Since completion of the CIPPE, have you experienced any episodes of unexplained shortness of breath, wheezing, and/or chest pain?
5.	* Since completion of the CIPPE, are you taking any NEW prescription medicines or pills?
6.	* Do you have any concerns that you would like to discuss with a physician?

Explain “Yes” answers here

I hereby certify that to the best of my knowledge all of the information herein is true and complete.

Signatures

Student Athlete

Print Name:

Signature:

Date:

Parent / Guardian

Print Name:

Signature:

Date:

My clicking on the Sign & Submit Form button below is my signature and indicates that to the best of my knowledge, my answers and information provided to the above questions are complete and correct. I understand that the information about my account that I have provided on this form may be used for analytical and research purposes anonymously (without any personally identifying information). I consent to the access and use of this data by Pennsylvania Interscholastic Athletic Association, the Notre Dame Sd, BigTeams, LLC.