REVISED JANUARY 2021
VIRGINIA HIGH SCHOOL LEAGUE, INC.
1642 State Farm Blvd., Charlottesville, Va. 22911
ATHLETIC PARTICIPATION/PARENTAL CONSENT/PHYSICAL EXAMINATION FORM
Separate signed form is required for each school year MAY 1 of the current year through JUNE 30 of the succeeding year.
For school year_________ PART I- ATHLETIC PARTICIPATION Male___
(To be filled in and signed by the student) Female___
PRINT CLEARLY
Name _________________________________________________________________ Student ID#______________________________
(Last) (First) (Middle Initial)
Home Address ________________________________________________________________________________________________________
City/Zip Code ________________________________________________________________________________________________________
Home Address of Parents ________________________________________________________________________________________________
City/Zip Code ________________________________________________________________________________________________________
Date of Birth ____________________________________ Place of Birth ________________________________________________
This is my _______ semester in _________________________ High School, and my _______ semester since first entering the ninth grade. Last
semester I attended __________________________________ School and passed _______ credit subjects, and I am taking _______ credit subjects
this semester. I have read the condensed individual eligibility rules of the Virginia High School League that appear below and believe I am eligible to
represent my present high school in athletics.
INDIVIDUALIZED ELIGIBILITY RULES
To be eligible to represent your school in any VHSL interscholastic athletic contest, you:
Must be a regular bona fide student in good standing of the school you represent.
Must be enrolled in the last four years of high school. (Eighth-grade students may be eligible for junior varsity)
Must have enrolled not later than the fifteenth day of the current semester.
For the first semester must be currently enrolled in not fewer than five subjects, or their equivalent, offered for credit and which may be used
for graduation and have passed five subjects, or their equivalent, offered for credit and which may be used for graduation the immediately
preceding year or the immediately preceding semester for schools that certify credits on a semester basis. (Check with your principal for
equivalent requirements.) May not repeat courses for eligibility purposes for which credit has been previously awarded.
For the second semester must be currently enrolled in not fewer than five subjects, or their equivalent, offered for credit and which may be
used for graduation and have passed five subjects, or their equivalent, offered for credit and which may be used for graduation the
immediately preceding semester. (Check with your principal for equivalent requirements.)
Must sit out all VHSL competition for 365 consecutive calendar days following a school transfer unless the transfer corresponded with a family
move. (Check with your principal for exceptions.)
Must not have reached your nineteenth birthday on or before the first day of August of the current school year.
Must not, after entering ninth grade for the first time, have been enrolled in or been eligible for enrollment in high school more than eight
consecutive semesters.
Must have submitted to your principal before any kind of participation, including tryouts or practice as a member of any school athletic or
cheerleading team, an Athletic Participation/Parent Consent/Physical Examination Form, completely filled in and properly signed attesting
that you have been examined during this school year and found to be physically fit for competition and that your parents’ consent to your
participation.
Must not be in violation of VHSL Amateur, Awards, All Star or College Team Rules. (Check with your principal for clarification about
cheerleading.)
Eligibility to participate in interscholastic athletics is a privilege you earn by meeting not only the above-listed minimum standards, but also all
other standards set by your League, district and school. If you have any question regarding your eligibility or are in doubt about the effect an
activity might have on your eligibility, check with your principal for interpretations and exceptions provided under League rules. Meeting the
intent and spirit of League standards will prevent you, your team, school and community from being penalized. Additionally, I give my consent and
approval for my picture and name to be printed in any high school or VHSL athletic program, publication or video.
LOCAL SCHOOL DIVISIONS AND VHSL DISTRICTS MAY REQUIRE ADDITIONAL STANDARDS TO THOSE LISTED ABOVE.
→Student Signature:_____________________________________________________ Date:_______________________________
PROVIDING FALSE INFORMATION WILL RESULT IN INELIGIBILITY FOR ONE YEAR.
Page 1 of 4
REVISED JANUARY 2021
The pre-participation physical examination is not a substitute for a thorough annual examination by a student’s primary care physician.
PART II- MEDICAL HISTORY (Explain “YES” answers below)
This form must be complete and signed, prior to the physical examination, for review by examining practitioner.
Explain “YES” answers below with number of the question. Circle questions you don’t know the answers to.
GENERAL MEDICAL HISTORY
YES
NO
MEDICAL QUESTIONS CONTINUED
YES
NO
1. Do you have any concerns that you would like to discuss with
your provider?
24. Have you had mononucleosis (mono) within the last month?
25. Are you missing a kidney, eye, testicle, spleen or other
internal organ?
2. Has a provider ever denied or restricted your participation in
sports for any reason?
26. Do you have groin or testicle pain or a painful bulge or hernia
in the groin area?
3. Do you have any ongoing medical conditions? If so, please
identify: Asthma Anemia Diabetes Infections
Other: _________________________
27. Have you ever become ill while exercising in the heat?
28. When exercising in the heat, do you have severe muscle
cramps?
4. Are you currently taking any medications or supplements on
a daily basis?
29. Do you have headaches with exercise?
5. Do you have allergies to any medications?
30. Have you ever had numbness, tingling or weakness in your
arms or legs or been unable to move your arms or legs
AFTER being hit or falling?
6. Do you have any recurring skin rashes or rashes that come
and go, including herpes or methicillin-resistant
Staphylococcus aureus (MRSA)?
31. Do you or does someone in your family have sickle cell trait
or disease?
7. Have you ever spent the night in the hospital? If yes, why?
______________________________________
32. Have you had any other blood disorders?
8. Have you ever had surgery?
33. Have you had a concussion or head injury that caused
confusion, a prolonged headache or memory problems?
HEART HEALTH QUESTIONS ABOUT YOU
YES
NO
9. Have you ever passed out or nearly passed out DURING or
AFTER exercise?
34. Have you had or do you have any problems with your eyes
or vision?
10. Have you ever had discomfort, pain, tightness, or pressure in
your chest during exercise?
35. Do you wear glasses or contacts?
36. Do you wear protective eyewear like goggles or a face shield?
11. Does your heart race, flutter in your chest or skip beats
(irregular beats) during exercise?
37. Do you worry about your weight?
38. Are you trying to or has anyone recommended that you gain
or lose weight?
12. Has a doctor ever ordered a test for your heart? For
example, electrocardiography or echocardiography.
39. Do you limit or carefully control what you eat?
13. Has a doctor ever told you that you have any heart problems,
including:
High blood pressure A heart murmur
High cholesterol A heart infection
Kawasaki Disease Other _______________
40. Have you ever had an eating disorder?
41. Are you on a special diet or do you avoid certain types of
foods or food groups?
42. Allergies to food or stinging insects?
43. Have you ever had a COVID-19 diagnosis? Date:
44. What is the date of your last Tdap or Td (tetanus) immunization?
(circle type) Date: ____________
14. Do you get light-headed or feel shorter of breath than your
friends during exercise?
FEMALES ONLY
YES
NO
15. Have you ever had a seizure?
45. Have you ever had a menstrual period?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
YES
NO
46. Age when you had your first menstrual period: ___________
16. Does anyone in your family have a heart problem?
47. Number of periods in the last 12 months: _______________
17. Has any family member or relative died of heart problems or
had an unexpected or unexplained sudden death before age
35 (including drowning or unexplained car crash)?
48. When was your most recent menstrual period? __________
EXPLAIN “YES” ANSWERS BELOW
# >>
18. Does anyone in your family have a genetic heart problem
such as hypertrophic cardiomyopathy (HCM), Marfan
syndrome, arrhythmogenic right ventricular cardiomyopathy
(ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS),
Brugada syndrome, or catecholaminergic polymorphic
ventricular tachycardia (CPVT)?
# >>
# >>
# >>
19. Has anyone in your family had a pacemaker or an implanted
defibrillator before age 35?
# >>
BONE AND JOINT QUESTIONS
YES
NO
20. Have you ever had a stress fracture or an injury to a bone,
muscle, ligament, joint, or tendon that caused you to miss a
practice or game?
# >>
# >>
21. Do you currently have a bone, muscle or joint injury that
bothers you?
List medications and nutritional supplements you are currently taking here:
MEDICAL QUESTIONS
YES
NO
22. Do you cough, wheeze or have difficulty breathing during or
after exercise?
23. Do you have asthma or use asthma medicine (inhaler,
nebulizer)?
→ Parent/Guardian Signature: _______________________ Date: ______ → Athlete’s Signature: _____________________
Page 2 of 4
REVISED JANUARY 2021
PART III- PHYSICAL EXAMINATION
(Physical examination form is required each school year dated after May 1 of the preceding school year
and is good through June 30
of the current school year)**
NAME__________________________________________ DATE OF BIRTH________________ SCHOOL____________________________________
Height
Weight
Male
Female
BP /
Resting pulse
Vision R 20/
L 20/
Corrected Yes
No
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance (Marfan stigmata: kyphoscoliosis, high-arched palate, pectus
excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse, and
aortic insufficiency)
Eyes/ears/nose/throat (Pupils equal, hearing)
Lymph nodes
Heart (Murmurs: auscultation standing, supine, +/- Valsalva)
Pulses
Lungs
Abdomen
Skin (Herpes simplex virus, lesions suggestive of MRSA or tinea corporis)
Neurological
MUSCULOSKELETAL
NORMAL
ABNORMAL FINDINGS
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional (i.e. Double leg squat, single leg squat, box drop or step drop test)
Emergency medications required on-site: Inhaler Epinephrine Glucagon Other:
COMMENTS:
I have reviewed the data above, reviewed his/her medical history form and make the following
recommendations for his/her participation in athletics:
MEDICALLY ELIGIBLE FOR ALL SPORTS WITHOUT RESTRICTION
MEDICALLY ELIGIBLE FOR ALL SPORTS WITHOUT RESTRICTION WITH RECOMMENDATION FOR FURTHER EVALUATION OR TREATMENT OF:
_______________________________________________________________________________________________________________________
MEDICALLY ELIGIBLE ONLY FOR THE FOLLOWING SPORTS:______________________________________________________________________
Reason:_________________________________________________________________________________________________________
NOT MEDICALLY ELIGIBLE PENDING FURTHER EVALUATION OF: _________________________________________________________________
NOT MEDICALLY ELIGIBLE FOR ANY SPORTS
By this signature, I attest that I have examined the above student and completed this pre-participation
physical including a review of Part II- Medical History.
→ PRACTITIONER SIGNATURE: ____________________________________________ (MD, DO, NP or PA)
+
DATE**: ________________________
EXAMINER’S NAME AND DEGREE (PRINT): ___________________________________________ PHONE NUMBER: ___________________________
ADDRESS: ________________________________________ CITY: _________________________________ STATE: _________ ZIP: ______________
+Only signature of Doctor of Medicine, Doctor of Osteopathic Medicine, Nurse Practitioner or Physician’s Assistant
licensed to practice in the United States will be accepted.
Rule 28B-1 (3) Physical Examination Rule/Transfer Student (10-90)- When an out-of-state student who has received a current physical examination elsewhere
transfers to Virginia and attaches proof of that physical examination to the League form #2, the student is in compliance with physical examination requirements.
Page 3 of 4
REVISED JANUARY 2021
PART IV- ACKNOWLEDGEMENTS OF RISK AND INSURANCE STATEMENT
(To be completed by parent/guardian)
I give permission for _____________________________________ (name of child/ward) to participate in any of the
following sports that are NOT crossed out: baseball, basketball, cheerleading, cross country, field hockey, football, golf, gymnastics,
lacrosse, soccer, softball, swim/dive, tennis, track, volleyball, wrestling, other (identify sports): _______________________________
I have reviewed the individual eligibility rules and I am aware that with the participation in sports comes the risk of injury to
my child/ward. I understand that the degree of danger and the seriousness of the risk varies significantly from one sport to another
with contact sports carrying the higher risk. I have had an opportunity to understand the risk inherent in sports through meetings,
written handouts or some other means. He/she has student medical/accident insurance available through the school (yes__ no__);
has athletic participation insurance coverage through the school (yes__ no__); is insured by our family policy with:
Name of medical insurance company: _____________________________________________________________________________
Policy number: ______________________________________ Name of policy holder: _______________________________
I am aware that participating in sports will involve travel with the team. I acknowledge and accept the risks inherent in the
sport and with the travel involved and with this knowledge in mind, grant permission for my child/ward to participate in the sport
and travel with the team.
By this signature, I hereby consent to allow the physician(s) and other health care provider(s) selected by myself or the
school to perform a pre-participation examination on my child and to provide treatment for any injury or condition resulting from
participation in athletics/activities for his/her school during the school year covered by this form. I further consent to allow said
physician(s) of health care provider(s) to share appropriate information concerning my child that is relevant to participation in
athletics and activities with coaches and other school personnel as deemed necessary.
Additionally, I give my consent and approval for the above named student’s picture and name to be printed in any high
school or VHSL athletic program, publication or video.
To access quality, low-cost comprehensive health insurance through FAMIS for your child, please contact Cover Virginia by
going to www.coverva.org or calling 855-242-8282.
PART V- EMERGENCY PERMISSION FORM*
(To be completed and signed by the parent/guardian)
STUDENT’S NAME: ____________________________________________ GRADE: __________ AGE: _______ DOB: ______________
HIGH SCHOOL: ___________________________________________________________ CITY: _______________________________
Please list any significant health problems that might be significant to a physician evaluating your child in case of an emergency:
____________________________________________________________________________________________________________
PLEASE LIST ANY ALLERGIES TO MEDICATIONS, ETC: _________________________________________________________________
____________________________________________________________________________________________________________
IS THE STUDENT CURRENTLY PRESCRIBED AN INHALER OR EPI-PEN? ______ LIST THE EMERGENCY MEDICATION: ________________
IS THE STUDENT PRESENTLY TAKING ANY OTHER MEDICATION? _______ IF SO, WHAT? ____________________________________
DOES THE STUDENT WEAR CONTACT LENSES? ______________________ DATE OF LAST Tdap OR Td (TETANUS) SHOT: ___________
EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by
the coaches and staff of ____________________________________ High School to hospitalize, secure proper treatment for and to
order the injection and/or anesthesia and/or surgery for the person named above.
DAYTIME PHONE NUMBER (WHERE TO REACH YOU IN AN EMERGENCY): _________________________________________________
EVENING TIME PHONE NUMBER (WHERE TO REACH YOU IN AN EMERGENCY): ____________________________________________
CELL PHONE NUMBER: ____________________________________________
→ SIGNATURE OF PARENT/GUARDIAN: ________________________________________________ DATE: _____________________
RELATIONSHIP TO STUDENT: ____________________________________________________________________________________
*Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency treatment in needed.
→ I CERTIFY ALL OF THE ABOVE INFORMATION IS CORRECT: __________________________________________________________
Parent/Guardian signature
The pre-participation physical examination is not a substitute for a thorough annual examination by a student’s primary care physician.
Page 4 of 4
Page 1 of 4
SY 2023 - 2024
2023-2024
ATHLETIC PREPARTICIPATION FORMS
_______
Sudden Cardiac Arrest In Sport
What is cardiac arrest?
Cardiac arrest is the sudden loss of heart function that results in an individual’s loss of consciousness. Cardiac arrest is a
true medical emergency and must be treated immediately to increase the likelihood of survival. Cardiac arrest can occur
at any age and may appear suddenly, or after an individual experiences warning signs. It is not the same as a heart
attack. Sudden cardiac arrest is the number one cause of exercise related death in youth athletes.
Who is at risk for sudden cardiac arrest?
Risk Factors
Warning Signs That May Lead to Cardiac Arrest
▪ Family history of heart disease, attack, or
cardiac death
▪ Cardiac conditions such as high blood
pressure, diabetes, obesity, smoking or
high cholesterol
▪ Underlying or unknown cardiac condition
▪ Unexplained fainting or near fainting
▪ Chest Pain or Tightness
▪ Heart racing (chest palpitations)
▪ Abnormal shortness of breath
▪ Lightheadedness
Sudden Cardiac Arrest Association (n.d.). Fact Sheet: Sudden Cardiac Arrest [Fact sheet]. Microsoft Word - Fact Sheet SCA 2011.doc (associationdatabase.com)
What Should you do if you think your child is at risk?
If you think your child may have risk factors, or has exhibited warning signs of cardiac arrest, you should -
✓ Remove your child from physical activity
✓ Schedule an appointment to see your primary care physician or family doctor
✓ Do not allow your child to participate in any physical exertion until cleared by a physician
What is done in a sudden cardiac arrest emergency?
✓ Check the scene and for a response from patient
✓ Call 911
✓ Ask someone to get an Automated External Defibrillator (AED), if available
✓ Begin CPR (cardiopulmonary resuscitation)
Page 2 of 4
SY 2023 - 2024
How does Norfolk Public Schools Athletics prepare for a sudden cardiac arrest emergency?
As with all emergencies, Norfolk Public Schools Athletics works to prepare for sudden cardiac arrest:
✓ Each High School & Middle School has an Emergency Action Plan in place that is reviewed annually by coaches,
medical personnel, and staff
✓ Each coach and athletic staff member must hold a First Aid, CPR, and AED certification from a nationally
recognized organization
✓ Automated External Defibrillators are available within each of our schools
✓ Policies in place to encourage safe participation in various environmental hazards
✓ Preparticipation exams (physicals) are required annually for each student-athlete prior to participation in activity
While these prevention strategies are in place for everyone’s safety, Norfolk Public Schools cannot guarantee that a
cardiac emergency will not occur. Furthermore, participating in athletics could increase your child’s risk.
By signing this document, I have received the educational information above and that I have reviewed the risk factors
and warning signs of cardiac arrest.
_________________________ __________________________ _________
Print Name: Parent/Guardian Signature: Parent/Guardian Date
_________________________ __________________________ _________
Print Name: Athlete Signature: Athlete Date
The code of Virginia requires all school divisions to provide educational material regarding cardiac arrest to student-athletes and their parent or guardian on an annual
basis. This fact sheet is provided in accordance with § 22.1-271.8. Sudden cardiac arrest prevention in student-athletes.
CONTINUE TO NEXT PAGE
Page 3 of 4
SY 2023 - 2024
Concussions In Sport
Parents/Guardians of Athletes: In order to help protect the student athletes of Norfolk Public Schools, the Virginia General
Assembly in accordance with Senate Bill 652 (Concussion in Student-Athletes) has mandated that all student athletes, parents and
coaches follow the Norfolk Public Schools Concussion Policy. Please read and
sign this
fact sheet and return it to your school’s
Athletic Director prior to participation in any school sponsored athletic activity. This form must be reviewed and signed on a yearly
basis.
What is a
Concussion?
A concussion is a brain injury, otherwise known as a traumatic brain injury (TBI). A concussion is characterized by an onset of
impairment of cognitive and/or physical functioning, and is caused by a blow to the head, face or neck, or a blow to the body that
causes a sudden jarring of the head (i.e. a helmet to the head, being knocked to the ground). A concussion can occur with or
without a loss of consciousness, and proper management is essential to the immediate safety and long-term outcomes of the
injured individual. A repeat concussion that occurs before the brain recovers from the first can slow recovery or increase the
likelihood of having long term problems. In rare cases, repeat concussion can result in edema (brain swelling), permanent brain
damage, and even death.
What are the Signs and Symptoms of a Concussion?
Signs observed by teammates, coaches, parents/guardians include:
1. Appears dazed or stunned
2. Is confused about assignments and positions
3. Forgets instructions and answers questions slowly or
inaccurately
4. Is unsure of game, score, or opponent
5. Loss of balance/coordination and moves clumsily
6. Shows mood, behavior, or personality changes
7. Cannot recall events prior to hit or fall
8. Cannot recall events after hit or fall
Symptoms reported by athlete may include one or more of the following:
1. Headache or “pressure” in head
2. Nausea/vomiting
3. Balance problems or dizziness
4. Sensitivity to light or sound/noise
5. Feeling sluggish, hazy, groggy, or foggy
6. Difficulty with concentration, short-term
memory and/or confusion
7. Double vision or changes in vision
8. Irritability
9. Just not “feeling right” or is “feeling down”
How can you Help your Child Prevent a Concussion?
Every sport is different, but there are steps your child can take to protect themselves from concussion:
▪ Follow the coach’s rules for safety & the rules
of the sport
▪ To always practice good sportsmanship
▪ Properly wear the right protective equipment that is
required for their sport
▪ Learn the signs and symptoms of a concussion
Page 4 of 4
SY 2023 - 2024
How can a concussion affect my child in the classroom?
A concussion can result in cognitive disturbances, in addition to physical symptoms. While recovering from a concussion, a student-
athlete’s academic performance, or ability to tolerate an academic environment, may be affected. In order to facilitate recovery, a
Licensed Healthcare Provider may make temporary academic adjustments, or accommodations.
Effects of concussion that can be observed by a teacher, or in the classroom:
1. Difficulty tolerating the school
environment/cafeteria/hallways
2. Difficulty concentrating
3. Difficulty remembering
4. Falling asleep
5. Head on desk
6. Changes in academic performance
7. Trouble with test taking
8. ‘Daydreaming’
9. Less engaged in class and/or with classmates
What Should you do if you Think your Child has a
Concussion?
1. Seek medical attention right away. A licensed health care professional will be able to decide how serious the
concussion is and when it is safe for your child to return to sports.
2. Keep your child out of play. Concussions take time to heal. Don’t let your child return to play
until an appropriate licensed health care professional gives clearance to return. Children who return to play too
soon, while the brain is still healing, risk a greater chance of having a second concussion. Second or later
concussions can be very serious. This can lead to prolonged recovery, or even to severe brain swelling (second
impact syndrome) with devastating and even fatal consequences.
3. Tell your child’s coach about any recent concussions. School personnel should be notified if your child had a
recent concussion in any sport. Your child’s coach may not know about a concussion your child received in
another sport or activity unless you tell the coach.
Brief Overview of the Norfolk Public Schools Concussion Policy
A student-athlete who sustains a concussion must complete all of the following prior to return to participation
in NPS athletics:
1. Return to full participation in academic activities, without accommodations/adjustments
2. Six-stage Graduated Return to play Protocol
3. Have been seen, and released, by a physician who has been
trained in concussion management
4. Receive final clearance from the school’s Athletic Trainer
By signing this document, I acknowledge that I have reviewed the signs and symptoms of a concussion, agree to
report a concussion, and agree to follow the NPS Concussion Policy
(Full version available to view in Student Handbook).
Print Name: Parent/Guardian Parent/Guardian Signature Date
Print Name: Athlete Athlete Signature Date
REMEMBER: Don’t hide it. Report it. Take time to recover.
It’s
better to miss one game than the whole season!
