SOUTH BURLINGTON HIGH SCHOOL

SPORT PHYSICAL FORM

This form (or equivalent proof of a physical) must be on file in the South Burlington High School Nurse’s office before a student is eligible to participate in a co-curricular athletic activity

Name of Student ___________________________________________________________

Student’s Address:__________________________________________________________

Date of Birth: ________________________Age ______ Grade ________

Height _________ Weight _________ Blood Pressure __________ Pulse ________

Significant Past Illness or Injury ____________________________________________

____________________________________________________________________________

Scoliosis Screening: o Negative o Re-screen o Watch ____________

Laboratory Urinalysis -Protein _______ Glucose ______ Others ________________

Weight Loss Permitted -Yes _____ No _____ If "yes," may lose ________ Pounds

Please check one of the following: o Eligible for all sports

o Exceptions

o Follow up necessary

Comments: ______________________________________________________________________________

Physician's Signature: ________________________ Address: ______________________

__________________________________

Date of Examination: _______________________

ATHLETIC PARTICIPATION FORM

STUDENT NAME

STUDENT PARTICIPATION: This application to compete in interscholastic athletics for SBHS is entirely voluntary on my part and is made with the understanding that I have not violated any of the eligibility rules and regulations of the Vermont Principals' Association.

Please circle the sport(s) in which you will participate:

Date: ________________ Student Signature: ___________________________________

PARENTAL/GUARDIAN PERMISSION

I hereby give my consent for the above named student to participate in Vermont Principals' Association approved athletic programs as a representative of South Burlington High School. I also give my consent for the above student to travel with his/her team on out-of town trips.

Date:___________ Parent/Guardian Signature:__________________________________

INSURANCE INFORMATION

(Vermont Principals' Association requires proof of insurance to participate)

Please check one:

o My son/daughter is covered under our own insurance policy.

Policy Number: ______________________Company: ________________________

o My son/daughter will or has purchased the school accident insurance policy, and paid extra premiums, if necessary, for participation. This policy will give her/him coverage during any school activities.