Physician`s Certificate - Discovery Middle School - Penn

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Penn Harris Madison Middle School Athletics 2015 - 2016
Athletic Medical Insurance Certification
RE: _________________________________ at
DISCOVERY_____________
(Name of School)
SHERYLL HARPER________
(Principal)
Birth Date: ___________________________
Grade in the Fall: (Circle One)
6
7
8
Gender: (Circle One)
Male
Female
Parents: I hereby give my consent for the aforementioned student to participate in the following
interscholastic sport(s) circled below:
Cross Country
Football
Volleyball
Wrestling
Girl's Basketball
Boy's Basketball
Boy's Track
Girl's Track
Cheerleading
I will NOT hold school authorities responsible in case of accident or injury as a result of this
participation.
He/She:
(ONE OF THE ITEMS MUST BE CHECKED)
(1) Is purchasing school student accident insurance
(see application & check attached)
________
(2) Has family insurance coverage and declines
student accident insurance offered through
PHM
_______
A parent/guardian must purchase the school student athletic insurance when family insurance
coverage is no longer available in order for a child to participate in Middle School Athletics.
SIGNED:______________________________
(Parent/Guardian)
_________________________________
(Student)
DATE: _________________________
Physician’s Certificate
PHYSICIAN: I have examined the heart action, blood pressure, lungs, and general
physiological condition of aforementioned student and believe him/her to be physically fit to
participate in all interscholastic sports except _______________________________ during the
present year. I have found him/her to be free from serious heart
and lung disorder.
Date: _____________________________
Physician: _________________________________
Previous to a student’s first practice or tryout for any interscholastic athletic contest, he/she
shall have on file in the principal’s office for each school year, a Parent & Physician’s
Certificate of physical fitness, giving written consent from the father, mother or guardian for
such athletic participation. According to the IHSAA, a physical executed on or after April 1st is
good for the remainder of the current school year and for the next school year. The physical
examination shall be made prior to the student’s first practice or tryout for any
interscholastic contest by a physician licensed to practice medicine in Indiana. A student
properly certified to participate in interscholastic athletic activities who is absent from school or
who is physically unable to practice for five consecutive days due to illness or injury, must
present to his principal a statement from a physician licensed to practice in Indiana that he/she is
again physically fit to participate in interschool athletics.
Revised 4/13
PENN-HARRIS-MADISON SCHOOL CORPORATION
MIDDLE SCHOOL ATHLETIC/ACADEMIC
COMPETITION AND EXTRACURRICULAR
ACTIVITY CODE OF CONDUCT
It is a privilege and an honor to represent PHM Middle Schools in any contest, competition, or activity.
We expect our students and their behavior to be a source of pride and dignity at these events.
Any student choosing to become involved in any athletic, academic, or extracurricular program is expected
to consistently observe specific behavioral and academic expectations in order to maintain continuing
eligibility for participation in these programs.
1.
2.
3.
4.
5.
6.
7.
No involvement with or use of alcohol.
No involvement with or use of tobacco.
No involvement with or use of drugs.
Comply with PHM Students Policy 360 (Random Drug Screening).
No act of gross misconduct.
Follow team, activity, or club rules and expectations.
Maintain passing grades meeting school eligibility rules.
Students who violate any of these basic expectations on or off school property will be subject to immediate
disciplinary consequences.
Also, it is recommended that parents of students participating in intramural activities have their child
examined by a physician if there is any doubt about the child’s health. THE SCHOOL CORPORATION
DOES NOT COVER INSURANCE COSTS FOR ANY STUDENT INJURED DURING
EXTRACURRICULAR ACTIVITIES.
ALL STUDENTS DESIRING TO PARTICIPATE IN ANY ATHLETIC, ACADEMIC, OR OTHER
EXTRACURRICULAR PROGRAM MUST CONSENT TO PARTICIPATE IN THE STUDENT DRUG
EDUCATION AND TESTING PROGRAM. STUDENTS MAY NOT PARTICIPATE UNTIL A
CONSENT FORM IS COMPLETED AND ON FILE IN THE SCHOOL OFFICE.
Consequences for a positive drug test are as follows:
First positive test = ineligible for current season.
Second positive test = ineligible for one calendar school year (12 months).
Students participating in athletics will follow academic guidelines established by the PHM School
Corporation, which state: Participants’ grades will be evaluated at three-week intervals. Any individual
failing two subjects will be ineligible for the following three weeks. Athletes who are receiving one F will
not be allowed to participate for one week. If they are passing after one week, they may be reinstated on
the team. If they are failing at that time, they are ineligible for two more weeks.
SIGNATURES BY BOTH PARENT AND STUDENT ARE REQUIRED PRIOR TO STUDENT
PARTICIPATION IN ANY CONTEST, COMPETITION, OR ACTIVITY
PLEASE PRINT
Student Signature
Parent Signature
STUDENT NAME
Date
Grade
Date
THIS FORM COVERS ALL ATHLETIC/ACADEMIC COMPETITIONS AND
EXTRACURRICULAR ACTIVITIES FOR THE 2014 – 2015 SCHOOL YEAR
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