PIAA - Sec 8 Recertification-combined

PIAA: RE-CERTIFICATION BY PARENT/GUARDIAN

School Year*

School District*

Athlete First Name*

Athlete Last Name*

MaleFemale

Athlete Date of Birth*

Date

Age of Athlete on Last Birthday*

Athlete Home Address*

Athlete Home Phone Number*

Athlete Home Phone Number 2*

Athlete Cell Number*

Grade for Current School Year*

Winter Sport(s)

Spring Sport(s)

Parent/Guardian #1 Name*

Parent/Guardian #1 Cell Number*

Relationship to Athlete*

Parent/Guardian #1 Email Address*

Parent/Guardian #1 Physical Address*

Parent/Guardian #1 Cell Number*

Parent/Guardian #2 Name

Relationship to Athlete

Parent/Guardian #2 Physical Address

Parent/Guardian #2 Cell Number

You are required to provide medical insurance coverage in order to participate in our interscholastic program. This certifies that my child has proper and adequate coverage.

Medical Insurance Carrier*

Policy No.*

Group No.

Medical Subscriber Name*

Subscriber SS #

Medical Insurance Address*

Medical Insurance Phone Number*

Family Physician Name*

Family Physician Address*

Family Physician Phone Number*

Dentist

Dentist Phone Number

Is your athlete allergic to any medication?

Is there any condition other than stated above, that a physician should be aware of?

If any SUPPLEMENTAL HEALTH HISTORY questions below are checked YES, the Athlete must submit a completed PIAA form Section 9, Re-Certification by Licensed Physician of Medicine or Osteopathic Medicine.

YESNO

If you marked YES to any above, please explain.

Does your athlete wear: contacts/ glasses Has your athlete ever had: asthma/ diabetes / kidney injury / heart condition If yes, please explain:

If yes, please explain

Athlete Signature*

Date*

Date

Parent/Guardian Signature*

Date*

Date

Radnor Township School District Permission from Parent, Guardian for Medical Treatment

Winter Sport

Athlete Last Name*

Athlete First Name*

Grade*

Athlete Date of Birth*

Date

As a parent/guardian I expect every effort will be made to contact me in order to receive my specific authorization before any treatment or hospitalization is undertaken.

Parent/Guardian #1 Name*

Parent/Guardian #1 Cell Number*

Parent/Guardian #2 Name*

Parent/Guardian #2 Cell Number*

Athlete Home Address*

If Parent/Guardian cannot be reached call:

Emergency Contact #1 Name

Emergency Contact #1 Phone Number

Relationship to Athlete

Emergency Contact #2 Name

Emergency Contact #2 Phone Number

Relationship

In the event of an emergency requiring medical attention, I grant permissison to a physician or other hospital personnel designated by the Radnor coaching staff to attend my son/daughter.

Print Parent/Guardian Name*

Signature Parent/Guardian*

Date*

Date

Family Physician*

Family Physician Phone Number*

Medical Insurance Company*

Policy No.*