SPORTS SCREENING FORM
SPORTS PHYSICAL EXAMINATION FOR ALL ATHLETES
TUESDAY, JUNE 4, 2019
5:00 PM TO 9:00 PM
RILL GYMNASIUM AT CONESTOGA VALLEY HIGH SCHOOL
1. Fill out the attached forms (including the first two lines of Section 6) before arriving at the physical. Write the grade for the upcoming school year on the appropriate line. Be sure to complete every item on the checklist below. Physicals cannot be administered for students with incomplete forms.
2. Wear shorts and a t-shirt to the physical.
3. Bring $20.00 in cash or check made payable to Conestoga Valley High School. If you pay by check, please write “sports physical” on the memo line. You may write one check for multiple children.
4. Parents are welcome but not required to attend.
5. June 4 is the only day that CV will offer sports physicals for the 2019-2020 school year. Fall, winter, and spring athletes may all attend. If you do not attend this physical, you are responsible to arrange an exam with your own doctor.
Help us avoid long lines! Please arrive within the following time frame (based on last name):
A-E: 5:00-5:45 PM
F-L: 6:00-6:45 PM
M-R: 7:00-7:45 PM
S-Z: 8:00-8:45 PM
- If you cannot arrive within your recommended time, please contact Mrs. Hess by May 29 to ensure that we can accommodate your schedule. Otherwise, if you arrive outside of your window, you will be asked to wait until students in that window have been registered.
This sports physical is also acceptable for the state-mandated 11th-grade physical. Copies of all current 10th-graders’ physicals will be sent to the school nurse.
Regardless of whether you attend the sports physical at the high school or go to your own physician, the exam must be recorded on the CV/PIAA form. All forms are due before the first day of practice:
High school football – Wednesday, July 31
All other high school fall sports AND junior high cross country – Wednesday, August 7
All other junior high fall sports – Wednesday, August 14
CHECKLIST
Please write student’s grade for the upcoming school year on the appropriate lines on the form
_____ CV Sports Medicine Information Form
_____ CIPPE Section 1
_____ CIPPE Section 2, parts A, B, C, D, E, and F
_____ CIPPE Section 3 (be sure to include both student and parent signatures)
_____ CIPPE Section 4 (be sure to include both student and parent signatures)
_____ CIPPE Section 5 (be sure to include both student and parent signatures)
_____ CIPPE Section 6 (complete top two lines ONLY)
QUESTIONS? Contact Jessica Hess, LAT, ATC, head athletic trainer:
Office: (717) 397-5231, ext. 1074 E-mail: jessica_hess@
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