Miami-Dade County Public Schools Division of Athletics and ...

MIAMI-DADE COUNTY PUBLIC SCHOOLS

DIVISION OF ATHLETICS AND ACTIVITIES

ATHLETIC PHYSICAL FORM PROCEDURES

PROCEDURES FOR COMPLETING M-DCPS ATHLETIC PHYSICAL FORM FM-3439 - REVISED (05/23)

? Please be sure to complete the following sec?ons:

o Sec?on I �C Student Informa?on

o Sec?on II �C Parent/Guardian Informa?on

o Sec?on III �C Parent/Guardian Insurance Informa?on

? The physical will not be accepted as complete if any informa?on is missing.

FHSAA CONSENT AND RELEASE FROM LIABILITY CERTIFICATE �C EL3 �C REVISED (3/23)

Page 1 �C Student and Parent/Guardian Consent, Acknowledgment and Release (Completed form MUST be submited to the

school)

? Complete school name and school district (Miami-Dade County Public Schools) at top of page.

? Part 1: Student Acknowledgment and Release

o Read thoroughly with student and parent/guardian(s).

? Part 2: Parent/Guardian Consent, Acknowledgement and Release

o Read thoroughly and complete appropriate sec?ons.

o Sec?on A �C Parent/Guardian should list any sport(s) in which the student is NOT allowed to par?cipate.

o Sec?on G �C Parent/Guardian must check o? all insurance op?ons that apply to his/her child.

o The form must be signed and dated by the student and parent/guardian(s).

Page 2 �C Consent and Release from Liability Cer??cate �C Concussion Informa?on (Completed form MUST be submited to the

school)

? Complete school name and school district (Miami-Dade County Public Schools) at top of page.

? Read thoroughly with student and parent/guardian(s).

? The form must be signed and dated by the student and parent/guardian(s).

Page 3 �C Consent and Release from Liability Cer??cate �C Sudden Cardiac Arrest Informa?on (Completed form MUST be submited

to the school)

? Complete school name and school district (Miami-Dade County Public Schools) at top of page.

? Read thoroughly with student and parent/guardian(s).

? The form must be signed and dated by the student and parent/guardian(s).

Page 4 �C Consent and Release from Liability Cer??cate �C Heat-Related Illness Informa?on (Completed form MUST be submited to

the school)

? Complete school name and school district (Miami-Dade County Public Schools) at top of page.

? Read thoroughly with student and parent/guardian(s).

? The form must be signed and dated by the student and parent/guardian(s).

Page 5 �C Consent and Release from Liability Cer??cate �C FHSAA Eligibility Rules (Completed form MUST be submited to the

school)

? Complete school name and school district (Miami-Dade County Public Schools) at top of page.

? Read thoroughly with student and parent/guardian(s).

? The form must be signed and dated by the student and parent/guardian(s).

M-DCPS Contract for Student Par?cipa?on in Interscholas?c Compe??ons or Performances Form FM-7155 REVISED (5/23)

? Please be sure to complete the informa?on at top of page.

? Read thoroughly with student and parent/guardian(s).

? The form must be signed and dated by the student and parent/guardian(s).

GMAC Student-Athlete Sportsmanship Contract REVISED (5/23)

? Read thoroughly with student and parent/guardian(s).

? The form must be signed and dated by the student.

Student and Parent/Guardian Acknowledgment and Consent FM-3439 REVISED (5/23)

? Read Sec?on 1 and Sec?on 2 thoroughly with student and parent/guardian(s).

? The form must be signed and dated by the student in Sec?on 1.

? If the parent/guardian(s) grant the student permission to par?cipate in all interscholas?c athle?cs, write ��NONE�� in the

space provided.

? If the parent/guardian(s) do not grant the student permission to par?cipate in all interscholas?c athle?cs, list the sports NOT

allowed for par?cipa?on in space provided.

? The form must be signed and dated by the parent/guardian(s) in Sec?on 2.

? The form MUST BE NOTARIZED WITH AN OFFICIAL NOTARY STAMP AND SIGNATURE.

? Sec?on 3 is a Sportsmanship Agreement that must be signed and dated by the parent/guardian(s).

FLORIDA HIGH SCHOOL ATHLETIC ASSOCIATION (FHSAA) PREPARTICIPATION PHYSICAL EVALUATION �C EL2 �C REVISED (4/24)

(The following physical evalua?on forms have been strategically placed as the last pages of the athle?c physical packet for ease of detachment.)

Page 1 �C Medical History Form (Completed form to be retained by healthcare provider and/or parent)

? Complete Sec?on 1 �C Student Informa?on

? Complete Sec?on 2 �C Pa?ent Health Ques?onnaire version 4 (PHQ-4)

o Circle one response (0, 1, 2 or 3) based on criterion provided.

? Complete Sec?on 3 �C General Ques?ons/Heart Health Ques?ons

o Check ��Yes�� or ��No�� to ques?ons 1-13.

Page 2 �C Medical History Form (Completed form to be retained by healthcare provider and/or parent)

? Complete student��s full name, date of birth and school name at top of page.

? Complete Sec?on 4 �C Bone and Joint Ques?ons/Medical Ques?ons

o Check ��Yes�� or ��No�� to ques?ons 14-29.

? Read the later por?on of the form thoroughly. The form must be signed and dated by student and parent/guardian(s).

Page 3 �C Physical Examina?on Form (Completed form to be retained by healthcare provider and/or parent)

? Complete student��s full name, date of birth and school name at top of page.

? All other sec?ons of the physical examina?on form are to be completed by a licensed physician, licensed osteopathic

physician, licensed chiroprac?c physician, licensed physician assistant, or cer??ed registered nurse prac??oner.

? The form must be signed and dated by healthcare professional.

NOTE: PAGES (4 & 5) MUST BE SUBMITTED TO THE SCHOOL

Page 4 �C Physical Examina?on Form (Completed form MUST be submited to the school)

? Complete Sec?on 1 �C Student Informa?on

? Complete Sec?on 2 �C Medical clearance

o Must be completed, signed, and dated by medical provider.

? Complete Sec?on 3 - Shared Emergency Informa?on

o Must be completed at ?me of medical assessment by medical provider and parent.

o Please ensure any medica?on needs are listed as well as any relevant medical history is provided to be reviewed by

athle?c trainer/team physician.

o The medical provider must stamp page with medical provider stamp.

o The form must be signed and dated by the student and parent/guardian(s).

Page 5 �C Medical Eligibility Form �C Referred Provider Form (Completed form MUST be submited to the school)

? This form is a referral form. It should only be used if the student is referred to a specialist or another doctor for medical

clearance to par?cipate in sports.

? If referred, complete Sec?on 1 �C Student Informa?on

? Sec?on 2 �C Medical Clearance

o Must be completed by medical provider.

o The medical provider must stamp page with medical provider stamp.

o The form must be signed and dated healthcare professional.

NOTE: ONCE PHYSICAL PACKET IS COMPLETE WITH ALL REQUIRED SIGNATURES, DATES AND NOTARIZATION, THE STUDENT IS

ELIGIBLE TO PARTICIPATE IN THE PRESEASON SPORTS PHYSICAL EXAMINATION.

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MIAMI-DADE COUNTY PUBLIC SCHOOLS

DIVISION OF ATHLETICS AND ACTIVITIES

ATHLETIC PHYSICAL FORM

SCHOOL NAME _________________________________________ SCHOOL YEAR _______ /________ GRADE __________

SPORT(s) _____________________________ ______________________________ _____________________________

SECTION I �C STUDENT INFORMATION

LAST NAME __________________________________ FIRST NAME ________________________________ M.I. ________

BIRTHDATE ___________________________

FEMALE ___

MALE ___

ID# ______________________

HOME ADDRESS ____________________________________________ CITY ______________________ ZIP ___________

STUDENT EMAIL ADDRESS ___________________________________________ CELL PHONE _______________________

SECTION II �C PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN ______________________________ PHONE ________________ EMAIL ______________________

PARENT/GUARDIAN ______________________________ PHONE ________________ EMAIL ______________________

EMERGENCY CONTACT NAME _______________________________________ RELATIONSHIP _____________________

EMERGENCY CONTACT PHONE ___________________________

SCHOOL BOARD INSURANCE INFORMATION

IN ACCORDANCE TO SCHOOL BOARD POLICY 2431, INTERSCHOLASTIC ATHLETICS:

It must be understood that the school, the athletic department, and/or the School Board assumes no direct or implied

responsibilities for expenses resulting from any athletic injury. All students taking part in the interscholastic athletic

program must participate in a Board-approved insurance program for that sport. Purchase of School Board-approved

insurance is required prior to participation in the fall football program, spring football program, and all other

interscholastic sports programs. Benefits under this insurance program are secondary to benefits covered under any

other hospital-medical-surgical coverage that you may have purchased. Only those charges in excess of the amount

payable by your other insurance will be paid, and the total payment will not exceed 100% of all bills for any one accident.

Any charges or expenses, including deductibles not covered by the School Board-approved insurance policies, are the

responsibilities of the parent or guardian. All School Board-approved insurance is non-refundable.

SECTION III �C PARENT/GUARDIAN INSURANCE INFORMATION

NAME OF INSURED ________________________________________ EMPLOYER _________________________________

INSURANCE COMPANY NAME _____________________________________________ PHONE ______________________

INSURANCE COMPANY ADDRESS _______________________________________________________________________

INSURANCE POLICY# __________________________ GROUP # ______________________

PRIMARY CARE PHYSICIAN _______________________________________________ PHONE _______________________

FM-3439 Rev. (05-24)

THIS PAGE LEFT BLANK INTENTIONALLY

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EL3

Florida High School Athletic Association

Consent and Release from Liability Certificate (Page 1 of 5)

Revised 3/23

This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.

This form is non-transferable; a change of schools during the validity period of this form will require this form to be re-submitted.

School: _______________________________________________________ School District (if applicable): __________________________________

Part 1: Student Acknowledgement and Release (to be signed by student at the bottom)

I have read the (condensed) FHSAA Eligibility Rules printed on page 5 of this ��Consent and Release from Liability Certificate�� and know of no reason why I am not eligible to

represent my school in interscholastic athletic competition. If accepted as a representative, I agree to follow the rules of my school and FHSAA and to abide by their decisions. I

know that athletic participation is a privilege. I know of the risks involved in athletic participation, understand that serious injury, including the potential for a concussion, and even

death, is possible in such participation, and choose to accept such risks. I voluntarily accept any and all responsibility for my own safety and welfare while participating in athletics,

with full understanding of the risks involved. Should I be 18 years of age or older, or should I be emancipated from my parent(s)/guardian(s), I hereby release and hold harmless

my school, the schools against which it competes, the school district, the contest officials, and FHSAA of any and all responsibility and liability for any injury or claim resulting from

such athletic participation and agree to take no legal action against the FHSAA because of any accident or mishap involving my athletic participation. I hereby authorize the use or

disclosure of my individually identifiable health information should treatment for illness or injury become necessary. I hereby grant to FHSAA the right to review all records relevant

to my athletic eligibility including, but not limited to, my records relating to enrollment and attendance, academic standing, age, discipline, finances, residence, and physical fitness.

I hereby grant the released parties the right to photograph and/or videotape me and further to use my name, face, likeness, voice, and appearance in connection with exhibitions,

publicity, advertising, promotional, and commercial materials without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein.

I understand that the authorizations and rights granted herein are voluntary and that I may revoke any or all of them at any time by submitting said revocation in writing to my

school. By doing so, however, I understand that I will no longer be eligible for participation in interscholastic athletics.

Part 2: Parent/Guardian Consent, Acknowledgement and Release (to be completed and signed by parent(s)/guardian(s) at

the bottom; where divorced or separated, parent/guardian with legal custody must sign.)

A.

I hereby give consent for my child/ward to participate in any FHSAA recognized or sanctioned sport EXCEPT for the following sport(s):

____________________________________________________________________________________________________________________________________________

List sport(s) exceptions here

B. I understand that participation may necessitate an early dismissal from classes.

C. I know of and acknowledge that my child/ward knows of the risks involved in interscholastic athletic participation, understand that serious injury, and even death, is possible

in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. With full understanding of the risks involved, I

release and hold harmless my child��s/ward��s school, the schools against which it competes, the school district, the contest officials, and FHSAA of any and all responsibility and

liability for any injury or claim resulting from such athletic participation and agree to take no legal action against the FHSAA because of any accident or mishap involving the athletic

participation of my child/ward. As required in F.S. 1014.06(1), I specifically authorize healthcare services to be provided for my child/ward by a healthcare practitioner, as defined

in F.S. 456.001, or someone under the direct supervision of a healthcare practitioner, should the need arise for such treatment, while my child/ward is under the supervision of the

school. I further hereby authorize the use of disclosure of my child��s/ward��s individually identifiable health information should treatment for illness or injury become necessary. I

consent to the disclosure to the FHSAA, upon its request, of all records relevant to my child��s/ward��s athletic eligibility including, but not limited to, records relating to enrollment

and attendance, academic standing, age, discipline, finances, residence, and physical fitness. I grant the released parties the right to photograph and/or videotape my child/ward

and further to use said child��s/ward��s name, face, likeness, voice, and appearance in connection with exhibitions, publicity, advertising, promotional, and commercial materials

without reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein.

D. I am aware of the potential danger of concussions and/or head and neck injuries in interscholastic athletics. I also have knowledge about the risk of continuing to participate

once such an injury is sustained without proper medical clearance.

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD/WARD ENGAGE IN A POTENTIALLY DANGEROUS

ACTIVITY. YOU ARE AGREEING THAT, EVEN IF YOUR CHILD��S/WARD��S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT,

THE CONTEST OFFICIALS, AND FHSAA USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD/WARD MAY BE

SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH

CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM, YOU ARE GIVING UP YOUR CHILD��S/WARD��S RIGHT AND YOUR RIGHT TO RECOVER

FROM YOUR CHILD��S/WARD��S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS, AND FHSAA

IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD/WARD OR ANY PROPOERTY DAMAGE THAT RESULTS FROM THE

RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND YOUR CHILD��S/WARD��S SCHOOL,

THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS, AND FHSAA HAS THE RIGHT TO REFUSE TO LET

YOUR CHILD/WARD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

E. I agree that, in the event we/I pursue litigation seeking injunctive relief or other legal action impacting my child/ward (individually) or my child��s/ward��s team participation in

FHSAA State Series contests, such action shall be filed in the Alachua County, Florida, Circuit Court.

F.

I understand that the authorizations and rights granted herein are voluntary and that I may revoke any or all of them at any time by submitting said revocation in writing to

my child��s/ward��s school. By doing so, however, I understand that my child/ward will no longer be eligible for participation in interscholastic athletics.

G. Please check the appropriate box(es):

My child/ward is covered under our family health insurance plan, which has limits of not less than $25,000.

Company:_________________________________________________________________ Policy Number: _____________________________________________________

My child/ward is covered by his/her school��s activities medical base insurance plan.

I have purchased supplemental football insurance through my child��s/ward��s school.

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (only one parent/guardian signature is required)

______________________________________________

Name of Parent/Guardian (printed)

_____________________________________________

Signature of Parent/Guardian

_________________________

Date

______________________________________________

Name of Parent/Guardian (printed)

_____________________________________________

Signature of Parent/Guardian

_________________________

Date

I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (student signature is required)

______________________________________________

Name of Student (printed)

_____________________________________________

Signature of Student

_________________________

Date

FM-3439 Rev. (05-24)

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