Athletic Eligibility - Health Forms

Dear Parents and Guardians,

Students must have the following forms on file in the school Health Office to participate in school sports.

Health Appraisal Form – This is the form that is completed by the health care provider (Medical Doctor, Doctor of Osteopathy, Nurse Practitioner or Physician’s Assistant) when a physical is done. The form must be dated within 12 months of the start of the sport. Physicals are available at school prior to each sports season. Call your school Health Office to schedule an appointment. Physicals are not given without an appointment. Students must bring a signed Parental Permission for Pre-Participation Sports Physical Examination form with them to the appointment.

Irondequoit High School School Nurse Mary Piston - 585-336-2937 / FAX 336-8294

Dake Junior High School School Nurse Nancy Bottiglier - 585-336-2964

The school physician will review the completed Health Appraisal Form for vision tests, blood pressure and clearance by the health care provider to participate in sports.

Eligibility Form – An eligibility form must be completed and signed by the student and parent/guardian for each sports season. Forms are available from the Main Offices and Health Offices at each school and from the Athletic Office at IHS. This form cannot be dated sooner than 30 days before the sport begins, and must be turned in to the Health Office 7 days before the sport begins.

Release of Information Form - This form is available from the Main Offices and Health Offices at each school and from the Athletic Office at IHS. It must be turned in to the school nurse with the eligibility form.

Parent and Prescriber's Authorization Form - Students requiring any medication during the sports activity (e.g. inhalers, Epi-Pens, prescription medication and over-the-counter medications) must have this form on file in the Health Office. These forms are valid for one school year (September – June) and must be signed by both the parent/guardian and the health care provider.

Students with an outstanding illness or injury must have written clearance from a health care provider to participate in sports, even if the injury or illness occurred the previous school year. (For example, if a student was injured in May, he would need written clearance to participate in a fall sport.)

The Health Office is happy to assist you in completing these forms. Please call me at 336-0816 with any questions.


Mary Piston, RN, District Contact Nurse

Website by SchoolMessenger Presence. © 2017 West Corporation. All rights reserved.