(Regulation 2431.2 Medical Examination to Determine Fitness for Participation Athletics) Attachment B

Washington Township Public SchoolsHEALTH HISTORY UPDATE QUESTIONNAIRE

(INTERSCHOLASTIC/INTRAMURAL ATHLETIC PROGRAM REQUIREMENT)

To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose physical examination was completed more than 90 days prior and less than 365 days prior to the first day of official practice shall provide a health history update questionnaire completed and signed by the student’s parent or guardian.

SECTION A: Student Demographic InformationSchool: GradeStudent Age

Date of Last Physical Examination Sport

SECTION B: Medical Information UpdateSince the last Preparticipation physical examination, has your son/daughter:1. Been medically advised not to participate in a sport? If yes, describe in detail Yes No

2. Sustained a concussion, been unconscious or lost memory from a blow to the head? If yes, describe in detail Yes No

3. Broken a bone or sprained/strained/dislocated any muscle or joints? If yes, describe in detail Yes No

4. Fainted or “blacked out?” If yes, was this during or immediately after exercise? Yes No

5. Experienced chest pains, shortness of breath or “racing heart?” If yes, describe in detail Yes No

6. Has there been a recent history of fatigue and unusual tiredness? Yes No7. Been hospitalized or had to go to the emergency room? If yes, describe in detail Yes No

8. Since the last physical examination, has there been a sudden death in the family or has any member of the family under age 50 had a heart attack or “heart trouble?” Yes

No

9. Started or stopped taking any over-the-counter or prescribed medications? If yes, name of medication(s) Yes No

SECTION C: Immunization UpdatePlease list any recent immunization(s) and the date(s) administered.

Description of Immunization Date Administered

SECTION D: Parent Signature

Name of Parent/Guardian (Please Print):

Signature of Parent/Guardian: Date:

PLEASE RETURN COMPLETED FORM TO THE SCHOOL ATHLETIC OFFICE

(Regulation 2431.2 Medical Examination to Determine Fitness for Participation Athletics) Attachment C

Washington Township Public Schools“Sudden Cardiac Death In Young Athletes”

Pamphlet Receipt Acknowledgment

Name of Student (Please print):

Name of School:

Pamphlet Receipt Acknowledgment

(Check ( ) below as applicable):

I/We acknowledge that we received and reviewed the “Sudden Cardiac Death in Young Athletes” pamphlet.

I/We acknowledge that we have accessed the online version of the “Sudden Cardiac Death in Young Athletes” pamphlet through the district’s website and we have reviewed it.

Student Student Signature: Date:

Parent or GuardianName of Parent or Guardian (Please print) Signature of Parent or Guardian: Date:

(Regulation 2431.2 Medical Examination to Determine Fitness for Participation Athletics) Attachment C

BUNKER HILL MIDDLE SCHOOL372 Pitman-Downer RoadSewell, New Jersey 08080

Notification of Student’s Medical Eligibility/Ineligibility to Participate in School Athletics

Student Name: _______________________ Grade: ______________Sport: ___________________________

Dear Parent/Guardian:This letter serves as written notification that your son/daughter can /cannot participate in athletics at Bunker Hill Middle School for the current school pursuant to N.J.S.A. 6A: 16-2.2. Please be advised that this letter reflects the recommendation of the examining physician who completed and signed the Athletic Pre-Participation Examination submitted to the school on behalf of your son/daughter.

If your child is deemed unable to participate based on an incomplete form, please ensure that the original examining physician completes the form and then kindly return it to school to be reviewed for eligibility.

Thank you for your cooperation.

Examining Physician’s School Physician’s Stamp and Initials Stamp and Initials

Date Approved: __________ Date Approved: ___________ School Nurse’s Initials: _________ Date Reviewed by Nurse:__________