PLEASE MAKE A COPY OF ALL FORMS FOR YOUR RECORDS.

PLEASE COMPLETE:

q  Physical Form* (dated March 2013 – June 2014):  (All sections)

*Physical Forms are valid for one (1) year after date of physical exam.

Note:  The following are required from the examining doctor (see Page 4):

q  Doctor’s signature

q  Date of exam (please also write the date of exam on the first line of Page 1)

q  Doctor’s official stamp – name of practice/address/phone

PLEASE SIGN AND DATE: (Parent or Legal Guardian and student signatures required):

q  Physical Form: 

q  Page 1

q  Page 2 (If applicable)

q  Page 5

q  Page 6

q  Ohio Department of Health Concussion Information Sheet for Interscholastic Athletics:

q  Sign, date and turn in only the signature page of the Concussion Information Sheet.

q  PLEASE NOTE: THE CONCUSSION INFORMATION SHEET NEEDS TO ON FILE FOR EVERY ATHLETE – A NEW FORM FOR EACH SPORT IN WHICH THEY PARTICIPATE.