PIAA Sports Form and Physical Information Sheet

As of 5/19/14, SCHOOL SPORTS PHYSICALS WILL COST $45.00.

Payment must be paid prior to your child receiving a physical.

Completing the CIPPE form:

  1. For students who are playing in their first sport of the school year, fill out this page and sections 1-6 only. Page 6 is the physical paper and must be signed by a physician. This page, section 3, 4 and 5 require student signature. This page, sections 2, 3, 4 and 5 require parent signature. Don’t fill out section 7 and 8!
  1. For students who are playing a second or third sport and who have not experienced any injuries in the previousseason, fill out this page, and sections 2 and 7 only. This requires student and parent signature, but no physician signature.
  1. For students who are playing a second or third sport and who HAVE experienced an injury in the previous season that required medical attention, fill out this page, sections 2, 7, and 8. Section 8 requires a physician’s signature. In addition, certain papers from the original physical CIPPE form (sections 5 and 6) must be taken along to the doctor visit. Please see your School Nurse before going to your appointment so that she can provide you with the forms needed.
  1. In the event that you cannot get your physical done at school and your family doctor cannot fit in your child for a physical in a timely manner, Med Express in Selinsgrove will do a physical for $30.00 (this was current 03/01/16 but be aware the price can go up). They can also fill out section 8 for those students that had an injury during the previous sport season. Their hours are 8-8 and they can usually get you in immediately. You can reach them at 1-570-743-7821. This is for your information only and does not constitute a recommendation for their services.

By signing this form, we, the parents/guardians agree to give trainers, coaches, ambulance personnel and/or emergency room staff permission to obtain emergency treatment for the above student athlete.

HIPAA (Health Insurance Portability and Accountability Act) sets limitations and guidelines to protect your son/daughter’s personal and medical information as it pertains to health care in all settings (clinical and/or on the field, etc). Access to the athlete’s information is limited to the minimum amount reasonable and to the limited personnel required to permit the athlete to participate safely (AT, C, coaches, school administrators and staff and physicians). It sets boundaries on the use and release of the athlete’s health records and establishes safeguards for health care providers and others to protect the privacy of your son/daughter’s health information.

I have read the above information and acknowledge that a complete copy of Geisinger’s HIPAA policy is available upon request. I therefore have read and understand the above information and give the Athletic Trainer permission to release the necessary information required for my child to participate in JCSD athletics.

Student Name ______Grade: ______Sport: ______

Parent Signature: ______Phone Number: ______

If unavailable, alternate person to contact: ______Phone: ______