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MEDICAL INFORMATION AND PHYSICAL EXAMINATION FORM

FOR INCOMING STUDENTS 2021-2022

ALL INCOMING STUDENTS MUST SUBMIT A PHYSICAL EXAMINATION FORM—

PHYSICALS COMPLETED PRIOR TO APRIL 2021 WILL NOT BE ACCEPTED.

In compliance with KRS 158.035, KRS 214.0, and KAR 2:060

the original certificate of immunization against diphtheria, tetanus, poliomyelitis, measles, rubella, hepatitis A, and meningitis

must be submitted by every student and kept on file by the school.

Student's final admission status is not complete until the physical examination form and the required

certificate of immunization status have been submitted.

Important Information for Incoming Students Planning to Participate in Athletics

In accordance with KHSAA regulations, the student’s medical history and physical must be reported on the KHSAA form which follows.

Students trying out for CHEERLEADING AND DANCE: physical examination must be completed and health forms turned in prior to tryouts in mid-April. If the physical was conducted between April 2020 and March 2021, it will satisfy the KHSAA requirement, but a current physical examination, conducted April-July 2021, is required by July 29, 2021, to meet the school requirement.

PART 1 - STUDENT INFORMATION

Student's Full Legal Name: _____________________________________________________________________________________

LastFirstMiddle2021-2022 Grade

Student’s Home Address: ______________________________________________________________________________________

PART 2 – PARENTAL PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATION/ PARENTAL CONSENT/PERMISSION TO TREAT AUTHORIZATION – 2021-2022

Parent/guardian signatures are required in order for your daughter

to receive any necessary medical treatment or medication (including Tylenol, Advil, etc.).

In the event of an injury or illness during the school day or at a school event or, if applicable, an athletic event or practice session, I give

permission for my daughter,, to receive proper/necessary care from the school nurse, staff member, certified athletic trainer, or coach. In addition, I authorize treating physicians and/or their representatives to release medical information to representatives of the Assumption Administration, Athletic Department, and coaching staff, as applicable.

In the event of an emergency during the school day or at a school event or, if applicable, an athletic event or practice session, I give

permission for my daughter,, to be transported to an appropriate medical facility for treatment. Furthermore, I give permission for the staff at the medical facility to render any and all treatment that is necessary for the well-being of my daughter. In addition, I authorize treating physicians and/or their representatives to release medical information to representatives of the Assumption Administration, Athletic Department, and coaching staff, as applicable.

Signature: _____________________________________________________ Date: __________________________________

New Kentucky Immunization Laws

The following is a summary of the recent changes, effective June 21, 2017, to 902 KAR 2:060:

Immunizations schedules for attending child day care centers, certified family child care homes, other licensed facilities which are for children, preschool programs, and public and private primary and secondary schools, https://www.lrc.ky.gov/kar/902/002/060.htm . This amended Kentucky Administrative Regulation requires all children to have a current immunization certificate on file, contains the required immunizations schedule for attending, and has a process to obtain a religious exemption from the required immunizations.

One new age-specific immunization requirement and one booster dose requirement effective for the school year beginning on or after July 1, 2018:

2-Dose Series of Hep A ( Age: 12 months through 18 years, to be compliant for the series the second Hep A is given six months after the first inject.)

Quadrivalent meningococcal vaccine (MenACWY) booster dose (Age: 16 years)

Homeschooled children are required to submit to current immunization certificate to participate in any public or private school activities (classroom, extra curriculum activity, or sports).

All vaccines administered are printed on the Commonwealth of Kentucky Certificate of Immunization Status now including immunizations not required for school entry.

Out of state immunization certificates may be accepted if they meet the same age – specific requirements as outlined in this regulation.

A Commonwealth Certificate of Immunization Status printed from the Kentucky Immunization Registry (KYIR) does not require a signature

Routine certificate reviews are to occur at enrollment in a day care center, kindergarten, new enrollment at any grade; upon legal name change; and at a school required examination pursuant to 702 KAR 1:160.

A child whose certificate has exceeded the date for the certificate to be valid shall be recommended to visit the child’s medical provider or local health department to receive immunizations required by this administrative regulation. An updated and current certificate shall be provided to the:

Day care center, certified family child care home, or other licensed facility that cares for the children by a parent or guardian within thirty (30) days from when the certificate was found to be invalid.

School by a parent or guardian within fourteen (14) days from when the certificate was found to be invalid.

serious injury or impairment to other aspects of the body, or eects to the general health and well being of the child. Because of these inherent risks, the student and parent/legal guardian recognize the importance of the student obeying the coaches’ instructions regarding playing techniques, training and other team rules . By signing this form, the student and parent/legal guardian acknowledge that the stude nt’s participation is wholly voluntary and to having read and understood this provision.

The student and parent/legal guardian individually and on behalf of the student, hereby irrevocably, and unconditionally release, acquit, and forever discharge the KHSAA and its ocers, agents, attorneys, representatives and employees (collectively, the “Releasees” ) from any and all losses, claims, demands, actions and causes of action, obligations, damages, and costs or expenses of any nature (including a ttorney’s fees) that the student and/or parent/legal guardian incur or sustain to person, property or both, which arise out of, result from, occur during or are otherwise connected with the student’s participation in interscholastic athletics if due to the ordinary ne gligence of the Releasees.

The student and parent/legal guardian acknowledge that they have read and understood the KHSAA Bylaws by distribution under the handbook links at http://khsaa.org/. Please be aware that a student is subject to the one-year period of ineligibility the bylaw commonly referred to as the "Transfer Rule," upon participation in any varsity contest regardless of the amount of participation or lack thereof.

The student and parent/legal guardian agree to abide by the KHSAA Bylaws and Due Process Procedure as now enacted or later amended. The student and parent/legal guardian further acknowledge that they agree to abide by the rulings of the Commissioner, Assistant Commissioner, Hearing Ocer and Board of Control.

The student and parent/legal guardian acknowledge that the student must have medical insurance coverage up to a limit of $25,000 in order to be eligible to participate in interscholastic athletics.

The student and parent/legal guardian, individually and on behalf of this student, give the high school, the KHSAA and their representatives permission to release this student’s demographic information (including motion picture and still photographic images) and participation statistics (including height, weight and year in school, participation history and other performance based statistics) and other informa tion as may be requested, and agree that the student may be photographed or otherwise digitally or electronically cap tured during school-based competition. All of this material may be used without permission or compensation specically related to the KHSAA and its events .

The student and parent/legal guardian consent to this student receiving a physical examination as r equired by the KHSAA.

The student and parent/legal guardian, individually and on behalf of this student, consent to the high school and the KHSAA and their representatives to use and disclose the necessary personally identiable information from the student’s education records including academic, nancial and health care information, to third parties including school representatives, coaches, athletic trainers, medical facilities, m edical stas, KHSAA legal counsel and the media, for the purpose of receiving proper/necessary medical care and complying with the KHSAA bylaws, including making determinations regarding eligibility to participate in interscholastic athletics and any administrative or legal proceedings resulting from participation or attempted participation in interscholastic athletics, without such disclosure constituting a violation of rights under the Family Educational Rights and Privacy Act. The student and parent/legal guardian, individually and on behalf of this student, further release the high school, the KHSAA and their representatives from any and all claims arising out of the use and disclosure of said necessary personally identiable information, and agree to release to the high school, the KHSAA, and their representatives, upon request, the detailed and completed application for nancial aid.

The student and parent/legal guardian, individually and on behalf of the student, hereby acknowledge that they are aware of and will review if desired, the education materials availab le through the KHSAA, the Centers for Disease Control and other agencies regarding education all individuals with respect to nature and risk of concussion and head injury, including the continuance of play after concussion or head inj ury.

The student and parent/legal guardian, individually and on behalf of the student, hereby consent to allow the student to receive medical treatment that may be deemed advisable by the high school, the KHSAA, and their representatives in the event of injury, accident or ill ness while participating in interscholastic athletics, including, but not limited to, transportation of the student to a medical facility.

STUDENT AND PARENT/GUARDIAN ACKNOWLEDGMENT OF RISK, ELIGIBILITY RULES, LIABILITY WAIVER AND

Please list above any health problems/concerns this student may have, including allergies (medications / others) and any medications presently being used

ASTHMA AUTHORIZATION FORM 2021-2022

If your daughter has asthma, this form must be completed, signed, and returned to the School Office by Thursday, July 29, 2021.

Kentucky House Bill 353 allows students with asthma to have unobstructed access to asthma medications. The key points of this law are as follows: Public and private school students are allowed to possess and use asthma medications provided that:

•The student has written authorization from a parent and her health care provider to self-administer her asthma medications.

•The written authorization is kept on file at school.

•A parent or guardian must sign a statement acknowledging that the school has no liability from any injury sustained by a student from self-administration of medication.

•Permission for self-administration of medications is effective for the current school year and must be renewed each school year.

If you have any questions regarding this law or any asthma issue, please contact the Director of Education & Advocacy, American Lung Association, at 363-2652.

If your daughter has asthma, but does NOT need to self-administer asthma medications at school,

complete and sign only this section of the form and return the signed form to the School Office.

I,_______________________ , parent/guardian of the above named student, verify that my daughter has asthma, but does not need to

carry or self-administer any asthma medications at school, at school-sponsored activities or at any time that she is present on Assumption High School's property.

If your daughter has asthma and must self-administer asthma medications at school,

the parent and the student's health care provider must complete and sign all sections below.

You must return the completed form to the School Office before she will be given permission to self-administer her asthma

medications on school property or at any school-sponsored activity.

I,_________________________, parent/guardian of the above named student, authorize Assumption High School to allow the student

to carry with her and self-administer her asthma medications.

Signature: _______________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student acknowledge that Assumption High School shall incur no

liability as a result of any injury sustained by the student from the self-administration of asthma medications. I agree to indemnify, hold harmless, waive and relinquish any and all claims I may have against Assumption High School and its officers, agents, employees, representatives or volunteers.

Signature: _______________________________________________ Date:_____________________________

If your daughter has asthma and she must self-administer asthma medications at school,

THE STUDENT'S PHYSICIAN MUST COMPLETE THIS SECTION AND SIGN WHERE INDICATED.

I, _________________________________________________, verify that ________________________________________________

has asthma and that the student has been instructed in self-administration of the asthma medications listed below:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

FOOD ALLERGY AND ANAPHYLAXIS MEDICATION AUTHORIZATION FORM 2021-2022

If your daughter has a severe food allergy or other allergy that could require the administration of emergency rescue medication,

this form must be completed, signed, and returned to the School Office by Thursday, July 29, 2021.

If your daughter has a severe allergy and may need to self-administer anaphylaxis rescue medication

(epinephrine via EpiPen, Twinject, Auvi-Q, etc.) at school,

the parent and the student's health care provider must complete and sign all sections below.

You must return the completed form to the School Office before she will be given permission to self-administer her anaphylaxis

rescue medication on school property or at any school-sponsored activity.

I,_________________________, parent/guardian of the above named student, authorize Assumption High School to allow the student

to carry with her and self-administer her anaphylaxis rescue medication.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student, authorize Assumption High School personnel to

administer anaphylaxis rescue medication to the student in the event the student is unable to self-administer due to the severity of the allergic reaction/anaphylaxis or not having her rescue medication with her.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student acknowledge that Assumption High School shall incur no

liability as a result of any injury sustained by the student from the self-administration of anaphylaxis rescue medication or from Assumption High School personnel administering emergency rescue medication to her. I agree to indemnify, hold harmless, waive and relinquish any and all claims I may have against Assumption High School and its officers, agents, employees, representatives or volunteers.

Signature:________________________________________ Date:_____________________________

I,_________________________, parent/guardian of the above named student hereby give permission for the health care provider

completing and signing this form (below) to verify this information with Assumption High School and consult with AHS staff regarding this information.

Signature:________________________________________ Date:_____________________________

If your daughter has a severe allergy and may need to self-administer anaphylaxis rescue medication at school,

THE STUDENT'S PHYSICIAN MUST COMPLETE THIS SECTION AND SIGN WHERE INDICATED.

I, _________________________________________________, verify that __________________________________________________

Physician/Health Care Provider's Name (please print) _Print Student's Name

is extremely reactive to the following allergens (specify) _____________________________________________________________,

has been instructed in self-administration of her anaphylaxis rescue medication, and may carry it with her to self-administer if necessary.

In the event of mild symptoms (itchy mouth, runny nose, mild rash, etc.)., the student may self-administer or school personnel may administer

Antihistamine Brand or Generic: _________________________________________________ Dose ________________________________

In the event of severe symptoms (shortness of breath, tightness of throat, dizziness, etc.)., the student may self-administer or school personnel may administer

Antihistamine Brand or Generic: _________________________________________________ Dose ________________________________