Dear Parents and Guardians,
Students must have the following forms on file in the school Health Office
to participate in school sports.
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 ParentalPermission 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
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.
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
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