Bishop O'Connell High School

Bishop O'Connell High School
Mandatory School Health Requirements for 2013-2014 School Year
All forms should be sent to the Admissions Office:
Bishop O’Connell High School
Admissions Office
6600 Little Falls Road
Arlington, VA 22213
FORM TITLE TO BE SIGNED/COMPLETED BY
A Permission for Emergency Care Parent/Guardian
B Certificate of Immunization Licensed Health Care Provider
C Consent for Athletics Parent/Guardian
D Sports Participation Evaluation Parent/Student/Physician
E Tuberculosis Screening Licensed Health Care provider
All Medical forms are DUE by AUGUST 1, 2013
Students must submit all medical forms prior to any tryouts for fall sports.

FORM A
Side 1
PERMISSION FOR EMERGENCY CARE
To be completed annually by parent/guardian
Student’s Last Name ______________________ First Name ____________________ Nickname _______________ Grade ____
Address ________________________________________________________________________________________________
Street City State Zip
Student’s Date of Birth ____/____/____ □ Male □ Female Home Phone (______)__________________
Father’s Name ____________________________________ Work Phone (______)_________________ Hours _____________
Father’s Email Address _______________________________________ Cell/Pager (______)________________________
Mother’s Name ____________________________________ Work Phone (______)_________________ Hours _____________
Mother’s Email Address _______________________________________ Cell/Pager (______)________________________
Father’s Address (if different) ________________________________________________________________________________
Street City State Zip
Mother’s Address (if different) _______________________________________________________________________________
Street City State Zip
Father’s Workplace and Address _____________________________________________________________________________
Mother’s Workplace and Address ____________________________________________________________________________
Name(s) of person(s) or agency having legal custody* ____________________________________________________________
*If not parent, appropriate custody paperwork must be attached.
Address (if not parent)_____________________________________________________________________________________
Persons NOT authorized to pick up child from school** Name _____________________________________________________
Relationship ____________________________________________ **If parent, appropriate custody paperwork must be attached.
Child’s Doctor ___________________________________________ Office Phone (______)_____________________________
Current Medical Conditions (e.g. diabetes, heart disease, contact lenses, hearing aids, etc.) ______________________________
_______________________________________________________________________________________________________
Child’s Allergies (if any) ________________________________ Action to Take _______________________________________
Medication(s) Child is Taking _____________________________________ Date of Last Tetanus Shot ____________________
Health Insurance Company ________________________________________ Policy Number ____________________________
Emergency Contacts: In the event a parent/guardian cannot be reached, you must give the name, address and phone
number of two persons who could pick up and take your child home in a timely manner.
1. ____________________________________________________________________________________________________________________________
Full Name Relationship Address Phone
2. ____________________________________________________________________________________________________________________________
Full Name Relationship Address Phone
I agree to notify the school within 24 hours if my child or any member of my immediate household has developed a communicable disease.
I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injured child in a timely manner when
contacted. If I cannot be reached, the above emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in
an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical
staff to provide treatment which a physician deems necessary for the well-being of my child.
Parent/Guardian Signature ______________________________________________
Date ____________________________
Appendix F-1 of Diocese of Arlington Handbook

FORM A
Side 2
CONFIDENTIAL STUDENT HEALTH HISTORY UPDATE

FORM B
Side 1
BISHOP O’CONNELL HIGH SCHOOL CERTIFICATE OF IMMUNIZATION
Student’s Last Name ________________________________ First Name ________________________
Grade_________
IT’S THE LAW!
1) This document must be completed and signed by a licensed health care provider.
2) Virginia State Law 22.1-271.2 requires that a child must present documentary proof of immunization before he/she can
attend any public, private or parochial school. Dates (month, day, and year) of administration of all vaccines are required.
3) Only vaccines marked with an asterisk are currently required for school entry.
IMMUNIZATION
RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5
*Diphtheria, Tetanus (DT) or Td (given after 7 years
of age)
*Tdap booster (6 th grade entry) 1
1 2 3 4 5
*Poliomyelitis (IPV, OPV) 1 2 3 4
Hemophilus influenze Type b (Hib conjugate)
only for children

FORM B
Side 2
*Minimum Immunization Requirements for Entry into Virginia Schools (requirements are subject
to change)
□ 3 DTP or DTaP - at least one dose of DTaP or DTP after 4 th birthday unless received 6
doses before 4°’ birthday
□ 3 Polio - at least one dose after 4 th birthday unless received 4 doses of all OPV or all IPV
prior to 4 th birthday
□ Hib - 2/3 doses in infancy; 1 booster between 12-15 months; 1 dose between 15-60 months
if unvaccinated, for children up to 60 months of age only
□ Pneumococcal - 2-4 doses, depending on age at 1 st dose for children up to 2 years of age
only
□ 2 Measles - one dose on/after 12 months of age; 2 nd dose prior to entering kindergarten
□ 1 Mumps - on/after 12 months of age
□ 1 Rubella - on/after 12 months of age
Note: Measles, Mumps, Rubella requirements also met with 2 MMR -1 st dose on/after 12
months of age; 2 nd dose prior to entering kindergarten
□ Hep B -3 doses required (2 doses if Merck adult formulation given between 11-15 years of
age; check the indicated box in on front if this formulation was used)
□ 1 Varicella - to susceptible children born on/after January 1, 1997; dose on/after 12 months
of age
*Additional Immunizations Required at Entry into 6 th Grade
□
Tdap - booster required for entry into 6 th grade if at least 5 years since last tetanuscontaining
vaccine
For current requirements consult the Virginia Department of Health, Division of Immunization web site:
http://www.vdh.virginia.gov/epidemiology/immunization

Form C
BISHOP O’CONNELL HIGH SCHOOL
PARENTAL CONSENT FOR ATHLETIC PARTICIPATION 2013-2014
An original of this form and a current physical exam must be on file
with Mr. Don Tillson, Athletic Trainer, before being allowed to participate with a team.
Student’s Last Name _____________________ First Name______________________ Grade _______
Date of Physical Exam ____________________
must be on or after 4/1/13
Birth Date ______________________
This student has permission to participate in any sport not crossed out below
FALL WINTER SPRING
cross country basketball baseball
cheerleading hockey crew
dance swimming golf
field hockey wrestling lacrosse
football
softball
soccer
tennis (boys)
tennis (girls)
track & field
volleyball
CONCUSSION EDUCATION
We have reviewed and understand the information provided by the athletic training department on effects of concussions.
(Information is available as a handout or can be found on the O’Connell web site under athletics)
___________________________
Signature of Parent/Guardian
_________________________
Signature of Student/Athlete
EMERGENCY INFORMATION
Student’s Full Name _________________________________ Birth Date ________________ Grade _____
Parent/Guardian’s Name __________________________________________________________________
Address _______________________________________________________________________________
Street City State Zip
Home Phone __________________________
Father’s Work/Cell Phone _____________________ Mother’s Work/Cell Phone _____________________
Health Insurance Company _________________________
Policy Number ___________________
ALLERGIES _________________________ MEDICAL CONDITIONS ____________________________
In the event that I cannot be reached in an emergency, I hereby give permission to the physicians selected by the athletic
staff of Bishop O’Connell High School to provide proper treatment necessary for the well being of my child named above.
________________________________________
Signature of Parent/Guardian
(OVER)
_____________________
Date

Parental Consent for Participation and Acknowledgement of Risks
The undersigned is the parent/guardian of the student named on this form and is familiar with
his/her wishes to participate in sports at Bishop O’Connell High School in the 2013-2014 school
year.
I am aware that with participation in sports comes a risk of injury to my child/ward. I understand that
the degree of danger and the risk of injury vary significantly from one sport to another with contact
sports having a higher risk. In addition, I am aware that participation in sports will involve travel with
the team.
I acknowledge and accept the risks inherent in sports and with the travel involved. With this in
mind, I grant permission for my child/ward to participate in the sports not crossed out on the reverse
side of this form and to travel with the team.
_____________________________________
Signature of Parent/Guardian
_____________________
Date
Athletic Training Policies
• Before participating in sports, students must turn in a completed physical exam form (dated after April 1), and
this parent consent/emergency information form. This should be done at least a week before tryouts to allow
for processing. Do not carry forms to the first practice and expect to be allowed to participate.
• Virginia law requires that in order to participate in any athletic activity, each student-athlete and their parent/guardian
shall review information on concussions provided by the school. After reviewing these materials describing the effects
of concussions, each student-athlete and their parent/guardian shall sign a statement acknowledging, receipt, review,
and understanding of such information. This information is available as a handout from the athletic trainer or on the
O’Connell web site under athletics/athletic training. There will be a presentation at the beginning of each season for
parents and athletes.
• Athletes should report all significant injuries to the athletic trainer and continue coming for treatment until
cleared for full participation.
• Parents will be called for injuries requiring emergency transportation. For injuries that are not emergencies,
but need to be seen by a physician, parents may be called and/or a “physician’s report form” will be sent
home with the athlete.
• When an athlete has been under a physician’s care, the athlete must bring to the athletic trainer the
“physician’s report form” or a note from the physician. This is necessary for the athletic trainer to provide
proper follow-up care and to advise the coach about the athlete’s playing status.

Form D
Bishop O’Connell High School
Sports Preparticipation Evaluation
Medical History
This information should be completed by the parent and student prior to the physical examination.
Student’s Last Name ________________________ First Name ________________________
Male____ Female ____
Date of Birth ____/____/____ Grade for School Year 2013-2014 ______
Sport(s)________________________________
Allergies_____________________________________________
Date of last Tetanus shot _____/_____/______
Has student ever had any of the following—explain “Yes” answers:
Heart murmur Yes □ No □ _________________________________
High blood pressure Yes □ No □ _________________________________
Other heart problems Yes □ No □ _________________________________
Relative with heart problems Yes □ No □ _________________________________
Dizziness, chest pain or passed Yes □ No □ _________________________________
out after exercise
Concussion Yes □ No □ _________________________________
Been knocked out Yes □ No □ _________________________________
Seizures or epilepsy Yes □ No □ _________________________________
Muscle, bone or joint injuries Yes □ No □ _________________________________
Surgery Yes □ No □ _________________________________
Been hospitalized Yes □ No □ _________________________________
Does student currently have any of these conditions—explain “Yes” answers:
Trouble breathing or cough Yes □ No □ _________________________________
after exercise
Significant allergies Yes □ No □ _________________________________
Asthma Yes □ No □ _________________________________
Adrenaline/inhaler prescription Yes □ No □ _________________________________
Take medicine regularly Yes □ No □ _________________________________
Illness lasting a week or more Yes □ No □ _________________________________
Blood disorder Yes □ No □ _________________________________
Contacts, glasses, braces Yes □ No □ _________________________________
Missing/Non-functioning organ Yes □ No □ _________________________________
Skin problem Yes □ No □ _________________________________
Special equipment for sports Yes □ No □ _________________________________
Any other significant health problem Yes □ No □ _________________________________
Date _____/_____/______
Signature of Student ____________________________________________
Signature of Parent/Guardian _____________________________________

Sports Preparticipation Evaluation
Physical Examination
To be completed and signed by the student’s physician
Student’s Last Name ____________________________ First Name ____________________ Date of Exam ____/____/____
Height ____________ Weight ____________ Resting Pulse ____________ BP ______/______
Vision R 20/______ L 20/______ Corrected Yes No
Normal -- please put a check mark below
Abnormal Findings -- please explain in space provided below
______ Heart: __________________________________________________________________________________
______ Pulse: __________________________________________________________________________________
______ Lungs: __________________________________________________________________________________
______ Skin: ___________________________________________________________________________________
______ Lymphatic: _______________________________________________________________________________
______ Abdomen: _______________________________________________________________________________
______ Genitalia/Hernia: __________________________________________________________________________
______ Eyes: ___________________________________________________________________________________
______ Ears: ___________________________________________________________________________________
______ Nose: ___________________________________________________________________________________
______ Throat: __________________________________________________________________________________
______ Neck: ___________________________________________________________________________________
______ Back: ___________________________________________________________________________________
______ Shoulders: _______________________________________________________________________________
______ Elbows/Wrists/Hands: ______________________________________________________________________
______ Hips/Knees: ______________________________________________________________________________
______ Ankles/Feet: ______________________________________________________________________________
Optional when medically indicated:
Tanner Stage: 1 2 3 4 5 Percent Body Fat: ______________________
Labs: Urine ________________________________
Labs: Hemoglobin/HCT: ___________________________
______ Full Participation
Clearance for Sports
______ Needs additional evaluation/rehabilitation for__________________________________________________________
______ Limited/No participation due to _____________________________________________________________________
Physician’s Name (please print) ________________________________ Physician’s Signature_________________________
Date________________________ Office Phone Number (_______)____________________

FORM E: CHILD AND YOUTH TUBERCULOSIS SCREENING CERTIFICATE