LAKE-LEHMAN JUNIOR- SENIOR HIGH SCHOOL HEALTH SERVICES

P.O. Box 38 Lehman, PA 18627-0038 Karen Muldoon, R.N., B.S.N., M.S., Certified School Nurse Phone: (570) 255-2801

Sport Physical Examination Process

In accordance with the Purpose and Spirit of the PIAA by-laws, Article V and the Lake-Lehman School District, all student athletes are required to have a physical examination in order to participate in athletics for the Lake-Lehman School District. All attached forms must be completed and returned to the School Nurse or Athletic Trainer. This is the only form that will be accepted in order to participate in athletics at Lake-Lehman School District. If the PIAA Pre-Participation Physical Evaluation is to be completed at Lake-Lehman Junior Senior High School by the School Physician, please sign below. I give my consent for the School Physician (MD, DO, PAC, or CRNP) to examine ____________________________________

s : __________________________________ Date: ______________________

I authorize an appropriate workforce member of the above entity(ies) to release information from my medical record to:

AUTHORIZATION TO RELEASE

MEDICAL INFORMATION

Patient Name: _______________________________ Address: ___________________________________ Address: ___________________________________ Birthdate: ___________________________________ Medical Record No.: __________________________

● GEISINGER EMPLOYEE USE ONLY ● X Geisinger Medical Center X Geisinger Wyoming Valley Medical Center X Geisinger Clinic (GMG) 100 N. Academy Avenue 1000 E. Mountain Boulevard _________________________ Danville, PA 17822 Wilkes-Barre, PA 18711 _________________________ (AS APPLICABLE) (Specify site and address)

Officials of the school that I (Student Athlete) attend. This would include, the coaching staff, athletic directors, insurance carriers and health- care professionals who are involved with my participation in interscholastic athletics.

Lake Lehman School District Market Street PO BOX 38 Lehman, PA 18627

(Address and Phone number of receiving party) for the purpose of: X continuation of medical treatment X payment of bill □ Worker’s Compensation X education X legal purposes X insurance purposes X at the request of the patient or the patient’s legal representative for personal access or other (specify): _________________________________________________ The information to be released will cover the time period from _____8/10/19_______ to ____8/10/20__________

SPECIFIC INFORMATION TO RELEASE: □ Discharge Summary □ History & Physical □ Consultation Report(s) □ Operation Report(s) □ Catheterization Report □ Clinic Notes □ Emergency Room Notes □ Laboratory Report(s) □ Pathology Report(s) □ X-ray Report(s) □ X-ray Film(s) □ Itemized Bill(s) X Other (specify): All information concerning my health that impacts my ability to participate in interscholastic athletics.

This may include information about injuries (such as sprains), surgeries, or medical conditions (such as asthma). This is to inform the above referenced people of my health –related limitations and abilities to continue to participate in interscholastic athletics.

X Other (specify): To provide the above referenced people with information on how to help me safely participate in interscholastic athletics

I understand that in order to process this request for the reproduction of medical record information on a timely basis, the above entity(ies) may utilize a contracted medical record copy service, and I further authorize the release of my medical record information to such record service for this purpose. I understand that this authorization is revocable by me, in writing, at any time, except to the extent that action has been taken in reliance on it. I will contact the above entity(ies) immediately if I wish to revoke this authorization. As described in the Notice of Privacy Practices for the above entity(ies), I may request such Notice of Privacy Practices for my ease of reference. I also understand that this consent will expire six months after the date of signature or automatically when the records requested on this authorization have been released. I understand that the information released may be re-released by the recipient and may no longer be protected by HIPAA (Federal regulations). The above entity(ies) may not condition my treatment or payment for my treatment on obtaining this authorization from me, unless this authorization is requested (i) to provide research-related treatment to me, or (ii) because the health care being provided to me is solely for the purpose of creating protected health information for disclosure to a third party.

SPECIAL AUTHORIZATION (if applicable) If you are authorizing the above entity(ies) to release information related to the testing, diagnosis and/or treatment for any of the following conditions, please sign your initials in front of the section which describes the type of information to be released. ____ My evaluation, testing, diagnosis or treatment for alcoholism and/or drug abuse or dependence may be released to (initials) the recipient noted on the signed authorization. ____ My evaluation, testing, diagnosis or treatment concerning my mental health/rehabilitation and/or neuro-psychological (initials) information may be released to the recipient noted on the signed authorization. ____ My testing, diagnosis or treatment for HIV/AIDS may be released to the recipient noted on this signed authorization. (initials)

AUTHORIZATION SIGNATURES NOTE: IF PATIENT IS UNDER 14 YEARS OF AGE AND IS NOT AN EMANCIPATED MINOR THE PARENT OR GUARDIAN MUST SIGN.

Date:_____________________ Patient Signature: _______________________________________________________

Date:_____________________ Witness Signature: _______________________________________________________

If patient is unable to sign authorization form because of physical condition or age, complete the following: Patient is a minor or patient is unable to sign authorization because: ___________________________________________

Date: __________ Signature: _______________________________________ Relationship: _______________________ (Parent/legal or personal representative)

Date: _____________________ Witness Signature: _______________________________________________________ ********COPY OF COMPLETED AUTHORIZATION FORM MUST BE GIVEN TO PATIENT********

#A-560-008-DMR ADDRESSOGRAPH Rev. 5/03js MRPC Approved: 6/03 Stores Item # 1091280 Copy: Medical Record Copy: Patient

Lake-Lehman School District Athletic Training Department

Emergency Contact Information

This form MUST be filled out by a parent or guardian of the student-athlete participating in athletics in the Lake-Lehman School District. Failure to do so will result in your son or daughter being held out of ALL

sport activities until it is handed in.

Student-Athlete’s Name: _________________________________________ Grade: ________________

Parent or Guardian Name: ______________________________________________

Address: _____________________________________________________________________________

Street City State Zip Code

Parent or Guardian’s Home/Cell Phone Number: _____________________________________________

Parent or Guardian’s Work Phone Number: _________________________________________________

Additional Emergency Contact Name and Number: _____________________________________________________________________________________

List the Student-Athlete’s allergies: ________________________________________________________

List the Student- Athlete’s Medical Conditions/Issues: _____________________________________________________________________________________

List emergency medications Student- Athlete is required to carry (ex.EPIPEN, Insulin, inhaler):

_____________________________________________________________________________________

_____________________________________________________________________________________

I understand that my student-athlete is responsible for carrying their emergency medications during after school activities and events (ex.games, practices). I hereby agree to allow the athletic trainer or coach to call emergency medical services (ex.911) in the event my son or daughter is injured and I am not present. The information above will only be used in these cases to facilitate the health care process.

Parent or Guardian Signature: ____________________________________________________________

Sport(s) Student-Athlete is participating in: __________________________________________________