This form is to be used after a student has sustained a substantial physical injury other than concussions, which includes, but is not limited to, fractures and any other physical injury that in the opinion of the school administration, coaching staff or athletic trainer should be evaluated by a licensed health care provider prior to resuming participation in the school activity. The athlete shall not be returned to any athletic activity until the student is examined by a licensed health care provider and written authorization is obtained from the licensed health care provider and the parent/guardians.

 

Student: _________________________________    School: _______________________ Grade: ____________

 

Activity engaged in at time of injury: ______________________________           Date of injury: ___________

 

Activity(ies) student wishes to play: ____________________________________________________________

 

REASON FOR ATHLETE’S INCAPACITY:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 

LICENSED HEALTH CARE PROVIDER’S CERTIFICATION

 

I certify that I am a licensed health care provider and have examined the named student following a substantial physical injury and have determined the following:

 

The student in my care wishes to engage in the following athletic activity(ies):___________________________

__________________________________________________________________________________________

 

_____ Permission is not granted for the student to return to athletic activity.

_____ Permission is granted for the student to return to the above listed activity(ies) in the following capacity:

 

[  ]        Light exercise (walking or stationary bike)

[  ]        Sport specific activity without body contact

[  ]        Resistance training

[  ]        Practice without body contact

[  ]        Practice with body contact

[  ]        Return to full competition with no restrictions

 

COMMENT: ______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

 

            _____________________________________________      Date: ________________

Licensed Health Care Provider

 

            _____________________________________________      Date: ________________

            Parent/Guardian/Student (if over 18 years of age)

 

            _____________________________________________      Date: ________________

            School Administrator or Athletic Trainer