STATESVILLE CHRISTIAN SCHOOL COMPREHENSIVE INITIAL PRE-PARTICIPATION PHYSICAL EVALUATION INITIAL EVALUATION: Prior to any student participating in Practices, Inter-School Practices, Scrimmages, and/or Contests, in the
students first sport in a school year, the student is required to (1) complete a Comprehensive Initial Pre-Participation Physical
Evaluation (CIPPE); and (2) have the appropriate person(s) complete the first four Sections of the CIPPE Form. Upon completion of
Sections 1,2, and 3 by the parent/guardian, and Section 4 by an Authorized Medical Examiner, those Sections must be turned in to the
Principal, or the Principals designee, of the students school for retention by the school. The CIPPE shall be performed no earlier than
June 1st and shall be effective, regardless of when performed during a school year, until the next May 31.

SUBSEQUENT SPORT(S) IN THE SAME SCHOOL YEAR: Following completion of a CIPPE, the same student seeking to participate
in Practices, Inter-School Practices. Scrimmages, and/or Contests in subsequent sport(s) in the same school year, must complete Section
5 of this form and must turn in that Section to the Principal, or Principals designee, of his or her school. The Principal, or the
Principals designee, of the students school will then determine whether Section 6 need be completed. SECTION 1: PERSONAL AND EMERGENCY INFORMATION PERSONAL INFORMATION Students Name_________________________________________________________________ Age_______ Grade_______ Current Physical Address___________________________________________________________________________________ Current Home Phone #( )_____________________ Parent/Guardian Current Cellular Phone # ( )____________________ EMERGENCY INFORMATION Primary Emergency Contact Persons Name:______________________________________________ Relationship:___________ Address_______________________________________________ Emergency Contact Telephone # ( )___________________ Secondary Emergency Contact Persons Name:____________________________________________ Relationship:___________ Address_______________________________________________ Emergency Contact Telephone # ( )___________________ Medical Insurance Carrier _________________________________________Policy Number _____________________________ Address______________________________________________________ Telephone # ( )_____________________________ Family Physicians Name ________________________________________________________________MD or DO (circle one) Address ________________________________________________________Telephone # ( )___________________________ Students Allergies_________________________________________________________________________________________ Students Health Condition(s) of Which an Emergency Physician Should be Aware _____________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Students Prescription Medications___________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ (Page 1 of 6) S ECTION 2: CERTIFICATION OF PARENT/GUARDIAN The students parent/guardian must complete all parts of this form. A. I hereby give my consent for _________________________________________________ born on_________________
who turned_____on his/her last birthday, a student of Statesville Christian School to participate in Practices, Inter-School Practices,
Scrimmages, and/or Contests during the 2008- 2009 school year in the sport(s) as indicated by my signature(s) following the name of the said sport(s) approved below: FALL SPORTS Signature of Parent or Guardian Cross Country Football
Soccer-Boys & MS Tennis-Girls
Volleyball
WINTER SPORTS Signature of Parent or Guardian Basketball
Cheerleading
SPRING SPORTS Signature of Parent or Guardian Baseball
Golf
Soccer-Girls
Softball
Tennis-Boys
OTHER
B. Understanding of eligibility rules: I hereby acknowledge that I am familiar with the requirements of SCS concerning the eligibility of
students to participate in Inter-School Practices, Scrimmages, and/or Contests. Such requirements, which are included in the school handbook
include, but are not necessarily limited to age, school attendance, health, transfer from one school to another, season and out-of-season rules and
regulations, semesters of attendance, seasons of sports participation, and academic performance.

Parents/Guardians Signature ___________________________________Date:__________ C. Disclosure of records needed to determine eligibility: I hereby consent to the release to SCS of any and all portions of school record files,
beginning with the seventh grade, of the herein named student specifically including, without limiting the generality of the foregoing, birth and
age records, name and residence address of parent(s) or guardian(s), residence address of the student, health records, academic work completed,
grades received, and attendance data.

Parents/Guardians Signature ______________ _____________________ Date:__________
D. Permission to use name, likeness, and athletic information: I consent to SCSs use of the herein named students name, likeness, and
athletically related information in reports of Inter-School Practices, Scrimmages, and/or Contests, promotional literature of the school, and other
materials and releases related to interscholastic athletics.

Parents/Guardians Signature ____________________________________ Date:__________
E. Permission to administer emergency medical care: I consent for an emergency medical care provider to administer any emergency
medical care deemed advisable to the welfare of the herein named student while the student is practicing for or participating in Inter-School
Practices, Scrimmages, and/or Contests. Further, this authorization permits, if reasonable efforts to contact me have been unsuccessful, physicians to hospitalize, secure appropriate consultation, to order injections, anesthesia (local, general, or both) or surgery for the herein named
student. I hereby agree to pay for physicians and/or surgeons fees, hospital charges, and related expenses for such emergency medical care.

Parents/Guardians Signature _____________________________________ Date:__________
F. Permission to transport student: I consent to SCS arranging transportation to and from Inter-School Practices, Scrimmages, and/or
Contests, in either the schools bus or in personal vehicles of the parents or legal guardians of other players or by the coach. I understand that
my child will not be permitted to drive to any of the above mentioned activities without special permission and is never permitted to ride in a
vehicle to the above mentioned activities with another high school student.

Parents/Guardians Signature _____________________________________ Date:__________ (Page 2 of 6) Students Name_________________________________________________________ Age___________ Grade_________ SECTION 3: HEALTH HISTORY Explain Yes answers at the bottom of this form.
Circle questions you dont know the answers to. 1. Has a doctor ever denied or restricted your
participation in sport(s) fany reason? Y N 2. Do you have an ongoing medical condition
(like asthma or diabetes)? Y N 3. Are you currently taking any prescription or
nonprescription (over-the-counter) medicines or pills? Y N
4. Do you have allergies to medicines, pollens.
foods, or stinging insects? Y N 5. Have you ever passed out or nearly passed
out DURING exercise? Y N 6. Have you ever passed out or nearly passed
out AFTER exercise? Y N 7. Have you ever had discomfort, pain, or
pressure in your chest during exercise? Y N 8. Does your heart race or skip beats during exercise? Y N
9. Has a doctor ever told you that you have
(check all that apply): Y N High blood pressure Heart murmur High cholesterol Heart infection 10. Has a doctor ever ordered a test for your
heart? (for example ECG, echocardiogram) Y N 11. Has anyone in your family died for no
apparent reason? Y N 12. Does anyone in your family have a heart problem? Y N
13. Has any family member or relative died of
heart problems or of sudden death before age 50? Y N 14. Does anyone in your family have Marfan
Syndrome? Y N 15. Have you ever spent the night in a hospital? Y N 16. Have you ever had surgery? Y N














20. Have you ever had stress fracture? Y N


21. Have you been told that you have or have you had
an x-ray for atlantoaxial (neck) instability? Y N 22. Do you regularly use a brace or assistive device? Y N
23. Has a doctor every told you that you have
asthma or allergies? Y N 24. Do you cough, wheeze, or have difficulty
breathing DURING or AFTER exercise? Y N 25. Is there anyone in your family who has asthma? Y N 26. Have you ever used an inhaler or taken
asthma medicine? Y N 27. Were you born without or are your missing a
kidney, an eye, a testicle, or any other organ? Y N 28. Have you had infectious mononucleosis (mono)
within the last month? Y N 29. Do you have any rashes, pressure sores, or
other skin problems? Y N 30. Have you had a herpes skin infection? Y N 31. Have you ever had a head injury or
concussion? Y N 32. Have you been hit in the head and been
confused or lost your memory? Y N 33. Have you ever had a seizure? Y N 34. Do you have headaches with exercise? Y N 35. Have you ever had numbness, tingling, or
weakness in your arms or legs after being hit
or falling? Y N
36. Have you ever been unable to move your
arms or legs after being hit or falling? Y N 37. Then exercising in the heat, do you have
severe muscle cramps or become ill? Y N 38. Has a doctor told you that you or someone in
your family has sickle cell trait or sickle cell
disease? Y N
39. Have you had any problems with your eyes or 17. Have you ever had an injury, like a sprain,
muscle, or ligament tear, or tendonitis , that
caused you to miss a practice or contest? Y N If yes, circle affected area below:
I8. Have you had any broken or fractured bones
or dislocated joints? If yes, circle below: Y N 19. Have you had a bone or joint injury that
required x-rays , MRI. CT, surgery, injections,
rehabilitation, physical therapy, a brace,
a cast, or crutches? If yes circle below: Y N Head Neck Shoulder Upper arm Elbow Forearm Hand/Fingers
Chest Upper Back Lower Back Hip Thigh Knee Calf/Shin
Ankle Foot/Toes vision? Y N 40. Do you wear glasses or contact lenses? Y N 41. Do you wear protective eyewear, such as
goggles or a face shield? Y N 42. Are you unhappy with your weight? Y N 43. Are you trying to gain or lose weight? Y N 44. Has anyone recommended you change your
weight or eating habits? Y N 45. Do you limit or carefully control what you eat? Y N 46. Do you have any concerns that you would
like to discuss with a doctor? Y N FEMALES ONLY
47. Have you ever had a menstrual period? Y N 48. How old were you when you had your first menstrual period?________
49. How many periods have you had in the last 12 months? ____________
50. Are you pregnant? Y N No(s). Explain Yes answers here: I hereby certify that to the best of my knowledge all of the information herein is true and complete. Students Signature_____________________________________ Date____________ I hereby certify that to the best of my knowledge all of the information herein is true and complete. Parents/Guardians Signature_____________________________ Date____________ (Page 3 of 6) SECTION 4: COMPREHENSIVE INITIAL PRE-PARTICIPATION PHYSICAL EVALUATION AND CERTIFICATION OF AUTHORIZED MEDICAL EXAMINER Must be completed and signed by the Authorized Medical Examiner performing the herein named students Comprehensive Initial Pre-
participation Physical Evaluation and turned in to the Principal, or the Principals designee of the students school.
Students Name____________________________________________________Age____________ Grade____________ School Sport(s) ________________________________________________________________________ Height________ Weight______ % Body Fat (optional) _____________Pulse________ BP ______/______(______/______, ______/______) Vision R 20/___ L 20/___ Corrected YES NO (circle one) Pupils: Equal Unequal_____ MEDICAL NORMAL ABNORMAL FINDINGS Appearance Eyes/Ears/Nose/Throat Hearing Lymph Nodes Cardiovascular Cardiopulmonary Lungs Abdomen Genitourinary (males only) Neurological Skin MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand/Fingers Hip/Thigh Knee Leg/Ankle Foot/Toes I hereby certify that I have reviewed the HEALTH HISTORY, performed a comprehensive initial pre-participation physical evaluation of the herein named student, and, on the basis of such evaluation and the students HEALTH HISTORY, certify that, except as specified below, the student is physically fit to
participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in the sport(s) consented to by the students parent/guardian in Section 2 of the SCS
Comprehensive Initial Pre-Participation Physical Evaluation form: CLEARED CLEARED, with recommendation(s) for further evaluation or treatment for: NOT CLEARED for the following types of sports (please check those that apply): COLLISION CONTACT NON-CONTACT STRENUOUS MODERATELY STRENUOUS NON-STRENUOUS Due to:_____________________________________________________________________________________________________ Recommendation(s)/Referral(s) _________________________________________________________________________________ Authorized Medical Examiners Name (print/type) ________________________________________ License #__________________________ Address ______________________________________________________________Phone ( )____________________________________ Authorized Medical Examiners Signature________________________________MD, DO. PAC, CRNP, or SNP (circle one) Date___/___/___ (Page 4 of 6)
SECTION 5: STATESVILLE CHRISTIAN RE-CERTIFICATION BY PARENT/GUARDIAN This form must be completed by the parent/guardian of any student who (1) completed a Comprehensive Initial Pre-Participation Physical
Evaluation (CIPPE) between June 1st and participation in the students first sport seasons first Practice of the same school year; and (2) is
seeking to participate In Practices, Inter-School Practices, Scrimmages, and/or Contests in subsequent sport(s) in the same school year. The
Principal, or Principals designee, of the herein named students school must review the SUPPLEMENTAL HEALTH HISTORY and make a
determination as to whether the student should be reevaluated and re-certified by an Authorized Medical Examiner pursuant to Section 6. SUPPLEMENTAL HEALTH HISTORY Students Name________________________________________________________________ Age___________ Grade_________________ CHANGES TO PERSONAL INFORMATION (In the spaces below, identify any changes to the Personal Information set forth in the
original Section 1: PERSONAL AND EMERGENCY INFORMATION:
Current Home Address ________________________________________________________________________________________

Current Home Telephone #( )__________________ Parent/Guardian Current Cellular Phone # ( )________________________ CHANGES TO EMERGENCY INFORMATION (In the spaces below, identify any changes to the Emergency Information set forth
in the original Section 1: PERSONAL AND EMERGENCY INFORMATION:
Primary Emergency Contact Persons Name _____________________________________________ Relationship________________
Address _____________________________________________ Emergency Contact Telephone # ( )________________________ Secondary Emergency Contact Persons Name ________________________________________________ Relationship__________ Address_____________________________________________Emergency Contact Telephone # ( )________________________ Medical Insurance Carrier:________________________________________ Policy Number :________________________________ Address:______________________________________________ Telephone # ( ):_______________________________________ Family Physicians Name:___________________________________________________________________MD or DO (circle one) Address____________________________________________________________________ Telephone # _____________________ SUPPLEMENTAL HEALTH HISTORY: Explain Yes answers at the bottom of this form.
Circle questions you dont know the answers to.
1. Have you sustained an illness and/or injury
related to sport(s) since completion of the
CIPPE? Y N 2. Have you sustained an illness and/or injury
NOT related to sport(s) since completion or
the CIPPE? Y N 3. Have you been confined to an institution
and/or at home as a result of an illness
and/or injury since completion of the CIPPE? Y N 4, Have you had surgery since completion of
the CIPPE? Y N
5. Have you experienced dizzy spells,
blackouts, and/or unconsciousness? Y N 6. Have you experienced any episodes of
unexplained shortness of breath, wheezing,
and/or chest pain? Y N 7. Have you experienced any now health
problems since completion of the CIPPE? Y N 8. Are you taking any NEW prescription or non-
prescription (over-the-counter) medicines or
pills since completion of the CIPPE? Y N 9. Do you have any concerns that you would
like to discuss with a doctor? Y N No(s). Explain Yes answers here: SUBSEQUENT SPORT(S) TO BE PLAYED: ____________________________________ SEASON: Fall Winter Spring (circle one) I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Students Signature ______________________________ Date :___________ Grade_________

I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Parents/Guardians Signature ______________________________ Date :___________ NOTE: If any SUPPLEMENTAL HEALTH HISTORY questions are either checked yes or circled, the Principal, or Principals
designee, of the herein named students school shall require the student to complete Section 6 prior to being eligible to participate in
sport(s) identified above. (Page 5 of 6)
SECTION 6: STATESVILLE CHRISTIANCOMPREHENSIVE PRE-PARTICIPATION PHYSICAL RE-EVALUATION AND RE-CERTIFICATION BY AUTHORIZED MEDICAL EXAMINER Must be completed and signed by an Authorized Medical Examiner and turned in to the Principal, or the Principals designee, of the students school prior to participation in second and subsequent sport in the same school year. Students Name__________________________________________ Age____________ Grade____________ Enrolled in Statesville Christian School Sport(s):________________________________________________________ Height________ Weight______ % Body Fat (optional) ______________________ Pulse________ BP_____/______ Vision R 20/ ___L 20/____ Corrected YES NO (circle one) Pupils: Equal ____ Unequal____ MEDICAL NORMAL ABNORMAL FINDINGS Appearance Eyes/Ears/Nose/Throat Hearing Lymph Nodes Cardiovascular Cardiopulmonary Lungs Abdomen Genitourinary (males only) Neurological Skin MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand/Fingers Hip/Thigh Knee Leg/Ankle Foot/Toes I hereby certify that I have reviewed the SUPPLEMENTAL HEALTH HISTORY, performed a physical re-evaluation of the herein
named student, and, on the basis of such re-evaluation and the students SUPPLEMENTAL HEALTH HISTORY, certify that, except
as specified below, the student is physically fit to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests In the
sport(s) consented to by the students parent/guardian in Section 5 of the PIAA Comprehensive Initial Pre-Participation Physical
Evaluation form: CLEARED CLEARED, with recommendation(s) for further evaluation or treatment for ____________________________
NOT CLEARED for the following types of sports (please check those that apply):
COLLISION CONTACT NON-CONTACT STRENUOUS MODERATELY STRENUOUS NON-STRENUOUS
Due to _________________________________________________________________________________________________ Recommendation(s)/Referral(s) __________________________________________________________________________________ Authorized Medical Examiners Name (print/type) ________________________________________ License____________________ Address ______________________________________________ Phone _______________________________________________ Authorized Medical Examiners Signature ________________________________________MD, DO, PAC, CRNP, or SNP (circle one)Date __/__/__ (Page 6 of 6)