Athletic Forms

A new sports physical form must be completed before your child can participate in a sport. Your child will not be permitted to participate in the pre-season training if all of the necessary information have not been turned in to the Middle School or Upper School athletic trainers.
New Sports Physical Required:
A new sports physical is required each year prior to being permitted to participate in pre-season training. Parents and students need to complete the required Comprehensive Initial Pre-Participation Physical Evaluation form (CIPPE).  

Prior to the examination by a physician, parents need to complete sections 1, 2, 3, 4, and 5 of the PIAA Comprehensive Initial Pre-Participation Physical Evaluation (CIPPE) Form.  You may have your own physician give your son/daughter a physical using the CIPPE form.  The Pennsylvania Interscholastic Athletic Association (PIAA) has approved this method and requires athletes to complete the CIPPE form and submit them to Moravian Academy Athletic Trainers office before participation in any athletic program.  Please make note that this physical must be performed after June 1st, 2018.  Please be advised, your medical provider is to review sections 1-6 of the PIAA forms prior to completing and signing the physical exam.

Checklist for Parents/Guardians

•       Acquire a CIPPE form from the athletic website, Athletic Trainer, Main Office, or Athletic Coordinator
•       Complete CIPPE Section 1: Personal and Emergency Information
•       Complete CIPPE Section 2: Certification of Parent/Guardian  

         o      Parent/Guardian signature next to all sports that apply
         o      Parent/Guardian signatures in parts B, C, D and E.

•       Complete CIPPE Section 3: Understanding Risk of Concussion and Traumatic Brain Injury

         o      Student Signs and Dates
         o      Parent/Guardian Signs and Dates

•       Complete CIPPE Section 4: Sudden Cardiac Arrest

         o      Student must sign and date
         o      Parent/Guardian must sign and date

•       Complete CIPPE Section 5: Health History

         o      Student must sign and date
         o      Parent/Guardian must sign and date

•       Do not complete Section 6: Authorized Medical Examiner will complete this section during the course of the physical exam.

•       Complete the Consent to Treat Patient form

•       Complete the HIPAA Privacy Authorization Form

•       If you want your own physician to give the physical, please do the following
         o      Physicals must be dated AFTER June 1st, 2018.
         o      Complete Sections 1 – 5 as stated above and have your own physician complete Section 6
         o      Submit all properly documented papers to the Athletic Trainers (Upper School or Middle School) before August 10th to participate in a fall sport.


FOR ATHLETES WHO PARTICIPATE IN A FALL SPORT AND WISH TO PARTICIPATE IN A WINTER AND/OR SPRING SPRING SPORT, A RECERTIFICATION FORM WILL BE NECESSARY BEFORE THE WINTER AND/OR SPRING SEASON BEGINS.

Recertification Information:

If your child had a sports physical earlier this school year and participated in a sport, parents and students need to complete the PIAA Recertification Section 7 and 8 Form. Section 8 is only required if there are any “YES” answers in the supplemental health section of the Section 7 form. 
 
PIAA has made it clear that if your child has had a sports physical with your own doctor, any physician can sign the Re-Certification form as long as you have the original physical available for the physician to review. Therefore, if you DO NOT have the original physical, you need to see the original doctor.

A completed recertification form must be returned to the athletic trainer on or before the first day of practice or your child will not be able to participate.

All required forms must be returned to the athletic trainer on or before the first day of practice or your child will not be able to participate.

Please note that we will continue to use ImPACT testing to assist our team physicians and athletic trainers in evaluatiing and treating head injuries.  For additional information on ImPACT testing, please visit https://www.impacttest.com

If you have any questions please contact:
    Ms. Shelby Benner (Middle School Athletic Trainer) - shelby.benner@sluhn.org
    Ms. Stasia Burroughs (Upper School Athletic Trainer) - 610-691-1600, ext. 324 - stasia.burroughs@sluhn.org

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