Dear Parent/Guardian,

On May 14, 2008, Dr. Abel of the Wakarusa Clinic will be at Jimtown Junior High School giving “ free ” athletic physical examinations for our 2008-2009 7th and 8th grade students. Dr. Abel will start at 8:30 A.M. and continue until all student examinations have been completed. A staff member from the Intermediate will walk the students to the junior high school for the physicals and walk them back when they are finished.

There will be no charge for this physical examination. We urge you to sign the attached consent form and return it to the school office as soon as possible. This physical exam will be good for the 2008-2009 school year. Students participating in junior high athletics, or cheerleading, must have an athletic physical on file before they will be allowed to practice any sport or try out for cheerleading.

Using this service is a financial break for our parents. Please urge your son/daughter to return the paperwork quickly. This physical exam will be for Jimtown Junior High School 7 th and 8 th grade students only.

 

Sincerely,

Michael Groh, Principal

Charlie Sauter, Athletic Director

 

 

Please print and fill out the form below and return it to the school office as soon as possible.

Form is available here

 

Jimtown  Intermediate  School

And

Jimtown Junior High School

Athletic Physical

 

For the School Year, 20___ thru 20____

 

 

Parental  Consent

 

Student Name_______________________________

                                                Please Print

Grade _______                                                                       Date __________, 20______

 

            I hereby give my consent for __________________________________, a student at Jimtown Intermediate/Junior High School, to participate in all interscholastic athletics and contest, except ______________________________________________, during the present school year.

 

Please list student's health conditions ________________________________________________

 

List any medications your child uses ________________________________________________

                (If medication(s) is necessary for athletic activities, please also complete Medication Authorization                 form which is available in the school office.)

 

                        Parent or Guardian Signature _______________________________________

                                                                                   

 

Physician Certificate

 

                                                                                                Date ___________, 20_____

 

            I have examined the heart condition, blood pressure, lungs and general

physiological condition of __________________________________, a student at Jimtown Intermediate/Junior High School, and believe him/her to be physically fit to participate in interscholastic athletics and contests, except ________________________, (sports) with students of his/her age, during the present school year.  I have found this student to be free from serious heart or lung disorder, or hernia.

 

Physically fit to participate in interscholastic athletics?  Yes__________ No___________

 

If negative, please comment/recommendation: ________________________________________

 

______________________________________________________________________________.

 

 

 

Office Phone______________________     Physician Signature_________________________________